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Treatment Planning M.A.T.R.S: Treatment Planning M.A.T.R.S: UtilisingUtilising the ASIthe ASI

Treatnet Training Volume A: Module 3 – Updated 12 February 2008

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Module 3 WorkshopsModule 3 Workshops

Workshop 1:Workshop 1: Understanding Treatment Understanding Treatment Planning and the ASIPlanning and the ASI

Workshop 2:Workshop 2: Treatment PlansTreatment Plans

Workshop 3:Workshop 3: PrioritisingPrioritising ProblemsProblems

Workshop 4:Workshop 4: Putting Treatment Planning Putting Treatment Planning M.A.T.R.S. into M.A.T.R.S. into PractisePractise

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Module 3 training goalsModule 3 training goals

1.1. Increase familiarity with treatment planning Increase familiarity with treatment planning processprocess

2.2. Increase understanding of guidelines and Increase understanding of guidelines and legal considerations in documenting client legal considerations in documenting client statusstatus

3.3. Increase skills in using the Addiction Increase skills in using the Addiction Severity Index (ASI) in developing Severity Index (ASI) in developing treatment plans and documenting activitiestreatment plans and documenting activities

Workshop 1: Workshop 1: Understanding Treatment Planning Understanding Treatment Planning and the ASIand the ASI

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PrePre--assessmentassessment

Please respond to the prePlease respond to the pre--assessment assessment questions in your workbook.questions in your workbook.

(Your responses are strictly confidential.)(Your responses are strictly confidential.)

10 Min.

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IcebreakerIcebreaker

How do you define How do you define treatment planning?treatment planning?

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Icebreaker: The Good and the BadIcebreaker: The Good and the Bad

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The Good and the BadThe Good and the BadNegative Aspects of Negative Aspects of Treatment Planning Treatment Planning

Positive Aspects of Positive Aspects of Treatment PlanningTreatment Planning

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Workshop 1: Training objectives (1)Workshop 1: Training objectives (1)

At the end of this workshop, you will be able to:At the end of this workshop, you will be able to:

1.1. Use ASI information to develop Use ASI information to develop individualisedindividualised treatment plans treatment plans

2.2. Identify characteristics of a Identify characteristics of a programmeprogramme--driven and an driven and an individualisedindividualised treatment plantreatment plan

3.3. Understand how Understand how individualisedindividualised treatment treatment plans help to keep people in treatment and plans help to keep people in treatment and lead to better outcomeslead to better outcomes

Continued

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Workshop 1: Training objectives (2)Workshop 1: Training objectives (2)

At the end of this workshop, you will be able to:At the end of this workshop, you will be able to:

4.4. Use Master Problem List (provided) to Use Master Problem List (provided) to formulate treatment plans and develop:formulate treatment plans and develop:

Problem statements Problem statements Goals based on problem statementsGoals based on problem statementsObjectives based on goalsObjectives based on goalsInterventions based on objectivesInterventions based on objectives

5.5. PractisePractise writing documentation notes writing documentation notes reflecting how treatment plan is progressing reflecting how treatment plan is progressing (or not progressing)(or not progressing)

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What is What is notnot included in trainingincluded in training

Administering and scoring the ASIAdministering and scoring the ASI

Administering any other Administering any other standardisedstandardisedscreening / assessment toolscreening / assessment tool

Training on clinical interviewingTraining on clinical interviewing

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The goal of this training isThe goal of this training is……

To bring together the To bring together the assessment and treatment assessment and treatment

planning processesplanning processes

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““Same plan, different names.Same plan, different names.””

Treatment plans are often. . .Treatment plans are often. . .

““Meaningless & time consuming.Meaningless & time consuming.””

““Ignored.Ignored.””

The What, Who, When, The What, Who, When, and How of Treatment and How of Treatment PlanningPlanning

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What is a treatment plan?What is a treatment plan?

A written document that:A written document that:

Identifies the clientIdentifies the client’’s most important s most important goals for treatmentgoals for treatment

Describes measurable, timeDescribes measurable, time--sensitive sensitive steps towards achieving those goalssteps towards achieving those goals

Reflects a verbal agreement between Reflects a verbal agreement between the counselor and clientthe counselor and client

(Source: Center for Substance Abuse Treatment, 2002)

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Who develops the treatment plan?Who develops the treatment plan?

Client works with treatment providers to Client works with treatment providers to identify and agree on treatment goals identify and agree on treatment goals and identify strategies for achieving and identify strategies for achieving them.them.

