Lessons from a Case Consultation on how to assess what a client really wants and engage them in treatment; Observations and insights about my world travel.

Welcome to the November edition.

In SAVVY, I discuss a Case Consultation on a client mandated for treatment. I explain how probing the information in the “Client Description” with a few more questions helps assess what is most important to the client, in hopes of enhancing their motivation for recovery.

In SKILLS, I suggest how to assess mandated clients who also seem to express some pain over how addiction has affected their lives. Are they really wanting treatment and recovery or are they ambivalent? And how do you collaborate with a person who wants a less intensive level than has been assessed and recommended?

In SOUL, I review the many countries I had the privilege to travel and see this year. I share some observations, feelings and insights that I experienced, grateful for the health and resources to make that travel possible.

Once a month, I lead a one-hour case consultation webinar. This month, the case presenter provided the following “Client Description” as a prelude to discussing the client’s multidimensional assessment. There were several questions I raised as I sought to get a better sense of the client. Since this was a client assessed over the phone at a call-in and referral center, I can understand this was not meant to be a comprehensive evaluation.

Having said that, even in that telephone assessment situation, a few more probing questions would strengthen the assessment to more accurately determine the best treatment referral recommendation. As I raised questions prompted by the brief “Client Description,” it was clear the assessor had not probed much at all. We used the case consultation to identify what clarifying questions would be useful and why. (Details of the client have been altered to protect confidentiality.)

The Client Description:

29-year-old White single, unemployed man without any other income. The client has an open court case and was referred by an outpatient program for residential addiction treatment services. The client is assessed as needing 24-hour low-intensity residential treatment, but is wanting intensive outpatient treatment along with a recovery residence living situation. His diagnosis is documented as Opioid Use Disorder using oxycodone previously prescribed after a gun shot wound a year ago. The client states that he was recently released from legal custody and doesn’t want to return to those worst days of his addiction.

Tip 1

When people are mandated to treatment, it is useful to know what the open court case is all about. This illuminates what is most important to the client who is seeking treatment.

• If a client has a Child Protective Services court case open, the client might want most to get their children back.

• If there was an arrest for selling and dealing drugs with a potential long incarceration, the client might most want to avoid or reduce prison time.

Understanding what the court case is about can help improve the therapeutic alliance by tuning into what is most important to the client. It also helps assess how much of the motivation for treatment is related to avoiding the consequences of addiction versus accepting addiction treatment to embrace recovery.

Tip 2

Just because a person is mandated to treatment doesn’t mean they are only interested in avoiding negative consequences and are not serious about embracing recovery.

This client “doesn’t want to return to those worst days of his addiction.” A person may initially seek treatment because of a court mandate. But that legal problem can shake up the client to face the depth and destruction of their addiction illness and be a catalyst for accepting the need for treatment and recovery.

So with this client, a few more probing questions would aim to determine:

• If the client is motivated mainly to avoid a negative consequence.

• If the client was initially motivated to avoid a negative consequence, but is also now in enough pain to not “want to return to those worst days of addiction.”

• If the client is ambivalent about treatment and recovery, wanting to avoid a negative consequence while at the same time wanting to avoid those worst days of addiction. Both motivations can co-exist. But it will be the job of treatment to work on attracting the client into embracing recovery more resolutely than avoiding negative consequences.

SKILLS

Tip 1

How to probe more the clients who are mandated to treatment but who also seem to voice being done with their addiction.

Here are some questions and responses to consider:

1. What is the most important thing that you want that prompted you to call for an assessment? I am not interested in what other people think you need; or what I think you should want. I am actually interested in what you want... there is no right answer here except what is most important that you want.

If they answer:

• "Well they told me to call and if I don’t go to treatment I could lose my child or do way more prison time," then you know what is most important to the client... and it isn’t treatment for the goal of recovery.

• "I was mandated to come to treatment but I have also been realizing that I don’t want to return to those worse days of addiction," then you know that there is enough ambivalence to require motivational enhancement to attract the client into recovery, not just avoid a negative consequence.

