Sierra Tucson and EAGALA: Making connection through horses

ST Equine img_5937By Jessica Miceli, MAC, LSC, EAGALA Certified Professional

On January 19-21, 2017, Sierra Tucson will host the Equine Assisted Growth and Learning Association’s (EAGALA) “Training the Trainers” workshop. Founded in 1999, EAGALA is a nonprofit organization that has set the global standard in offering a fully developed, professionally endorsed treatment model for mental health professionals practicing equine-assisted psychotherapy. EAGALA has over 4,500 members in 50 countries (“The EAGALA Model” 2009-2010).

Since 1983, Sierra Tucson has been internationally renowned for its effective therapies, dedicated staff, and extraordinary setting. Sierra Tucson provides integrative treatment to identify and resolve underlying issues. This supportive path has led to recovery for over 30,000 individuals who have suffered from alcoholism, drug addiction, depression, anxiety, trauma, eating disorders, chronic pain, and other mental health disorders (Sierra Tucson 2016).

Sierra Tucson is one of the first facilities in the nation to use horses as therapeutic partners in residential treatment. Equine therapy at Sierra Tucson was founded by Barbara Rector, a pioneer in the field, and Wyatt Webb, who has written books such as “It’s Not About the Horse.” In 1981, before the adult unit opened in 1983, Sierra Tucson’s Integrated Riding Resource Program’s (STIRRUPS) purpose was to elevate the troubled adolescent’s self-esteem through therapeutic work with the horse and the horse experience.

Horses are large and powerful creatures. This creates a natural opportunity for some individuals to overcome fear and develop confidence. They are social animals, with defined roles within their herds. They respond with unique insight into exactly who we are in the moment. Because horses can read and respond to the nonverbal messages we are always sending, they begin to act in ways that feel familiar to other relationships or dynamics in our lives. The lesson is that by changing ourselves, the horses respond differently. They provide this immediate feedback to real changes that we make – not what we just talk about (“So Why Horses and No Other Animals?” 2009-2010).

Sierra Tucson’s equine services have evolved over the years to include EAGALA-based practices, and both entities share much of the same philosophies. Both models involve:

  • No riding or horsemanship
  • Client-centered and solution-oriented
  • Team approach (always two co-facilitators)
  • Horses are an integral part of the treatment team (they are our counselors!)

Working with horses on the ground enables clients to better perceive the horses’ actions and reactions as they work to process and solve their life challenges. Horses offer clients an understanding of how their processes and actions affect others and impact their lives (“The EAGALA Model” 2009-2010).

Additionally, Sierra Tucson and EAGALA see the clients as best at determining the kinds of life changes they need to make to improve their lives. The job of the staff is to engage the intuitive power of horses to help them understand their process and practice the changes they want to make in a safe, supportive setting (“The EAGALA Model” 2009-2010).

Sierra Tucson is hosting the “Train the Trainers” workshop January 19-21, 2017, because it allows for a unique exchange of ideas between the two pioneers in their respective fields. Sierra Tucson sees the value in paying it forward by providing a beautiful setting to a nonprofit organization that certifies equine therapists all over the world. Nestled in the foothills of the Santa Catalina Mountains, the breathtaking views, helpful staff, warm climate, and wide variety of horses make Sierra Tucson an ideal location.


Sierra Tucson. (2016). Retrieved from

The EAGALA Model. (2009-2010). Retrieved from

New Year’s Resolutions and Recovery

WSM_7492-EditEmbracing progress, not perfection

The New Year is upon us! As we bid farewell to 2016 and welcome 2017 with open arms, it seems only natural to make a list of resolutions. But when lofty goals become set-ups for let-downs, it can lead to depression and self-doubt.

At Sierra Tucson, we acknowledge the excitement that comes with a new year, and we believe in balancing that enthusiasm with realistic plans. Below are some healthy tips that we offer our residents during this time of year. We hope you’ll find them useful, too.

  1. Change the Language – Often, the term resolution has a negative connotation. Instead, setting intentions (“I am going to,” “I hold myself accountable by,” “I will try my best to”) can be a positive step. A shift in language creates a shift in mindset, and that can make all the difference.
  2. Focus on Healing – According to David Cato, LCSW, TCT, primary therapist for Sierra Tucson’s Trauma Recovery Program, “When we work on ourselves from within, [we begin to] find a way out of our old patterns and our old behaviors.” Somatic Experiencing® and other trauma-healing therapies help get to the root of a person’s challenges.
  3. Count Your Blessings  “Counting our blessings […] can help us deal more effectively with intense feelings, urges, and cravings,” says Kimberly Peters, MSSW, LCSW, primary therapist at Sierra Tucson. One way to achieve this is to fill up an empty jar with notes about the good things that take place in 2017. At the end of the year, you will literally be able to count your blessings!
  4. Try New Things – Rather than setting unrealistic goals, we can step outside of our routine from time to time. Expanding one’s horizons by learning a skill, trying a new dish, visiting a never-before-seen museum, or going on a new adventure are some practical ways to keep life fun.