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At the time of admissionAt the time of admission

And continually updated and revised And continually updated and revised throughout treatmentthroughout treatment

When is the treatment plan developed?When is the treatment plan developed?

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How does assessment guide treatment How does assessment guide treatment planning?planning?

The Addiction Severity Index (ASI), for The Addiction Severity Index (ASI), for example, identifies client needs or example, identifies client needs or problems by using a semiproblems by using a semi--structured structured interview formatinterview format

The ASI guides delivery of services The ASI guides delivery of services that the client needs that the client needs

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Treatment goals address those Treatment goals address those problems identified by the problems identified by the assessmentassessment

Then, the treatment plan guides the Then, the treatment plan guides the delivery of services neededdelivery of services needed

How does assessment guide treatment How does assessment guide treatment planning?planning?

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A reliable and valid instrument, widely A reliable and valid instrument, widely used both nationally and internationallyused both nationally and internationallyConducted in a semiConducted in a semi--structured structured interview formatinterview formatCan be effectively integrated into Can be effectively integrated into clinical careclinical care

(Sources: Cacciola et al., 1999; Carise et al., 2004; Kosten et al., 1987; McLellan et al., 1980; 1985; 1992)

What is the ASI?What is the ASI?

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Identifies 7 potential problem areas:Identifies 7 potential problem areas:1.1. Medical statusMedical status2.2. Employment and supportEmployment and support3.3. Drug useDrug use4.4. Alcohol useAlcohol use5.5. Legal statusLegal status6.6. Family/social statusFamily/social status7.7. Psychiatric statusPsychiatric status

What is the ASI?What is the ASI?

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The ASI is NOTThe ASI is NOT……

A personality testA personality test

A medical testA medical test

A projective test such as the Rorschach A projective test such as the Rorschach Inkblot TestInkblot Test

A tool that gives you a diagnosisA tool that gives you a diagnosis

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Why use the ASI?Why use the ASI?

1.1. Clinical applicationsClinical applications

2.2. Evaluation usesEvaluation uses

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Recent developmentsRecent developments

Efforts focused on making the ASI more Efforts focused on making the ASI more useful for clinical workuseful for clinical work

(Example: Using ASI for treatment (Example: Using ASI for treatment planning)planning)

The Drug Evaluation Network System The Drug Evaluation Network System (DENS)(DENS) Software uses ASI information to Software uses ASI information to create a clinical narrativecreate a clinical narrative

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ASI is now ASI is now moremore clinically useful!clinically useful!

New and Improved DENS Software New and Improved DENS Software (2005)(2005)

Uses ASI information to define possible Uses ASI information to define possible problem lists and prompt and guide problem lists and prompt and guide clinician in developing a treatment plan.clinician in developing a treatment plan.

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Uses a semiUses a semi--structured interview to structured interview to gather information a clinician gather information a clinician generally collects during assessmentgenerally collects during assessment

Shown to be an accurate or valid Shown to be an accurate or valid measure of the nature and severity of measure of the nature and severity of client problemsclient problems

Clinical applicationClinical application

(Sources: Kosten et al., 1987; McLellan et al., 1980; 1985; 1992)


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Prompts clinician to focus session on Prompts clinician to focus session on important problems, goals, and important problems, goals, and objectivesobjectives

Basis for reviews of progress during Basis for reviews of progress during treatment and documentationtreatment and documentation

Basis for discharge planBasis for discharge plan



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NIDA Principle 3:NIDA Principle 3:““To be effective, treatment must address the To be effective, treatment must address the individualindividual’’s drug use and any associated s drug use and any associated medical, psychological, social, vocational, and medical, psychological, social, vocational, and legal problems.legal problems.””

The ASI assesses all these dimensions.The ASI assesses all these dimensions.


Why use the ASI? Why use the ASI?

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Clinical Clinical applicationapplication

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Clinical use of ASI improves rapportClinical use of ASI improves rapport““. . . If patients. . . If patients’’ problems are accurately problems are accurately assessed, they may feel assessed, they may feel ‘‘heardheard’’ by their by their counsellorcounsellor, potentially leading to the , potentially leading to the development of rapport and even a stronger development of rapport and even a stronger helping alliance.helping alliance.””

(Sources: Barber et al., 1999, 2001; Luborsky et al., 1986, 1996)


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““. . . Patients whose . . . Patients whose problems are identified at problems are identified at admission, and then admission, and then receive services that are receive services that are matched to those matched to those problems, stay in treatment problems, stay in treatment longer.longer.””

