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March 2022

What to report to Probation and CPS; Dilemmas about drug testing; Client-centered doesn’t mean client anarchy; Win, lose and win

In SAVVY, SKILLS and STUMP THE SHRINK, treatment providers can be confused about their role when clients are referred by Probation, Child Protective Services and other mandating agencies. Focus on improved function and skills, not compliance with assignments and phases in a pre-determined program. How to be “client-centered”.

In SOUL, increasingly I make no distinction between ‘wins’ and ‘losses’. A ‘win’ is an opportunity to discern what works and what doesn’t; and a ‘loss’ is an opportunity to discern what works and doesn’t.

savvy, skills, & stump the shrink 

When clients are referred for treatment by Probation and Parole or Child Protective Services, very few, if any, want to embrace recovery from Day 1. Their usual perspective is to do the minimum possible to comply with the mandating agency and get what they want: to get off probation supervision and/or get their children back.

Treatment providers can easily become confused about their role:

  • Are they enforcers of the mandating agency to get the client to comply with treatment? 
  • Are they to focus on therapy and help the person actually change to be no longer a threat to public safety or to become a better parent?
  • How much should they report on: should it just be information that the client is in compliance; or should they report on whether the person is actually working on being a more prosocial citizen or better parent?

In this context, the following STUMP THE SHRINK question addresses the dilemma about what to report to mandating agencies.

Question:

I have a question about working with clients who are sent to us by Probation Officers or Child Protective Services (CPS). We have had a very difficult time with communication. They want us to provide all information and we typically just provide a letter that states attendance and treatment recommendations. CPS especially has wanted us to provide everything, including assessments and lately has been wanting us to drug test their clients on their behalf which is not great. Is there a standard best practice in situations like this?

Thanks,

Executive Director, Behavioral Health Services.

Iowa

Tip 1

Focus on improved function and skills, not compliance with assignments and phases in a pre-determined program.

My Response:

Here are my thoughts on communicating with mandating agencies:

  • Go beyond just reporting about compliance with attendance and treatment recommendations.
  • Work together as a team with Probation and CPS to help your client get what they want.
  • For a client to get what they want, a motivational interviewing and enhancement approach will inevitably bring them to focus on their function and skills.
  • Treatment is about facing and deciding what to do about substance use, anger management, parenting skills, people, places and things to get what they want – not complying with a program, phases and rules.
  • You shouldn’t share the whole record for confidentiality reasons. But if you are working as a team on real lasting change, let the mandating agency know if the participant is working in good faith on facing their behavior, thoughts and skills.
  • Report on whether there is actual improved function and skills to not threaten public safety and be a better parent.

I have written much more on treatment and functional change; sanctions and incentives in the March 2016 edition of Tips and Topics

In the July 2017 edition, Tip #2, Question 2, I suggested how to balance confidentiality concerns with what to report about the client. (Sorry, the formatting of this older edition needs some work. So finding Tip #2, Question 2 might be like finding Waldo. But worth the search.)

As regards drug testing, that is something you should be doing clinically just as you would test a patient’s blood sugar levels in managing a person with diabetes; or blood levels of medication in monitoring effectiveness of treatments with schizophrenia or bipolar disorder etc. Drug testing is a lab test that helps monitor a person’s ability to control substance use, not just taking their word for it.

See previous editions of Tips and Topics for more on:

Tip 2

What Treatment Courts and other Mandating Agencies Should Expect from Treatment Providers

Participants mandated to treatment are varied and can present with addiction, mental health and physical health complexity. These diverse clinical presentations highlight the need for individualized approaches that treatment providers should be pursuing with the client:

(a) Assessment of each client’s multidimensional needs as per The ASAM Criteria six dimensions*. For example, assessing if a person is developmentally disabled and suffers from an intellectual developmental disorder (previously called Mental Retardation) is important compared with a person who has antisocial personality disorder or lifestyle and is very institutionalized and used to incarceration.

  • The person with intellectual developmental disorder has deficits in reasoning, problem solving, abstract thinking, judgment, learning from instruction and experience. They have very different needs from the other person.
  • The institutionalized person with antisocial personality disorder or lifestyle experiences sanctions like water on a duck’s back.