From all of us at Sierra Tucson, we wish you good health and happiness in 2017!

For more information on Sierra Tucson’s comprehensive treatment programs, call our Admissions Coordinators at (800) 842-4487.

davidDavid Cato, LCSW, TCT, primary therapist and LGBTQ support specialist at Sierra Tucson, explains how to approach the New Year in a healthy manner. Watch now.

Depression and the Holidays

RedFinding peace and joy from within

Typical holiday messages suggest we should be filled with gladness and good cheer. Tidings of Joy. Peace on Earth. Happy New Year. Despite holiday buzzwords and societal expectations of how this time of year should look, not everyone feels so merry and bright.

From financial woes and high hopes, to shorter days and overwhelming to-do lists, this time of year can result in depression and anxiety. If you are battling the holiday blues, there are steps that you can take not only to endure the season, but enjoy the season as well.

  1. Take a Stroll – It’s no secret that walking is good for one’s health, but taking a 10-minute stroll three times a day is therapeutic, too. Just a few brief doses of sunlight throughout the day can lift your mood dramatically, especially during the winter months.
  2. Play with a Furry Friend – Whether you own a pet, borrow a friend’s pet, or volunteer at a local animal shelter, we encourage you to enjoy a few minutes of pet-friendly playtime each day. These lovable companions serve as great reminders to stay in the moment.
  3. Book a Therapeutic Massage – Sierra Tucson strongly believes in the power of integrative treatment for recovery from mental health conditions. Try to make massage a priority. Studies have shown that human touch not only eases aches and pains, but helps to relieve depression and anxiety as well.
  4. Schedule a Coffee Date – At Sierra Tucson, we encourage residents to surround themselves with positive people, places, and things. Regular social contact with loved ones is a surefire way to boost your mood and share a few laughs.
  5. Strive for Balance – Often, the holidays are jam-packed with parties and obligations. Staying balanced with one’s time is essential in recovery. Remember that resting the body is an excellent way to practice self-love.

For more information on Sierra Tucson’s Mood & Anxiety Program, call our Admissions Coordinators today at (800) 842-4487.


Depression and the HolidaysMichelle Chacon, RN, Transcranial Magnetic Stimulation (TMS) Coordinator for Sierra Tucson, discusses common reasons for holiday depression, as well as healthy coping strategies. Watch now.

 Learn more about how TMS Therapy is an effective alternative for depression treatment.

How to Enjoy the Holidays in Recovery

image001Below are some tips and words of encouragement from some of our alumni. Sierra Tucson Alumni Relations wishes you a healthy and happy holiday season. We Support You!

“My recipe for success during the holiday season includes meetings, meetings, and more meetings—especially extra Al-Anon meetings. Additionally, by using prayer and meditation, I’m better able to stay centered. I do make a plan when attending events. For me, my food plan is very important so I either eat before or bring my own, depending on the location. When offered so-called “goodies,” I respond with “Thank you for thinking of me… maybe later” or “Looks wonderful, but I’m too full!” At this time of year, with all the activities where it appears people are eating more, spending more, drinking more, stressing more, etc., Al-Anon meetings help me keep the focus on me. And, when I visit my family I keep it brief and kind (meaning I leave when I’ve had enough). Don’t get me wrong, I love them. I just want to be around people where I can be real and connect emotionally. So, to meetings I go!”
Peggy B.


“Last year the holidays were the beginning of a deep, dark slide for me. It ended with me going to Sierra Tucson in June. Thank God I got there because it saved my life. This year I plan on practicing a lot of self-care during this time: spending fun time with my kids, seeing my therapist more, and going out with friends. I’m also learning my limitations and I’ll remove myself when the crowd gets too big or I start feeling uncomfortable in any way.”
Devora H.


“During the holidays I have to make myself so much more self-aware. Physically, emotionally, mentally, I have to ‘check in’ with myself every couple of hours during the high-stress times. I have to take care of me during the holidays so I can be around to take care of them (kids) the rest of my life!”
Lisa G.


