TIPS & TOPICS from David Mee-Lee, M.D.
Volume 7, No.10
February 2010

In this issue
— SAVVY   Guiding Principles for Treatment Planning
— SKILLS   Documentation that Makes Sense to Clients
— SOUL Sudden Death and Living Each Day
— STUMP THE SHRINK  Missing appointments and Drug Courts
— Until Next Time

Welcome to the February edition of TIPS and TOPICS.
The content of my previous website is almost fully merged with The Change Companies revamped website with still a few items to post. You can find TIPS and TOPICS Archives if you click on “Tips & Topics” at The Change Companies home page- www.changecompanies.net.  The complete Search function is still being put in place. Stay tuned.

SAVVY

This month I have been training organizations on treatment planning and documentation.  Through the years of Tips and Topics, I have covered this topic several times however it’s always worthy of addressing again.  Here are some guiding principles to help you develop treatment plans (or service plans, recovery plans- whatever term you use) which make sense to clients and which really functions like a “living document”.

Tip 1
Think of a treatment plan as a “written expression of the therapeutic alliance” with the client.

The therapeutic alliance is:

• agreement between you and your client on goals
• agreement between you and your client on strategies and methods to reach those goals
• occurring within the context of an emotional bond with your client. (Miller, Mee-Lee and Plum).

As a clinician you might mistakenly develop a treatment plan with:

• the goal of abstinence and sobriety when your client has the goal of getting off  probation.
• strategies like attending Alcoholics Anonymous meetings plus a relapse prevention plan when your client doesn’t like AA, and moreover doesn’t even think he has an addiction problem.
• no real therapeutic relationship or “buy-in” from your client

Your treatment plan now has become a written expression of what you, the clinician, thinks is the best plan – certainly not one that your client is likely to put much effort into.

Tip 2
Helping clients get what they want from treatment involves assessing both strengths and liabilities, resources and barriers.

Start by clarifying what is most important to the client. Assess what has worked and not worked before in your client’s previous attempts to get what they want.  Understanding these strengths and barriers leads to priorities and strategies to be addressed in the treatment plan.You may be fortunate to have the perfect client who is totally motivated to never again be psychotic or manic; or someone totally committed to sobriety and recovery.  In such cases, the treatment plan is easy to develop.  The client will be open to do whatever you prescribe and put in the treatment plan because they are eager to follow whatever will work for them.Usually however, clients are filled with much more ambivalence about whether they have a problem – whether a mental health, addiction or co-occurring disorders one. Their goal for treatment may be a concrete one- to obtain housing, find a job, get their children back from Child Protective Services, retain an existing job, or keep a relationship intact. It’s obvious to us that there is a link between their mental health or substance use problems and their inability to succeed in these areas of life, but they do not themselves see the connection. They fail to see that what they’ve been doing is not working.  For example, they don’t recognize that their severe substance use has resulted in so many missed days at work and has lost them jobs.  Or your client can’t end the relationship with her drug-dealing boyfriend even when a part of her knows this relationship is unhealthy and really jeopardizes the chances of getting her child back.

In such cases, the treatment plan becomes more of a motivational “discovery” plan rather than a relapse prevention “recovery” plan – helping the client “discover” the relationship between their substance use and their repeated loss of relationships or jobs.

Tip 3
In Inpatient and Residential settings, the Treatment Plan should focus on whatever will reintegrate the client into the community, plus prepare them for continuing care in outpatient settings.

Historically, inpatient mental health and residential addiction treatment emphasized assessment plus treatment of intrapsychic and interpersonal psychopathology.  A long inpatient stay was seen as the place to break down a person’s defenses, and then, over time, rebuild healthier internal and interpersonal relationships.Most change is self-change where “treatment is an adjunct to self change” (DiClemente).  Thus the focus of treatment planning in inpatient and residential settings is to help the client address whatever ineffective coping skills landed them in a 24 hour setting. It is not the time for a total psychological makeover, trying to resolve all the underlying personal and interpersonal problems.

