Welcome to the March edition of TIPS and TOPICS. Spring is in the air for us here in California, but not yet for other parts of the country; and certainly not for our readers Down Under. Sorry that autumn is coming for you, unless you like cold weather, which I do not as I get older.

SAVVY
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Tips:

• Uncover the values and hidden attitudes of your current Discharge Categories

B. Discharged but with minimal participation
We have all worked with people who sign themselves into treatment, and then seem to do the bare minimum to participate. You feel like you're pulling teeth to elicit any meaningful investment in treatment. The time comes when you feel that enough is enough. Either the clock has run out - if you are a fixed length of stay program - or you feel like you are getting nowhere, so might as well discharge the person. So "Discharged but with minimal participation" seems to be a reasonable category.

But think about it.

If the client or consumer is so passive in their participation ----
Then there's a good chance the treatment plan and services you are providing are not meaningful to the client. If you are doing all the work, the treatment plan may be your plan, not the client's. So rather than discharging the person, the treatment plan needs re-working. Fresh and new conversation with the client is essential to craft a different approach - one in which the client is invested, and one they are willing to actively implement.

C. Transferred to another service
If the client wants treatment, but not at the current level of care-----
Then the new plan may mean transfer to another service or site of care within the continuum of care. That may make sense to do. Weigh it up. If you frequently transfer people to other services away from your agency, consider why it is you are repeatedly losing clients to other programs. It could mean you are not providing the services needed. Perhaps it's time to re-look at your Mission Statement, examine if it needs broadening.

If the client has changed his/her mind, really doesn't want treatment any more, and chooses no further treatment----
Then the Discharge category is just that: Chooses no further treatment.

• There are times when it is appropriate to ask a client to leave - when the client is doing time, not doing treatment.

D. Left at staff request/discharged for noncompliance
SAVVY tip 2 addresses this. I believe "Left at staff request/discharged for noncompliance" is an ill- advised Discharge category. Here is why.

If the individual is not making sufficient effort in his/her recovery plan, and your impulse is to invoke this Discharge category-----
Then first check to see if you have a "customer" for the treatment plan. If a person is not adhering to the plan, it may be a lousy plan. It needs to be renegotiated and changed with the client.

If the client knows what to do, but doesn't want to do it-----
Then they are choosing no further treatment. The client has chosen to leave. They are not a "bad client" whom you must now discharge for being non- compliant. For example, if a client is struggling with substance use or depression or both, your experience and expertise tells you total abstinence, therapy or antidepressants are the preferred treatments to recommend. You expect client compliance with proven methods.

The client however believes controlled use or less use would work for them; or therapy only but no medication; or medication but no therapy. If the client is not in imminent danger of harming himself or others, we cannot override his will. However we do want to work with the client to try to attract him into recovery.

What exactly does "attract" look like?

The clinician and client collaborate, for example, on a controlled drinking experiment; or a 'therapy with no medication plan' or vice versa. Together we agree if that plan works, then we continue the plan- i.e. if the substance use is in control or the depression is lifting, then we continue the existing plan. However, if the outcomes are poor, the substance use is still causing problems, the depression is worsening, we must change the plan in a positive direction. The client agrees to this.

What if it becomes clear the plan is actually not working, yet the client still insists on doing the same unsuccessful strategies? If the outcomes are not improving, the client is doing time not treatment. This is the time to make a shift - either to a "no treatment" monitoring/treatment plan or simply a "stopping of treatment" plan.

A "no treatment" treatment plan means we are not pretending to do treatment. We are merely monitoring the person for safety, a person who may have a severe and persistent mental illness.
A "stopping of treatment" plan means that the client and clinician agree to disagree, and therefore discontinue a treatment relationship.
For example, with mandated cases, we inform the referral source we are no longer doing treatment. We believe continued use of the same strategies - unsuccessful to this point- do not qualify as active treatment. It is not useful, accurate and real feedback for the client to be under the impression that doing time in a program is doing treatment. The probation officer, judge, employer or child protection worker would call the question. It is their decision whether to invoke the consequences of non- adherence to treatment.

The bottom line is this. We are encouraging a collaborative treatment plan to which the client agrees to adhere. It is not a passive treatment plan or program with which the client will comply, or else be asked to leave.

