TIPS & TOPICS 
Volume 2, No. 10
February 2005

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until Next Time

Welcome to the February (soon to be March) edition of TIPS and TOPICS. Thanks to all who write with comments and questions. I respond to as many as I can in a timely fashion, but please excuse my tardiness. I do read and appreciate all your messages.

SAVVY

I was recently reviewing some discharge categories that were being codified for an outcomes reporting system for treatment programs. What seemed like a straightforward task of finalizing five discharge categories, actually evoked some significant philosophical issues not obvious at first glance.

Tips:

    • Define the purpose and philosophy of your Discharge Categories.

How and what you select to measure and track depends on the purpose and philosophy underlying your discharge categories. Take for example the following list of Discharge categories, typical of many addiction treatment programs and that seem quite appropriate:

(a) Successfully completed all aspects of the program
(b) Discharged but with minimal participation
(c) Transferred to another service
(d) Left at staff request/discharged for noncompliance
(e) Left against staff advice/AMA
But consider the values that lie beneath some of them,or at least as I perceive them to be.

Take the first discharge category. “Completed” connotes to me a set array of program modules, phases or tasks that a client must do to “complete” the program. Clients often ask: “How long do I have to be here to complete the program?” when inquiring about treatment, especially a residential program. Or families or referral sources will ask: How long is the drug rehab program before he completes and graduates? Some programs are designed for a person to be in Phase 1 for “x” number of weeks or sessions; Phase 2 and Phase 3 etc. We “graduate” someone who has successfully completed all aspects of the program.

Sometimes a person uses a substance or relapses while in treatment. Some programs then restart the individual back at the beginning of Phase 1- i.e. they must redo the program. Clients are heard asking just that: “Do I have to start at the beginning again? Can’t I get credit for the two weeks I was already here for?” If your program’s philosophy centers on presenting the client with a discrete set of modules, therapeutic tasks and experiences to comply with in order to graduate, then Discharge Category (a) fits.

However, if you see substance use disorders as biopsychosocial and multidimensional; if you notice that clients present with a variety of needs, then a client requires an individualized service plan. What does this mean? There would be an array of services and tasks geared to fit the strengths, preferences and needs of the client and his/her family. How long does a person stay at any one level of care within a broad continuum of care? This depends on the client’s response to treatment, on the progress and outcome of the strategies agreed upon in the collaborative service plan.

Discharge category (a) would read something like:
>> Successful and maximum benefit achieved at this level of care.<<

What does this language connote?

> That there is an individualized service plan for this level of care.
> This service plan was designed and modified -as necessary- to address the client’s needs, only safely provided in this level of care.
> That there is a continuum of services.
> That the goals have been reached.
> Now the client has successfully achieved the maximum benefit from those services, they are ready to be discharged, or more correctly, transferred to the next level of care.


Stay tuned for the March edition of TIPS and TOPICS when I will look at the other Discharge Categories above and critique the values underlying those.

    • Consider different Discharge Categories compatible with individualized, person-centered treatment within a broad continuum of care.

Here are some possible categories with their rationale. These begin to move away from program- driven discharge categories. See what you think. Perhaps you can think of better ones.

(a)Discharge (from professional care to peer-led aftercare and/or mutual and self-help support)
Rationale: The client is discharged from professional care (aftercare) when they are able to self-manage their recovery sufficiently. All they need to maintain their progress are support groups run by peers; or even to self-manage without support groups.

(b) Chooses no further treatment
Rationale: The client does not want further services from you or your agency. Motivational enhancement strategies are used to engage the client. Multiple attempts have been made to collaborate and individualize service plans to address the client’s preferences and needs. Results have shown further changes in the plan are needed to reach the client’s goals. However the client is not interested in pursuing that with you or your agency.

(c) Dropped out – unable to contact
Rationale: Active attempts to reach client have failed. Clients “no show”, repeatedly miss outpatient appointments, walk off from a residential or inpatient program, or not return from a community visit. Rather than document “No show, no call” three times in a chart followed by a letter terminating the client, you try actively to reach out to the client and family by mail, telephone or e-mail. When these continue with no success, then this discharge category is appropriate.