For example:
When depressed, is the client so impulsive that the only way she can cope is to cut herself?  Can she phone a supportive friend when she feels the impulse to cut & physically go and be with them? Does she have some other self-calming strategies to draw on? What has worked before when she was depressed but did not act self-destructively?  The focus of the treatment plan should not be on investigating and resolving all the roots and history of her depression.  That is the focus of outpatient treatment.

References:

1. DiClemente CC (2006): “Natural Change and the Troublesome Use of Substances – A Life-Course Perspective” in “Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It” Ed. William R Miller and Kathleen M. Carroll.  Guildford Press, New York, NY. pp 91; 95.)

2. Miller, S.D., Mee-Lee, D., & Plum, B. (2005): “Making Treatment Count: Client-Directed, Outcome Informed Clinical Work with Problem Drinkers.”  In J. Lebow (ed.).  Handbook of Clinical Family Therapy. New York: Wiley.

SKILLS

The following SKILLS tips may help you individualize the treatment plan. However, the ultimate guide to what you document is your client. It is, after all, their life and their service plan.

Tip 1
Before you document any problem statement or issue in the treatment plan, ask yourself: What Made Me Say That?

• When Problem statements or Needs, Concerns or Issues are documented, they often become very generic, and begin to sound like other clients’ problems, like every other treatment plan. Nothing seems unique, particular or individualized. Read out the potential problem statement you are about to write down and ask yourself:  What Made Me Say That?  If you can immediately answer that question with something more specific to what your client said or what your assessment indicated, then that is what you should write down. It should not be abstracted back one or two levels to a generalized, generic problem.

• Example:
  Perhaps you have an impulse to write: “Lacks positive support recovery environment”.  Ask: What Made Me Say That?  If the immediate response that comes to mind is: “He lives with a drug dealer and sees no problem with that, but does not want to be re-arrested”, then that is the way to document the problem or issue.  Or the immediate response that comes to mind is: “Her husband beats her up, but she can’t bring herself to leave him”, then that is the problem to write down. It is straightforward, direct and concrete, not abstracted to a generic level like: “Domestic violence and Relationship problem.”

Tip 2
Involve your client in the wording of the Problem/Need statement and the Goal and Strategies.  This should make sense to him/her, not just to an auditor or your supervisor.

• Don’t struggle alone with what to write.  Collaborate with the client on wording/ phrasing that accurately makes sense to him/her.  Here is an example:
• What does your client really want? To get her children back, not serenity and sobriety or excellent parenting skills. Neither of these things are on her agenda.
  She may not even feel she has a drug or parenting problem. Respect that viewpoint, and “join” with her to help her get her kids returned to her. The way this will be done is by “proving” to the child protection worker that she does not have a drug problem or a parenting problem.
• How will we prove that she is a good parent who has no drug problem and is therefore fit to have her children back? Identify with your client the life areas that would demonstrate her being a responsible, non-drug using parent- i.e:
  * a clean, safe living situation for herself and the children, free of any negative boyfriend relationships
  * consistent control of substance use
  * an adequate income derived from legal and safe sources
  * parenting skills to handle frustration, exercising consistent discipline and limit-setting strategies etc. If, as the child protection worker suspects, the client does indeed have parenting problems and a substance use problem, then that will be revealed in the poor outcomes of the service plan. In the meantime while the outcomes are unfolding over time, you have created a collaborative plan with your client.  You are working in a way that has active “buy-in” and she is more likely to “adhere” actively to the jointly-created plan versus passively and resentfully complying with your plan.

• How would that treatment plan be expressed in writing?

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. Attend substance abuse group and share about what leisure activities and friends I have. Obtain feedback on whether these will help me 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.  Discuss which ones I do well with and which ones need improvement.
2. Give several examples in my own family of how I apply those skills already.
3. In role plays practice some of these tough parenting situations- to show how well I  can handle them and/or get feedback on how to improve.

Tip 3
In an acute psychiatric setting, a client may be too disorganized or psychotic to collaborate in treatment planning.  In this case, the focus of the initial plan is on stabilization and engagement as soon as possible.