E. Left against staff advice/AMA
This implies that the client had to 'vote' their dissatisfaction with the treatment by signing out, possibly after a tug-of-war with the staff. Should a client disagree with the plan and level of care, it is the staff's responsibility to initiate a review of the treatment plan with them. If you can design a new plan, one the client agrees to adhere to, then implement that. It may however involve a change in level of care or site of service.

What if no agreement can be reached with the client for a variety of reasons? Maybe the client wants treatment which is unethical- e.g. wanting large doses of methadone when objective signs indicate over- sedation or over-medication. It could be a client wants services beyond the mission of the program -e.g. the female client who wants her teenage children living with her in the program, when there is a necessary age limit for children. In these cases, the client does not have to sign out and leave. She has options. She can choose to continue services within the ethics and mission of the program. Or she can choose no further treatment at that agency where the services available are mismatched with what she wants.

The appropriate Discharge category would then be: Chooses no further treatment; or Transferred to another site of care within the continuum of care; or Referred to another agency.

SKILLS
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I received the following request from Bill Bauer of Burlington, Iowa:

"In the SKILLS section in Vol. 2 No. 10, last month on Q.1 on page 3 and Q.2 on page 4, you set up very practical examples for your lesson. I wish you had gone one step further and set out a treatment plan you would have used in each of those scenarios. What would you consider an appropriate treatment plan? I recognize from all you've written, it must be specific to the individual."

I get similar requests for more examples to help with documentation, so here are some ideas. Keep in mind that the principle is to have a treatment plan that speaks to the client and what they want help with. It isn't about wordsmithing the perfect problem, goal and treatment strategies.

• Tips on Q1. "How long do I have to be here and when will I be done?"

Here are the questions to explore with the client before documenting the plan.

-->What does the client want? To get her children back, not serenity and sobriety or excellent parenting skills. She may not even feel she has a drug or parenting problem. You then join the client in helping her get her children back. What will drive the plan is to prove to the child protection worker that she does not have a drug or parenting problem.

--> How will we prove that she is a good parent with no drug problem, and therefore fit to have her children back? Identify with the client the life areas and behaviors that would show her to be a responsible, non drug-using parent: a clean, safe living situation for her with the children free of any negative boyfriend relationships; adequate income derived from legal and safe sources; consistent control of substance use; and parenting skills to handle frustration, to exercise consistent discipline and limit setting strategies etc. If, as the child protection worker suspects, the client does indeed have a parenting problem along with a substance use problem, then that will reveal itself in poor outcomes of the service plan. If this is truly a collaborative plan, she will clearly adhere to this to prove her point. If it is your plan with which she must comply, don't be surprised if she's not invested in it.

What might that look like in a collaborative treatment plan?

Priority/ Problem #1: I want to show that I have full control over my substance use.
Goal: Demonstrate consistent, stable drug- free functioning.
Strategies: 1. Random urine drug testing to build a track record of consistent control of substance use.
2. Substance abuse group to share what leisure activities and friends she has and get feedback on whether these will help her control substance use or not.

Priority/ Problem #2: I believe I am a good parent with good child raising and coping skills.
Goal: Apply parenting skills in a variety of situations to strengthen and prove her parenting abilities.
Strategies: 1. Parenting skills group once a week to identify difficult parenting situations and discuss which ones she does well with and which ones need improvement.
2. Give several examples in her own family of how she applies those skills already.
3. Practice in role plays some of these tough situations to show how well she can handle them and/or get feedback on how to improve.

• Tips on Q2: Why do I have to come to all these groups and be here so often?

Here are some of the questions you ask yourself - your internal thought processes- before you get to writing down the treatment plan.

--> What does the client want? The focus is on helping the client to accumulate positive data that demonstrates her adequate parenting skills and drug stability. If there is a steady and consistent accumulation of data proving her adequate parenting skills, it will shorten how often and for how long the client will need to attend groups etc. If the data is trending in the opposite direction, that makes it impossible to decrease active involvement and attendance.

--> How will we prove that she is a good parent who has no drug problem and is therefore fit to have her children back? The various members of the team will monitor the progress of the strategies in the treatment plan. The parenting skills group leader will document to what degree the client is able to identify what she is doing well, and which situations she finds more challenging. If she is doing well at identifying and role-playing parenting skills, we will develop an increasing database of information that verifies she indeed is the good parent she believes, supporting her desire to get her children back.