“I will be mindful about my thoughts, actions, and emotions during the holiday season, because these three things are all that I can control. My mindfulness will help me treat others with respect and humility regardless of their behavior, and allow me to relinquish my attempt to control situations that would be best left alone.”
Scott W.


“I will best serve myself and others by caring equally for my body, mind, and spirit. I will remind myself that exercise is conveniently available outside my door in a brisk walk or a short trip to the gym. I lift my spirits the most when I am of service to others, especially through recovery work with others.”
Liz P.


“At this time of year, I will choose to do nothing different than what has gotten me here. I will continue to work on myself – through Step work, personal exploration, and active participation in recovery. I will seek opportunities to be of service as my life enlarges as a result. I will pray for courage to do the right thing and be shown the path that God would have me take. I will surrender and forego the temptation to take back control. I will avail myself of the few seconds of contemplation before embarking on an action that may feel justified in the moment, but that experience has demonstrated may cause long-term pain. I will accept responsibility when to do so is the right thing. I will stay engaged and connected. Today, I am committed to my sobriety and to my recovery. Life is too short to have it any other way.”
Brent B.


“To battle the winter and holiday blues, I’ve finally begun incorporating yoga back into my life. It’s really helping with feeling overwhelmed, overrun, tired, and down. Of course, it should not be any revelation to me that an exercise that gets my body and breath going would be so helpful, but there seems to always be that gap between what we know and what we do.”
Dennis C.


“The holidays can be a tough time. I suffer from a disease of loneliness and can experience it whether I’m around loads of people or by myself. I have to remember: this is a ‘we’ program and to reach out for support.”
Nancy S.


“Remember H.A.L.T. – never get too hungry, angry, lonely, or tired. Help others always and remember that it doesn’t have to be perfect – just do your best.”
Rae T.


“I plan on trying to come from my heart and not my head, and communicating love through gestures of love.”
Bryan F.


“The holidays always seem to bring some nervous anticipation to me. I work the holidays on a day-to-day basis. I attend more meetings during this time. They help ground me. If I attend a party, I arrive early, leave early, always have my own car, and make sure no one can block me in. I feel strong in ‘showing up’ and even stronger when I leave as people start to get ugly. I get outside for a hike every day to calm myself and be able to think. I spend a lot of time taking care of me, checking in with myself, and staying on the right path. I don’t schedule too many things for my family and myself. I make sure that I have a lot of quiet time to recharge. I stay away from unsafe places and people. I try to quiet the ‘committee’ that chatters in my head.”
Denise S.


“I’ve have discovered in recent years that to survive the holidays, I need to think of ways that I can give instead of receive. If I enter into the mindset of ‘Did I get what I wanted?’ then I’ll be sorely disappointed. Alternatively, I have found that when I am of service to my loved ones, my holidays usually turn out bright.”
Matthew P.


“Spend some extra time with friends from my group therapy and really try to get to know them better. Be grateful every day and never forget how lucky I was to be able to go to Sierra Tucson.”
Tim S.

Music Therapy: Finding the Rhythm of Recovery

music_therapyDid you know that incorporating music therapy into the treatment of addiction is beneficial to one’s recovery? It complements other treatment modalities used to help each individual. Music therapy can be active or passive; it can involve listening or singing. At Sierra Tucson, Family Therapist Michael Simpson, MSC, BCC, LAC, leads communal drumming circles. With the right rhythm and a new perspective on regaining harmony, music therapy can help open your mind to a different kind of intervention.

According to the American Music Therapy Association (AMTA), the definition of music therapy is the “clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.” Music therapy is also considered a creative approach that helps with expression. Music shares neural circuits with speech. By listening or singing aloud to music, we tap into neural circuits that assist with expression. Frequently recognizing and communicating emotions can often be difficult for people struggling with addiction.

Music therapy can be helpful across many strata of addictions, including substance dependence or process addiction(s). Sierra Tucson alumnus Paul N. shares his insight on the positive effects of music therapy:

“Music serves as a great form of communication and a different way to convey a message at a deeper level than words allow. Music evokes emotions, feelings, and memories, and has a way of transcending or bridging our inner voice to our current realities. In my own workshops and sessions that I facilitate, I use music to foster self-exploration. I compile songs in a specific way that guides an individual or group through a revealing journey and evokes experiences from their subconscious. Putting these experiences into words is sometimes difficult, so I invite them to compile a story, using a set of visuals that represent their music-evoked visions and feelings. Through reflection and meditation, participants can articulate their journey of self-exploration and affirm their self-worth, wisdom, and purpose.”