(d) Referral to another agency
Rationale: As much as possible we strive for continuity of care, and to maintain the therapeutic alliance. However if the needed services are not available internally in your agency, then the client may have to be referred elsewhere.

(e) Transferred to another site of care within the continuum of care
Rationale: To continue needed treatment, the client is transferred because you do not have that level of care at the same geographic location of your agency. The continuum of care is available within your organization however. If the needed level of care is not available in your organization, then you would use category (d) ‘Referral to another agency.’

Stay tuned for the March edition of TIPS and TOPICS. I will suggest some implications for your assessment, treatment and program philosophy of each of these suggested Discharge Categories.

SKILLS

Q.1 “How long do I have to be here and when will I be done?”

I don’t know. It depends on what you want that made you decide to come here today, and how we can help you get that, and whether it works or not. We don’t have any set program or length of stay. You and I have to work together to create a plan to get you what you want. How long that takes depends on how well the plan works or not, and whether you are achieving the goals we agree on. What do you want?

Here are some implications of this kind of response:

    • If you have a set program, and an agency culture of a fairly fixed length of stay, then obviously you cannot respond as I did. So then ask yourself: “Do I believe in assessment-based, individualized, collaborative treatment? Or program- driven treatment with prescribed phases and tasks with which the client must comply?”
    • Do you indeed want to know what the client wants? Or are you more focused on what you think the client needs? Or what the probation officer or employer or Employee Assistance Program or family member or judge wants? I suggest that if the client sees no link (in their heart) with what the treatment plan and program tells them to do and what they really want, then they will be merely jumping through the hoops and complying with the program.

  • For example: What the client wants may be 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. (To the judge and child protection services worker, these problems are so clear and obvious.) You may want to “join” strategically with the client around the goal of helping her get her children back. She will need to prove to the authorities – as she believes- that she does not have a drug or parenting problem. You as counselor will collaborate with her in developing a convincing service plan. At the time of intake, you don’t know how successful that plan will be, nor how long it will take. And that is why I answer “I don’t know” when she asks: “How long do I have to be here and when will I be done?”

Q2. “Why do I have to come to all these groups and be here so often?”

You don’t have to. What do you want again? And what are we working on together? The only reason we had agreed on all these groups and how often you come here was because it seemed that this plan would help you get what you want as quickly, safely and as effectively as possible. But if this isn’t making sense to you, we can change the plan and how often you come. Which groups don’t make sense and how often were you thinking you might want to be here?

Here are some implications of this kind of response:

    • What drives the individualized service plan is what the client is a “customer” for. What is it that they really want? If we are trying to gather data to show there is not a drug or parenting problem so we can help her get her children back, then each group, activity or random urine drug screen should make sense to her.

    • For example:  The parenting skills group we fashioned into the service plan was suggested so she could listen to parenting skills education. She then was going to discuss with the group and group leader how she was already well-skilled in all of the topics raised. She would then offer several examples from her own family of how she applies those skills already. The group leader’s job would be to document those examples. The purpose would be to develop an increasing database of information verifying she indeed was the good parent she believed, thereby supporting her desire to get her children back.

  • However:  When she does not show for the group, or passively listens with no participation, does not bring to group her examples of how she applies this already in her family, it makes it hard to remove the Parenting Skills group from her service plan. “Are we still working on getting your children back? Because, I would be happy to drop Parenting Skills group from your plan and not have you attend so often. But so far, the data is looking like we don’t have a strong case together to make them confident to return your children. Are we still working on getting your children back, or are you maybe thinking you don’t want them back? Because when you don’t show to group and don’t participate, it makes you look like you aren’t very interested in building a strong case for yourself.”

SOUL

This month has been a heavy travel month. It began with a trip to Germany to train a group of counselors serving adolescents in US military bases throughout Europe. So I didn’t have to speak German, dankeschön (Subtitle: thank-you). Then onto Italy to enjoy Venice and Bologna with our son who lives with four Italians doing his junior year of college, where he does have to speak Italian all day -wow! (Subtitle: wow). Michigan, Maui and Las Vegas round out the month.