However, actions like not showing for the group, passive listening, non-participation, or failure to offer to group her examples of how she is applying this already in her family, will make it hard to remove the parenting skills group from her service plan. Or if the client has several positive urine drug screens, even misses the appointment to get tested, it provides data in the opposite direction of demonstrating stability and control of her substance use.

What might that look like in a collaborative treatment plan subsequent to the initial plan?

Priority/ Problem #1: I am having trouble with positive urine results and control of my substance use.
Goal: Regain control of my substance use and identify what gets me off track.
Strategies: 1. Develop a log of when I use or have the strongest urge to use to identify what situations are most difficult.
2. In Substance abuse group get ideas on how others cope with the situation identified as most difficult.

Priority/ Problem #2: I am having trouble getting to groups consistently and sharing what I do well and not so well as a parent.
Goal: Identify what is interfering with consistent attendance and active participation about my parenting skills.
Strategies: 1. Review in an individual session what her usual day looks like; what strategies would help her show she is more responsible and reliable than it so far appears.
2. In Parenting skills group, be the first to speak up, so as to practice putting her needs first rather than passively waiting until an opening in the group process appears.

Bottom Line
It is not the specific wording to obsess about. Perfect wording is not what it's all about. It is about making the documentation and treatment planning process a conversation about what is important to the client, and how to get there from here. If it is not a living treatment plan that engages the client and strengthens the alliance, then it is just paperwork.

We need more peoplework-----not paperwork!

SOUL
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I won't quote the old thing about how few muscles it takes to smile versus how many muscles it takes to frown---- that is old stuff which might make you groan and frown. The other thing Seinfeld said that caught my attention was how much he enjoys what he does. I guess it is easier to enjoy that when he's not on a counselor's salary level. Nevertheless, his point was that a lot of people in show business get success, then complain about the paparazzi, or become mean and entitled. He does seem to enjoy what he does in a way that brings joy and smiles to a lot of us.

When the Seinfeld show first started, they had great difficulty convincing the higher ups that you could make a successful comedy show focused for 20 minutes on one subject like waiting in line at a Chinese restaurant. The conventional wisdom was that it wouldn't work. I'm glad Seinfeld et al persevered and believed in what they did. It has brightened the day for millions for years.

This all made me think about what I believe in, and how much I enjoy what I am doing. It also made me think about what action I need to take on anything I don't believe in or enjoy. I'll check my laughter meter on that to identify where to start. What are your numbers for today......400, 15 or 1?

STUMP THE SHRINK
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"I know there is no firm common consensus on what the criteria are for prognosis in addictions treatment. But we are required to give one to keep referents happy and as a result we do give our best 'guesstimate' based on our experience. For example I worked case management with homeless alcoholics for several years. What I would consider a good or improving prognosis would appear fairly grim for someone exiting intensive outpatient. When I worked at an inpatient facility for a fairly affluent clientele, it obviously required you to dig deeper into their state of being assessing beyond their outward appearance and resources. Thus I have worked with 'winos' who were recovering with more success than millionaires. We can't be afraid to say what we see and admit how a person's treatment went. When someone is able to run out their resources while in treatment, what's wrong with saying just that - we couldn't help them and from our experience it doesn't look very good for them. We have explained to them why we believe this. As care providers our professional/personal knowledge base tends to revolve around the people we serve that we have known that for years. We need to learn to trust it. Are the courts, probation departments, lawyers and insurance companies willing to accept this?

My response

I agree that we need to be straight forward with prognosis. I would try to stay with reporting level of function however, not comments about their compliance with a program we have constructed.

For example, I might say: "The client achieved and maintained abstinence (if that was one of the agreed upon goals of treatment); and that we verified that with family and random urine testing etc. The client's methods to prevent further uncontrolled substance use and drug related problems have worked in the course of treatment here. S/he has achieved a level of stability and does not appear to be in immediate danger of continued problematic use. However, the client never achieved agreement that s/he had an addiction problem and believes that s/he will have no further trouble with legal problems. Prognosis is questionable as the client's methods for avoiding further drug-related problems long term have not usually been found to be effective in the population of people we have served previously."

I know this is long winded, but it seeks to explain what the client has achieved and puts the emphasis on function, not completing a program. Also it does not simply say "Poor Prognosis" without explaining the rationale.

Until Next Time
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