You don’t need to be a musician or an opera singer to experience the many benefits of this creative art therapy. All you need is a willingness to try something new. There are many advantages and qualities of music therapy, including:

  • Shares neural circuits with speech
  • Helps us express emotion
  • Taps into our memories
  • Alleviates pain and anxiety
  • Promotes relaxation and wellness
  • Brings people together and is social

Certain types of music are rhythmic and predictable. Other types of music are unpredictable and improvisational. It is up to the therapist and the individual to select the type of music that will help the individual achieve his or her goals. Different combinations of music may be employed at different times to promote mental and physical health. At Sierra Tucson, we understand that treating addiction is comprehensive and personal – no one treatment is the same for every resident. Music therapy is simply one approach that works in concert with many other methods for addressing addiction, including psychotherapy, medication, and mindfulness, among others.

Call Sierra Tucson’s Admissions Coordinators at (800) 842-4487 for more information about our comprehensive residential treatment programs.

Eating Recovery and the Holidays

gork0bacw2i-aaron-burdenMinimizing Fear and Anxiety

For individuals in eating recovery, the holiday season can stir up feelings of fear and anxiety. From Thanksgiving and Christmas feasts, to holiday parties and Chanukah traditions, this time of year is when memories are made around calorie-laden meals.

Often, fighting the urge to fall into old patterns and behaviors feels like an uphill battle for the struggling individual. At Sierra Tucson, our goal is to provide residents with healthy tools and continued support. Below are a few ideas that you can practice for a healthy holiday season – body, mind, and spirit.

  1. Create & Maintain Structure – We encourage you to put together a holiday food plan that includes regular meals and snacks, as well as healthy coping strategies that are unrelated to food.
  2. Eat Peacefully – Just like the mind needs time to unwind, the body craves stillness also. To help you avoid the temptation to binge at a holiday party, eat peacefully at home before the event – preferably with loved ones, if possible.
  3. Bring Along Support – There is strength in numbers, so the next time you are headed to a holiday gathering, bring a supportive friend.
  4. Tangible Reminders – No matter how much an individual plans ahead, unexpected triggers are inevitable. Keeping something small and tactile in your pocket or wearing a rubber wristband can serve as a gentle reminder to breathe and stay in the moment.
  5. Up the “Recovery” Ante – At Sierra Tucson, we recommend at least one recovery-related activity a day for residents who are completing treatment and returning home. We encourage you to boost your recovery routine with even more support during the holidays.

For more information on Sierra Tucson’s Eating Recovery Program, call our Admissions Coordinators today at (800) 842-4487.


Screen Shot 2016-12-01 at 8.25.25 AM

Scott Frazier, MSC, Program Manager for Sierra Tucson’s Eating Recovery Program, identifies healthy ways to approach the holidays while maintaining recovery from an eating disorder. Watch online now.

A Healthy Food Attitude

image003How long has it been since you’ve taken a look at your relationship with food or the parameters around which you eat? Does this relationship matter to you? Why or why not? The answer to these questions can create such an opportunity for you. In a world full of “eat this, not that,” “super food,” and a surplus of health claims, somewhere down the line there has been an attack upon our ability to feed ourselves. The messages that we receive in this process tell a story, and this story depicts a setting in which we develop the idea as to how and why we eat as a culture. This development is the creation of your food attitude (i.e., one’s relationship with food).

To generate a food attitude, one has to become familiar with the boundaries necessary to either create or absolutely destroy his or her relationship with food. So how can one develop a food attitude that is helpful? The answer lies within a person’s ability to recognize how boundaries reflect his or her relationship with self, but also with others. In doing so, one can then examine his or her relationship with food and establish safety in the process. This develops an intuitive process toward the progression of one’s food attitude. So why are boundaries important and what do they have to do with you?

Boundaries & Food

Boundaries contain physical, emotional, mental, and sexual parameters that are created by you. These parameters cooperate with your relationship to yourself and others. They develop an important and innate opportunity to take responsibility for what you think, how you feel, and what you do in response to your own or others’ behaviors and feelings. Think about it this way: Whether you agree with some of the traffic laws or not, one thing is certain—if there are no speed parameters or stopping measures, the roads upon which we travel become a dangerous environment that could lead to injury. The same is true for a person’s lifestyle. If there are no parameters or value systems by which to live, injury – physical or emotional – can also be a result. Parameters are boundaries, and boundaries create safety. So how can safety and food cohabitate?