“So what’s the point? Trying to make me jealous of the interesting places you have been?”

Not really. Even with all the travel I do, there is still a part of me in awe of how modern day travel opens up so many incredible opportunities and experiences. It’s hard to resist sharing the amazement of being in one culture one day, and then transported to a very different one the next day. Or to take in the astounding costumes of people from all over the world parading in the charming, narrow streets of Venice during Carnevale. Or to watch a whale fluke and dive in the middle of a training in Maui. Or to see the lights and sights of Las Vegas.

It is so easy to get caught up in the constancy and confinement of the real demands of everyday life and work. I fight this not too successfully every day, especially when you run your own business. But others face this with the real demands of being a single working parent, or taking care of a sick parent or loved one, or working hard to decrease that waiting list and meeting tremendous service needs, or counseling those suffering from all kinds of physical and behavioral health distresses, or just surviving with their own ailments that rob them of vigor and joy.

Travel works for me in seeing the bigger picture – to catch a glimpse of how we are viewed through European eyes; to witness what brings joy to others who journey from far and wide each February to parade in the streets of Venice amidst freezing temperatures so others can photograph them in their incredibly elaborate costumes; to be in awe of the power of nature and the whales; or to be sobered by the contrast of the excess of Las Vegas and the homelessness in the streets not far from the Strip.

But travel doesn’t have to be the only way to broaden our horizons. For some, one’s faith or religion helps do that. For some it’s reading or the news or the internet or TV shows or movies. Or community service, or support groups, or whatever you find maintains your balance. For me, I have to be literally transported out of my usual environment to jolt me into re-viewing the world and getting things back in perspective. What works for you?

STUMP THE SHRINK

Question:

An adolescent counselor asked me this month about a young woman with whom she had been working for six months in their intensive outpatient adolescent treatment program. The client continued to show positive drug screens and said that she planned to keep using marijuana even after the program. Thus, the client said, the counselor might as well “complete” her from the program to which she was mandated, as she wasn’t going to change her mind about using anyway. The counselor questioned: How can I “complete” her and discharge her when she is still using and plans to keep using anyway? But then what do I do? Do I just keep her in the program when she hasn’t changed her mind in six months?

My response:

You are right, that if your goal is to keep the young woman in the program until she admits to having a drug problem, accepts and changes her life in hopeful sober recovery, then it would be hard to discharge her as having “completed” the program. However, the client has clearly said that she is not interested in that, and plans to continue to use whether in the program or not. But what does the client want that keeps her coming to the program for six months? What the client wanted was not to have her probation violated and be placed in juvenile hall. What the referral sources and family wanted was for the client to get into recovery for the drug problem they clearly see.

The focus of collaboration around the service plan needs to be on:

How are we going to get these people off your back and not send you to juvenile hall? How do you plan to show them that you don’t have a drug problem and gather the data that reassures them that you are not going to get into more trouble with drugs? When you keep showing positive drug screens I have a hard time sending them a letter that you have drugs under control. I can’t stop you using, and if that is what you say you want to do, I am willing to just tell them that there’s no need for you to be here in this addiction treatment program, as you don’t plan on stopping anyway?

She may then say something like: “But then they would violate me and send me to juvenile hall, which I don’t want.”

Right, I know and I thought that we were working hard on getting them off your back and not letting juvenile hall happen to you. So what shall we do? I can’t complete you if that will just let things blow up, get you violated and back in juvenile hall. How about we concentrate on proving to them that you don’t have a drug problem that they have to worry about, and then we can get them off your back. So we have some planning to do and brainstorming together to develop a plan that works and proves that drugs are not a problem for you.”

The focus then is not on “completing the program” but demonstrating sufficient understanding and stable control of substance use that we can give a report that reassures significant others and rules out the need for juvenile hall.

Until Next Time

Look for Savvy and Skills in March. Stay Tuned. To be Continued.

David