The tendency in such cases might be for the team to enforce medication compliance and delay more active attempts to engage the client about what is important to them.
The plan might look like this:

Priority/ Problem #1:  Jane is so disorganized that she cannot have a conversation about what she wants yet.
Goal:  To stabilize Jane’s mental status sufficiently to be able to engage her in planning for her life
Strategies:

1. Psychotropic medication to stabilize the psychotic illness.
2. Staff to attempt a five minute conversation each shift to see if Jane can say what she wants from the treatment team.

SOUL

When you leave your home each day, rarely do you think: “I may not see my loved ones or friends ever again”. The optimism of life and hope is a good thing, for to be morbidly pessimistic every day is the stuff that depression and anxiety is made of.

But today as I write this, I have strong reasons to be depressed, saddened, stunned and shocked. Twenty four hours ago I had a positive and productive training and consultation meeting with two treatment agencies in Delaware.  We brainstormed about how to better meet the needs of transitional age youth as they aged out of the child mental health and juvenile justice system but often fell through the cracks before getting engaged in the adult system. Two directors of Alcohol and Other Drug Services and Behavioral Health Services crafted solutions that held hopeful potential for better care for youth.

I was impressed with the commitment, vigor and competence of the team discussions and these leaders. I looked forward to seeing how these systems solutions could work for the improved care of the young people with co-occurring disorders. I looked forward to future meetings with these leaders to help in any way I could to support their good ideas. On returning home to California, I opened my e-mail and could not believe the message.

Just hours after our meeting yesterday morning, these two fathers, these two directors, these two family men were instantly killed when an aggressive driver crossed the median and hit them head on.  The loss to their wives and children, the treatment field and to the people they serve and served with is heart-breaking.  And as one of their colleagues said: “The loss of all that could have been is so devastating”.

Not for a long time have I been so close to death; and certainly not the kind of shocking reality when just hours before I was working, joking, brainstorming and planning with men who I will never see again. Yesterday I saw their smiling faces and optimistic commitment and cannot believe they are gone.

Each day, the gift of life presents us with the opportunity to live that day to the fullest.  And to hug your loved ones.

STUMP THE SHRINK

Question:

“Hi Dr. Mee-Lee:

Our question is about how to handle clients in our Drug Court program who continue to miss groups and scheduled appointments.  Most of the staff uses motivational interviewing techniques and yet many of our drug court clients miss a lot. How would you recommend handling this with the court?
Thanks for any thoughts!”

Henrietta Whelan, MSW, LISW-S
Clinical Services Director
Bayshore Counseling Services
hwhelan@bayshorecs.org

My Response:

Hi Henrietta:

Clients mandated to treatment agree to comply with the court’s expectation to do treatment instead of the usual criminal consequences for their illegal behavior.  The assumption is that their criminal behavior is due to a mental health, addictive illness or both.  As such, treatment may help a person embrace recovery, decrease legal recidivism, increase public safety and the well-being of children and families.  These are both clinical and criminal justice goals we all embrace.  However, if the person does not do treatment (missing groups and appointments etc.) then treatment is not happening and the person is non-compliant with court orders and should be sanctioned.

With overcrowded prisons and overworked probation and parole officers, courts can sometimes be inconsistent with sanctioning people who are not doing their treatment.  If the court does not follow through (with sanctioning people who do not do the treatment they agreed to do) then your clients will continue to miss groups and appointments.
A parallel: It is just like a parent who threatens to ground their daughter if she breaks her curfew, and then does nothing when it happens.  Pretty soon, the child knows that there is no reason to take responsibility and no need to honor her word to be home on time.

If the person is missing appointments and groups because they are so mentally unstable or so unable to maintain abstinence that they need more intensive treatment- whether mental health, addiction or co-occurring disorders treatment- then that is what should be the next step.  But if the client has learned that they don’t really need to do treatment and that missing appointments has no consequences, then more intensive treatment is not what is needed.  What is needed is more work with the courts to look at why they are not sanctioning non-compliance with court orders. A parallel: The real work should not be directed at the adolescent when the parents are inconsistent with limit-setting.  In this case it’s essential to work first with the parents and their ambivalence around setting limits. Work with the adolescent will unfold after that.

Hope this helps,

David

Until Next Time

Thanks for reading. See you in late March.

David