We now live in a culture where food will either kill you or save you. A recent poll taken in Science Daily (2008) revealed that 65 percent of women in America endorsed unhealthy thoughts, feelings, or behaviors related to food and their bodies. Sixty-five percent! On top of this, newer research suggests that the ratio of men diagnosed with eating disorders is no longer 1 in 10, but 1 in 4 (Hudson J et al., 2007). Again, why is there an attack on food? This should direct us back to boundaries. If we initiate sole blame on others for how they think, feel, or behave, then where is the empowerment to be able to choose or decide how this can affect us? You wouldn’t blame a chair (an inanimate object) for stubbing your toe in the middle of the night, would you? Then why are we placing blame on the food that our culture consumes and why is this the sole cause of the obesity epidemic or the disordered eating trend? As a consumer and an individual, we are given choices. What we decide is up to us. In the same way that we choose to set boundaries, we can also choose the “how” and “why” we nourish ourselves.

1.    Build Awareness: Ask yourself on a daily basis, “What am I hungry for?” It could be acceptance; it could be knowledge; or maybe even hunger for a certain food item. Hunger is an innate feeling and it works together with a multitude of chemical reactions in the body. As stated by Adam Drewnowski, PhD, director of the Nutritional Sciences Program at the University of Washington, “The human body evolved an elaborate and powerful appetite system to ensure we eat—and eat well—when food is around, with fat being the most efficient way to obtain energy.” (Drewnoski A, 1997) This statement helps initiate the normalcy of hunger and how to get those needs met, as well as the importance of decision-making. So whether you are choosing a salad or a sandwich, your task is to become aware of the trend regarding your choosing. Start with tools that can you build upon:

  • Record your meals in a food journal.
  • Ask for help, whether from a registered dietitian or someone who can provide insight.
  • Read and ask questions – it is perfectly OK to learn about food.

2.    Be Intuitive: The whole idea of being intuitive and/or mindful starts with intention. Being intentional about your thoughts and behaviors helps you to regain what were once experiences in autopilot (e.g., taking the time to plan for lunch versus skipping or grazing throughout the day). If your behavior represents who you are and want to be, then this is something that can be helpful; if not, well, maybe change is in order. In short, it is about being present. (Robinson E., et al., 2013) Examples of tools for honing your intuition include:

  • Shop for groceries when you are well fed and have a list, to help you refrain from food waste and be mindful of your budget.
  • Take away the TV, electronic devices, and reading materials while eating. It takes 20 minutes for your stomach to signal fullness. Take at least 20 minutes to enjoy your food.
  • Eat with your non-dominant hand to help slow down the eating process. Gauge your fullness at the halfway mark.

3.    Be Objective: When developing your food attitude, please know that it will not be perfect. Progress will yield more results than chasing perfection. Too rigid of food boundaries can create guilt and shame about food consumption. But when a person is able to connect with his or her ability to learn what works, only then is the individual able to change his or her food attitude. Trust with one’s self is a cooperative effort between healthy behavior and time (e.g., taking the time to try new foods and learning how to cook and enjoy them). Here are some tools to begin this process:

  • Host a dinner party or cook for someone you love. Give yourself time to practice.
  • Plan to implement one new food item per week, which develops variety.
  • Keep track of the foods and new recipes you are trying and examine if they work or not. This helps you recognize your ability to provide things that are good and good for you

By this time, the hope is that you are aware of how your relationship with food affects not only you, but also the relationships around you. Take a strong look at your ability to choose and develop your food attitude to reflect an idea that brings awareness and a willingness to coach yourself –and allow yourself to be coached. Being intuitive about this process will not show up perfectly, but it will show progress. Above all else, remember that this type of attitude will provoke an invitation to receiving the message that eating can be flexible. It can change in response to your hunger, your busy schedule, and your ability to feed yourself as well as your feelings. If you are patient with yourself, then you can begin to take the power back from the all-too-easy scapegoat: food.

Article written by Dezi Abeyta

Works Cited:
Drewnowski, A. (1997). Taste preferences and food intake. Ann R Nutr (17): 237-253

Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348–358.

Robinson, E., et al. (2013) Eating attentively: a systematic review and meta-analysis of the effect of food intake memory and awareness on eating. Am J Clin Nutr, 97(4), 728-742

University of North Carolina at Chapel Hill. (2008). Three Out Of Four American Women Have Disordered Eating, Survey Suggests. ScienceDaily.

A Warm Welcome to the UK

Lila and horseSierra Tucson regularly invites professionals from all over the world to meet our caring staff and see our beautiful campus. We were fortunate to host several guests from the United Kingdom in September. Brent Clark, BA (Hons), MSC, a therapeutic director in London, shares highlights from his recent visit.