•  "I know I was mandated to call and come to treatment, but I am wanting sobriety for myself and will do whatever it takes to get into recovery,” then you know that in this moment, the client is at Action for lasting change.

2. You mentioned that you didn’t want to return to the worst days of addiction. What about those days was so terrible?

If they answer:

• “Let me tell you about the family, health, money, physical and mental problems my addiction has caused,” then you know they are fully hurting from effects of addiction on their life and want the personal and social wellness that recovery can bring.

• "Well I had a seizure before when I was withdrawing and I don't want anything like that to happen again," then you know that the client is more focused on limited addiction problems and probably not interested in full multidimensional recovery.

Tip 2

Assess for life-threatening, imminent danger first. If no imminent danger, then collaborate with the client to start at the least intensive level of care they want.

The client is assessed as needing 24-hour low-intensity residential treatment, but is wanting intensive outpatient treatment along with a recovery residence living situation.

Here are some considerations on how to collaborate with a client who wants a less intensive level than what has been assessed and recommended:

1. A client is speaking of intense cravings that are so strong that they feel they would go on the street and get anything they could get their hands on regardless of fears of fentanyl on which they could overdose. Such a client may need 24-hour care to protect them from their out of control cravings that cause imminent danger. Transition them to their preferred level of care when their impulsivity has faded enough to allow safe transfer to a less intensive outpatient service.

2. A client speaks of intense cravings but has demonstrated by word and action that they could reach out if feeling overwhelmed and dangerously impulsive. Such a client may safely be started at a less intensive level than residential care, knowing that they have enough control of addiction cravings and impulses that they will reach out for help if getting impulsive.

SOUL

By the time you read this, I will be en route to Cairo, Egypt to start a tour of the iconic sights and enjoy a four-day cruise down the Nile River. I have had a full variety of travel this year that has encompassed:

• Dubai and visiting Khasab, Muscat and Abu Dhabi.

• Ghana and a fascinating exploration of that culture.

• A magical trip to the Maldives that has spoiled me for snorkeling any other place. It literally was like swimming in a huge aquarium surrounded by millions of colorful sea life.

• The stunning nature of Costa Rica and an informative Danube River cruise that started in Budapest and ended in Prague.

• August and September included France, and a cruise out of Reykjavik and visiting other Icelandic towns, Greenland and the fjords of Norway ending in Oslo.

Why am I telling you about these trips and what have I learned from these disparate travel experiences?

Firstly, I recognize the privilege that my long career has allowed for me to take trips that are out of reach for many.  So I am grateful that I have been blessed with the physical stamina, health and financial resources to make this possible. 

In a world where every day feels like bad news, conflict and pain, I want to share some of the uplifting observations, feelings and insights I gleaned from this year of travel:

• In the USA, we hear so much about the turmoil of the Middle East. But in Dubai, United Arab Emirates, it was so informative to see the planning for the future that was captured in the words of His Highness Sheik Mohammad Bin Rashid Al Maktoum: “We do not wait for things to happen, rather we make them happen.”

• In July's SOUL, I told of how in Ghana I saw women (mostly) carry heavy, deep and wide aluminum containers of water on their head every morning. I watched school children as their first duty of the day, each carrying a bucket to the water source and in a neat line following the leader back to school. 

• It was almost unfathomable to me that this daily, tedious water ritual did not seem to phase the women or children at all.  

• In February's SOUL, I wrote about how sobering it was to stand in the dungeons where thousands of enslaved African men and women were held and then loaded onto ships and sold in the Americas. I stood at the Door of No Return which was the last stop before crossing the Atlantic Ocean.

• The Maldives, Costa Rica and the Iceland, Greenland and Norway trips brought new awe for the wonders of nature in all its beauty. 

In all the cultural diversity I witnessed and experienced, I found myself thinking about how each person has their family and social relationships in their little slice of the world. While living under contrasting climates, clothing, customs and cultural norms, at the end of the day everyone just wants someone to love; work that has meaning and rewards; and play that brings relaxation and joy.

This Thanksgiving, I know I will have so much for which to sit in full gratitude. And you?

UNTIL NEXT TIME

Thank you for joining us this month. See you in late December.

David