* 1. Acute intoxication and/or withdrawal potential                

2. Biomedical conditions and complications                 

3. Emotional/behavioral/cognitive conditions and complications            

4. Readiness to Change

5. Relapse/Continued Use/Continued Problem potential

6. Recovery environment

(b) Assessment and methods to enhance treatment engagement and good faith effort of the client in treatment. For example, participants with co-occurring mental and addiction issues will have more difficulty with engagement and have needs that require awareness of their multiple vulnerabilities.

  • Treatment plans need to be assessment-based and person-centered not program and compliance-based. 
  • Because of different client learning styles and their array of needs, any manualized and evidence-based curriculum may require adaptation to fit each client’s problems and progress/outcomes. 

(c) Outcomes-driven treatment. Is the client making progress in real accountable change? 

  • How is the participant changing in attitudes, thoughts, feelings and behaviors?
  • Are they demonstrating improved functioning that will increase public safety, decrease legal recidivism and increase safety for children and families?
  • Active credible treatment is not just about compliance with attendance and negative drug screens.
  • Is the client invested in a change process at a pace that fits their assessed abilities, stages of change and multiple vulnerabilities? 
  • Or is the client merely passively complying, which does not translate into lasting change and increased safety? 
  • How do we impact the revolving door of repeated episodes of treatment and incarceration, or child protective services involvement, which wastes resources and does not produce the outcomes we all want?

Tip 3

Client-centered treatment doesn’t mean passively allowing clients to do whatever they want.

A Treatment Court Coordinator shared her frustration with me over Treatment Providers who have good intentions to implement “client-centered” treatment. However, their interpretation of “client-centered” services means to allow clients to make their own decisions without therapeutic challenge and accountability for the outcomes of their choices.

For example, a well-intended but ineffective treatment strategy:

  • The client doesn’t want to go to self help/mutual help support groups nor give up certain drug-using friends. They feel they can stop using substances on their own.
  • Provider allows the client to avoid support groups and still hang out with friends, hoping the client will come round eventually to going to meetings and giving up unsupportive friends.
  • This passive approach does not hold the client accountable for developing the impulse control or parenting skills needed to get what they want. It is not “client-centered”, it is client anarchy allowing people to “do time” in treatment, not “do treatment” for accountable change.

More effective client-centered approach:

  • Agree to allow the client avoid AA, NA or Smart Recovery etc. and to still hang out with unsupportive friends (Discovery, Dropout Prevention plan).
  • However, hold the client accountable for negative random drug testing to demonstrate that they have the support and skills to resist cravings and triggers to use.
  • If they are unable to function as evidenced by ongoing positive drug screens, then collaborate with the client to identify what went wrong and how to address those skill deficits in a new and improved treatment plan.
  • Help the client to connect the development of those skills with getting what they want – freedom from supervision or getting their children back.

soul

In the good old days BC (Before COVID), I attended a number of addiction treatment conferences held in Las Vegas casino hotels. That always seemed quite ironic to me, to hold an addiction conference with many attendees in short and long-term recovery needing to walk through halls with hundreds of people drinking, smoking and gambling.

It did however, give me a chance to try my hand at Lady Luck. Being the sophisticated gambler that I am, I sometimes wagered $10 on the penny slots. I have even splurged $20 on the 5 cent or can you believe it, the 25 cent slots. A few times I lost the whole $10 or $20. But most times I learned from my experience and had the gumption to cash out happily with my $1.95 winnings before I lost my whole spending money.

Others who suffer from addiction manifested as Gambling Disorder, are not wired to walk away and can end up losing fortunes, family and friends as they chase the losses and compulsively wager their life away. By the way, March is Problem Gambling Awareness Month.

Increasingly now I make no distinction between ‘wins’ and ‘losses’. Unless you have Gambling Disorder that needs specific addiction attention, a ‘win’ is an opportunity to discern what works and what doesn’t; and a ‘loss’ is an opportunity to discern what works and doesn’t. 

For example, my daughter’s family has been trying to buy a home in a still competitive real estate market. They recently found a house they wanted to bid on, but lost out to one of the ten bidders. The next house they lost to someone else even before they had a chance to put in a formal bid. The third house they wanted, they were ready to capitalize on what they had learned from two failed bids….and they won. Not only did they get their offer accepted but it was for a house in a more desirable location with a better layout than the first two targets.

Their first two losses resulted in a better ‘win’ than what they could have planned for.

Like they say, “you win some, you lose some”. It’s just that in my book, you always win.
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