I first heard about Sierra Tucson eight years ago when studying for my master’s degree in addiction psychology and counselling. Max Cohen, Sierra Tucson’s treatment placement specialist (TPS) for the UK, gave a lecture on excellence in holistic care, and used Sierra Tucson as an example of how things could and should be. I remember being inspired by the breadth of vision in treating addiction and other disorders. I work with the homeless and marginalise at Spitalfields Crypt Trust (SCT), a local charity based in East London. We provide residential rehabilitation and continuing care for people who have been dealt a harsh deal in life economically, emotionally, and spiritually.

In the spring of this year, after heading up and developing our continuing care, I was given a new role as therapeutic director with the job of redesigning our residential rehab’s therapeutic delivery, which for many years had relied on basic 12 Step and Big Book delivery. Max is now my clinical supervisor and supporter of our charity, so being cheeky I asked if there was any chance of visiting Sierra Tucson and immersing myself in the programme. I was bowled over when Max informed me that Sierra Tucson would like to support SCT by inviting me to its Professionals Weekend so I could observe and have meetings with key staff for the week preceding.

The visit exceeded my expectations. At SCT, we pride ourselves on the relational and caring attitude we strive to uphold for our clients. Our resources may be limited, but we love much. I was concerned that Sierra Tucson might be excellent in terms of resources and sharp evidence-based delivery, but I wondered if it might be institutional and lacking in the recovery community focus we have developed at SCT. Furthermore, I was concerned I would be an imposition, another responsibility in a hectic schedule.

When I arrived, I was met with a huge screen welcoming me by name, a small touch, but one that typified the welcome I received from every staff member I met. I was often poached by staff members who wanted me to see their work or understand their approach. The passion was palpable and very affirming. In the week that I stayed in Tucson, I recognised what we are trying to do in East London: to make people feel cared for with kindness and grace, using the best interventions we can afford to help them overcome complex life issues. The integrative model was best typified for me in the staff meetings I observed, where all team members addressed each other with the kind of respect that reflected the appreciation that everyone’s work is part of the solution.

I am now in the position in London of trying to translate what I experienced at Sierra Tucson to our programme here. My week at Sierra Tucson was a personal and professional delight—one for which I am deeply grateful and will positively change the lives of the people we treat.

What Does “Quality” Mean at Sierra Tucson?

Susan MenzieBy Sue Menzie, BSN, MS
Director of Quality Improvement

Usually the terms quality improvement, quality management, and performance improvement evoke some very interesting emotions and responses in the health care industry. For most of my health care career, the Quality Improvement Department was also the “Gotcha” Department. Basically, the department that was always negative and condemning, representing a challenge to show “good numbers” so the organization didn’t end up on anyone’s radar.

Somewhere along the line, my point of view on “quality” changed, as I observed firsthand how compliance failure was actually a quality failure. Then I began to view the Quality Improvement Department as the “protectors” of the health care organization, whose function it was to find solutions so the organization could remain in good standing with regulatory agencies.

Thankfully neither of those two viewpoints describe my current viewpoint, as I came to realize that quality drives excellence and the Quality Improvement Department is really the department that leads the organization in the changes necessary to become a true organization of excellence.

Sierra Tucson has a long history of providing cutting-edge treatment that results in excellent patient and resident care. As health care has changed, it is not just the provision of that cutting-edge treatment, but it is also the documentation of the care that is given that showcases excellence in treatment.

Quality is described as the standard of something as measured against other things of a similar kind; its degree of excellence. Quality at Sierra Tucson is being able to quantify that excellence, measure it, and then inspire, nurture, and drive improvement to showcase it.

To that end, the Quality Improvement Department at Sierra Tucson, which includes quality, risk management, compliance, patient/resident advocacy, and medical records, has made a wide range of improvements that have proven to display the excellence that embodies the treatment at Sierra Tucson.

These improvements include everything from minor issues like chart dividers and permanent file folders (which improved access to documents within the charts), to major projects like audits and surveys. Here are a couple of these projects that highlight that drive to a higher level of excellence:

A multidisciplinary peer review system was implemented this past year, which has improved documentation and systems in each of the clinical departments. Typically peer review is limited to the Medical Department in a health care organization. We expanded peer review to include Nursing, Clinical, and Quality Improvement departments. We asked these divisions to create a quality review based on the areas they wanted to monitor or improve. From a quality improvement standpoint, the review is based on the overall quality of different perspectives of treatment, such as discharge plans. Discharge planning spans multiple departments, so the quality peer review looks at the discharge planning from a more global view.

