In SAVVY, STUMP THE SHRINK and SKILLS, Amber asks a couple of questions about what to do when clients are recommended for inpatient treatment but decline and only want outpatient services. This edition explores how to meet the client where they are at, but also hold them accountable to the outcomes of whatever plan they agree to work on, even in outpatient services.
In SOUL, I am grateful for the “Right turn on red” law and ponder why we can’t have an “everybody wins” attitude to lots of challenges and problems.
Last month, Amber from Pottstown, Pennsylvania wrote:
Good morning Dr. Mee-Lee,
I hope this email finds you well. I so enjoy receiving these tips and topics emails, and forward them to my staff as well.
In a meeting today, we were discussing how we seem to have a large number of clients who are being recommended to an inpatient level of care (ASAM Criteria levels 3.5-4.0) however they decline the level of care and are only willing to do outpatient or Intensive Outpatient (IOP). While we try to focus on least restrictive levels, we also need to keep in mind the client’s safety.
Any suggestions for how to handle this?
I appreciate your time,
Amber
Tip 1
Take care of any imminent dangers first. Then start where the client is at and help them “discover” whether outpatient or IOP works.
My initial response:
Hi Amber, thanks for the nice feedback.
As regards your question, in general, whenever a client disagrees with a recommendation, here are the steps to take:
1. Listen to the client’s reasons for disagreeing and see if there is a way to address those concerns e.g., if the client is concerned about losing their job or housing if they are away in a residential setting for days or weeks, you can see if and how you can assist them in not losing their job or housing by advocating for them.
2. If the client is in imminent danger e.g., so impulsive with cravings to use opioids that you fear they will imminently seek drugs on the street regardless of any fears of fentanyl and could fatally overdose, you may have to over-ride their will for the time they are imminently dangerous just as you would do if someone was so suicidal, impulsive and had a gun they would want to use to die by suicide.
3. If the client is not imminently in danger, you should start where the client is at and help them “discover” whether outpatient or IOP works to help them get what they want. For example, if they are trying to prove they don’t have an addiction problem but keep getting positive drug tests as an outpatient, then you are helping them “discover” that they may have more a problem with loss of control than they initially thought. So you start with a treatment plan they are willing to do in good faith, even if it isn’t your best recommendation and plan. But hold them accountable to their plan delivering the outcomes that they want e.g., being able to maintain abstinence so they can get their children back; or to show their ability to cut back their use in the outpatient level of care; or to be able to avoid further arrests and getting into substance-related trouble even though in an outpatient level.
4. Such “discovery, dropout prevention” plans are designed to avoid a struggle over a recommended level of care and to put it back in the lap of the client to try it their way.
Hope this helps, but let me know if not.
Thanks,
David
Amber’s response:
Good morning again,
Thank you so much for your response. I love hearing you speak to these concerns, you have an amazing way of making it all just make sense.
Additional question then as well, what if the client is continuously not responding to the IOP or OP levels, in that they are guarded and unable to gain/maintain sobriety yet continue to decline need for higher level of care. Is there a point that it is appropriate to end treatment because it is just not working for them?
I have always struggled with this and tried to avoid going that route because I feel we need to build that trust and alliance with the client so that later when they feel ready, they may be open to having those discussions.
However, we sometimes have clients that are in and out and never gain any traction in treatment. How can we support them in being successful in meeting their goals?
Thank you again for your time,
Amber
Tip 2
Being person-centered means starting where the client is at, but holding them accountable to whether their plan works.
My second response:
Hi Amber:
In answer to your questions, I’ve written on this before, so take a look at the following:
Client-centered treatment doesn’t mean passively allowing clients to do whatever they want.
“Doing time” versus “Doing treatment”. How can you tell if a person is just “doing time, not treatment”? Ways to turn “doing time” into active treatment.
What to do with poor outcomes: ACCEPT is an acronym to help you think through what to do when a client, patient or participant is not doing well in treatment.
Lying and dishonesty in Treatment Courts and what to do; applying and using ACCEPT with dishonesty.
Two STUMP THE SHRINK questions on passive compliance and substance use while in treatment
All the best,
David
I was driving the other day and approached a stop light about to turn right. I stopped, checked for any approaching cars. Seeing none, I turned right even with the red stop light still shining because we have “Right turn on red” in the USA. No waiting for the light to change; no idling the car using up gasoline and time; fewer greenhouse gases to contribute to global climate change. (In Australia where people drive on the left hand side of the road, the law would be “Left turn on red”, but no such general law exists there.)
As I glided round the right turn, I felt grateful and pondered the joys of right hand turns on red…..everybody wins: the driver’s time, the gasoline savings, the environmental protection, and the safe efficient flow of traffic.
Then I started thinking Why can’t everything be like right turns on red? We would glide along much more smoothly if we worked on solutions where everybody wins…..not getting everything I want, but with some give and take.
Does it always have to be:
I realize this sounds like a naïve, idealistic notion. It explains why I would never win a political campaign. But especially now in the midst of elections and the news and political bubbles we gravitate to, I can’t help sighing and thinking wistfully of the joys of “turning right on red.” (No political puns intended or desired).