In the peer review audit process, each department designates a staff member who is able to review the chart from that discipline’s perspective. Charts selected for the peer review process are 100 percent of the charts that comprise our atypical discharges, including AMAs (Against Medical Advice), administrative discharges, medical and psychiatric transfers, and re-admissions to the hospital level of care. Additionally, the chief executive officer, chief medical officer, chief operations officer, or the director of quality improvement can request a chart to be submitted for peer review due to complaints, process or system review, or other related concerns.

Data from the peer review audits is aggregated, analyzed, and reported to our Clinical Quality Committee, which is comprised of representatives of each of the clinical departments and the Quality Improvement Department. As the data is reviewed, the director of quality improvement then identifies trends and requests action plans to address those trends. The committee also discusses these trends in relationship to processes and systems that are in place and determines which improvements can be made to specific areas.

An example of a system-wide improvement that resulted from this process is the documentation of discharge plans. Often, residents would receive a discharge plan from their therapist or continuing care coach, but created their own plan for discharge. Since the discharge planning process spanned multiple departments and functions, the actual final discharge plan was not consistently documented in the chart. The medical team first identified the problem, and then created a form that helped them document their portion of the discharge process. The clinical team followed, using the medical team’s format, creating a discharge note that documented the process from the primary therapist perspective. After a few months, it was clear that the discharge plan/destination was not consistently documented by the nurse (usually one of the last staff members to have contact with a discharging resident), so the Nursing Department, using a combination of the formats from medical and clinical, developed a form that captured the discharge process from the nursing perspective.

Another value of the peer review process is that the reviewers have the opportunity to discuss the cases with each other, and identify cases that might benefit from a review by the medical director. So from the peer review process, we developed the Medical Director Review process, which is a review for practice and/or process and can be triggered by the peer review process or by complaints or concerns. These cases are then reviewed by the medical director of designee, usually a psychiatrist, who can review the case from a practice perspective. These reviews are kept confidential and are used to improve practice and training for staff.

Another project that the Quality Improvement Department has spearheaded is our Resident Satisfaction Survey process. Most health care organizations survey residents’ satisfaction at the end of their treatment experience. While these surveys are helpful as a retrospective review and can be used to drive improvement in the future, they are not effective for intervening in poor patient/resident experiences, nor do they give detailed information specific to departments or processes in individual organizations.

Sierra Tucson is fortunate to have a Quality Coordinator in our Quality Improvement Department, who has developed surveys designed to capture the resident experience. One such survey is the “Mid-Treatment” survey, conducted by our patient advocates, which allows us to keep up to date on the trends of satisfaction in real time. From this survey, other survey tools designed to assist the staff on keeping up with the pulse of resident satisfaction in more definitive areas are developed. This process has resulted in improvements in food service, programming, scheduling of individual sessions, and changes in activities.

Another project we implemented over the past year has been the “Golden Pen Awards,” which are given to clinical, medical, or nursing staff on a monthly basis. Too often we rely too heavily on the monitoring of what is wrong in documentation, forgetting that the rewards are a higher motivator. Each month the Quality Improvement, Risk Management and Utilization Review departments nominate staff members that demonstrate excellence in documentation. The awards include a nomination award or a “Golden Pen Award” certificate and a “gold pen.” While this monthly award system seems a bit simplistic, it has prompted staff to ask how they can improve their documentation and demonstrate excellence. Since May, there have been over 60 staff nominations for this award, resulting in some positive energy around the entire process.

The goal of the Quality Improvement Department at Sierra Tucson is to provide a foundation of quality upon which to build a resident’s experience. All of our individual efforts, combined with our team efforts, are focused on improving quality to drive excellence.

Psychodrama at Sierra Tucson

psychodrama experiential therapyBy Bill Coleman, LMSW, TEP
Resident Psychodramatist

Psychodrama at Sierra Tucson has a long history. It has been offered since the opening days in 1983 and long considered one of the most powerful forms of group therapy.

Not easy to describe, psychodrama can be classified as experiential therapy. It is essentially role-playing, where disturbing and inhibiting forces on the inside of an individual are manifested on the outside, in the form of roles. It works with any condition, including addiction, mood disorders, trauma, pain, and eating disorders.

The method was created by J. L. Moreno (1889 – 1974), a Romanian-born physician trained in Vienna, Austria. Moreno was intrigued with ancient Greek theater and the concept of catharsis; yet, he felt it was too rigid and scripted. Over a 10-year period, he combined what he called psychodrama with the fundamental dynamics of spontaneity and creativity. He brought the method to the United States in 1925 and continued to expand and refine the process. Shortly after his death in 1974, a formal regimen of training and certification was instituted by the American Board of Examiners in Psychodrama, Sociometry, and Group Psychotherapy. Full certification as a certified practitioner currently involves 780 hours of training, facilitating a group under supervision for a year, and a five-hour written essay exam, as well as being observed by certified trainers and maintaining a graduate degree in mental health or a related field.

Why It Works

Most therapies work from the top down. First, identify the dysfunction and then use a variety of cognitive, analytic, or symbolic therapies to modify the accompanying behaviors. These approaches are well established and thoroughly researched, and Sierra Tucson residents engage in many of them with considerable success.

Psychodrama, as practiced at Sierra Tucson, works from the bottom up. It incorporates current neuroscience discoveries and seeks to drill down to the most fundamental developmental structures that are driving the dysfunctional states, even into adulthood. All children, when victimized by intolerable stress, will create psychological defenses designed to explain and protect. Such defenses will be created from the child’s world and thus, seem irrational to an adult. Nonetheless, they are some of earliest neural pathways formed in the child’s nervous system. Also, the child’s brain (again, when subjected to intolerable stress), converts itself from being a learning system to becoming a survival system. The resultant fear-driven and shame-based neural pathways (roles) are carried through regardless of age and they remain irrational. Psychodrama seeks to ameliorate these fundamental primitive conditions by treating them as unwanted neural pathways and building new ones. This is done by presenting the unwanted pathways as roles, extracted from the mind and placed in an empty chair. From there, they can be interviewed and the resident begins to develop autonomy over the role.

How It Works

In a group setting, an individual sits in a chair – separated from the other group members – and is asked to become the very thing he or she wants to change. This is initially confusing, but with a series of simple questions from the Director, the person quickly assumes the role. An example of such questions might be:

Director: “Please tell us what you are.”
Resident: “I am Alicia’s shame.”
Director: “Are you a big thing in her life?”
Resident: “Immense.”
Director: “Did you get up with her this morning?”
Resident: “I’m always there.”
Director: “Did you go to breakfast with her?”

The interview progresses from there, with questions about what you, Alicia’s shame, do for her, how long you have been around, how you came into existence, etc. It is important to note that the interview is not designed to explore the resident’s past traumas, but rather, the outcome of his or her trauma (in this case, shame).

The Director then asks the group if they would like to ask Alicia’s shame a question. This serves to draw the group into the process. Finally, at the end of this section of the psychodrama, the resident selects a group member to sit in the “shame” chair. The Director re-interviews “shame,” having the group member repeat what was originally said by the resident.

But that is not enough. The resident must begin to create new neural pathways experientially. The resident, as herself (in this case, Alicia), moves through three positions or empty chairs, which resemble the Procashka Stages of Change. The objective is for the resident to complete three different statements that represent neural pathways. These statements are: (1) “I am not willing to give up my shame because ____________”; (2) “I might be willing to give up my shame if I ___________”; and (3) “I am now completely willing to give up my shame because ________________.” The resident asks group members to sit in these chairs, in the role of the resident herself, and repeat what was said while the resident listens.

There is a very critical end-piece. All the chairs are removed with the exception of the shame chair still occupied by a group member playing that role. The resident is asked to identify actual people in her life who truly “get it” and can be helpful in overcoming her shame (i.e., sponsor, therapist, family member, friend, Higher Power, etc.). These people, chosen from the group, form a line in front of the resident, blocking shame. The resident is asked to stand behind each group member and give a supportive statement, which the group member then repeats.

Finally, holding hands, the group forms a circle around the resident and repeats their unique statements while rotating the circle. The resident is asked if she wants shame inside her circle. The final action is to have the group “group hug” the resident.

As mentioned above, simply describing this process in a narrative may not make it easier to understand and cannot communicate the extraordinary power of the psychodrama experience. Of course, this is true in all therapies.

A Healing Place

There is no one single therapy that resolves life-long difficulties, which is why Sierra Tucson is centered on the idea of integration. Truth be told, we don’t know exactly what combination of therapies are going to work for any one individual. We are, however, confident that, when given a little willingness, our residents will find their own pathways to health and wholeness. Or, put in recovery terms, a place in which they are happy, joyous and free.*

*Alcoholics Anonymous (“The Big Book”), p. 133