(Sources: Carise et al., 2004; Hser et al., 1999; Kosten et al., 1987; McLellan et al., 1999)

Clinical applicationClinical applicationUsing ASI to match services to client Using ASI to match services to client problems improves retention.problems improves retention.

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For For ProgrammeProgramme Directors:Directors:Identifies types of client problems Identifies types of client problems not addressed through the not addressed through the programmeprogramme’’ss treatment servicestreatment services

Quantifies client problems Quantifies client problems

Identifies trends over timeIdentifies trends over time

Evaluation usesEvaluation uses

Continued

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For For ProgrammeProgramme Directors:Directors:Assists with levelAssists with level--ofof--care choicescare choicesProvides measure of Provides measure of programmeprogrammesuccesssuccess

Documents unmet client service Documents unmet client service needsneedsIncludes data needed for reports to Includes data needed for reports to various stakeholdersvarious stakeholders


Continued

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For For ProgrammeProgramme DirectorsDirectors

Positions Positions programmesprogrammes for for increased funding though increased funding though participation in clinical trials and participation in clinical trials and other research opportunitiesother research opportunities


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For Clinical SupervisorsFor Clinical SupervisorsASI data can be used toASI data can be used to

Identify Identify counsellorcounsellor strengths and strengths and training needstraining needs

Match clients to Match clients to counsellorcounsellorstrengthsstrengths

Identify trends in client problemsIdentify trends in client problems


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Workshop 2: Treatment plansWorkshop 2: Treatment plans

Programme-Driven

Individualizedversus

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Biological Psychological

Sociological

Biopsychosocial ModelBiopsychosocial Model

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Sociological

Does the client have a car? Can they access public transportation?

Biopsychosocial Model example ...Biopsychosocial Model example ...

How close do they live to the treatment centre?

How available are drugs or alcohol in the home?

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Biological(e.g., medical

status)

Psychological(e.g., psychiatric

status)

Sociological(e.g., family & social

status)

ASI problem domains and the ASI problem domains and the biopsychosocialbiopsychosocial modelmodel

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Field of substance abuse treatment: Early workField of substance abuse treatment: Early work

ProgrammeProgramme--Driven PlansDriven Plans

““One size fits allOne size fits all””

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Client needs are not important as the client is Client needs are not important as the client is ““fitfit”” into the standard treatment into the standard treatment programmeprogrammeregimenregimen

Plan often includes only standard Plan often includes only standard programmeprogrammecomponents (e.g., group, individual sessions)components (e.g., group, individual sessions)

Little difference among clientsLittle difference among clients’’ treatment treatment plansplans

ProgrammeProgramme--driven plansdriven plans

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ProgrammeProgramme--driven plansdriven plansClient will . . .Client will . . .

1.1. ““Attend 3 Alcoholic Anonymous meetings Attend 3 Alcoholic Anonymous meetings a weeka week””

2.2. ““Complete Steps 1, 2, & 3Complete Steps 1, 2, & 3””

3.3. ““Attend group sessions 3 times / weekAttend group sessions 3 times / week””

4.4. ““Meet with Meet with counsellorcounsellor 1 time / week1 time / week””

5.5. ““Complete 28Complete 28--day day programmeprogramme””

“Still don’t fit right”

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ProgrammeProgramme--driven plansdriven plansOften include only those services Often include only those services immediately available in agencyimmediately available in agency

Often do not include referrals to Often do not include referrals to community services (e.g., parenting community services (e.g., parenting classes)classes)

“ONLY wooden shoes?”

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Individualised Treatment Plans

- Many colors / styles available -

Treatment planning: A paradigm shiftTreatment planning: A paradigm shift

- Custom style & fit -

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IndividualisedIndividualised planplan

“Sized” to match client’s problems and needs

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To To individualiseindividualise a plan, what a plan, what information is needed?information is needed?

1.1. What does a What does a counsellorcounsellor need to need to discuss with a client before developing discuss with a client before developing a treatment plan?a treatment plan?

2.2. Where do you get the information, Where do you get the information, guidelines, tools, etc.?guidelines, tools, etc.?

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To To individualiseindividualise a plan, what a plan, what information is needed?information is needed?

Possible sources of information Possible sources of information might include:might include:

Probation reportsProbation reports

Screening resultsScreening results

Assessment scalesAssessment scales

Collateral interviewsCollateral interviews

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Case A assessment information: JanCase A assessment information: Jan

2727--yearyear--old, single Caucasian femaleold, single Caucasian female3 children under age 73 children under age 7No childcare availableNo childcare availableSocial companions use drugs / alcoholSocial companions use drugs / alcoholUnemployed Unemployed Low education levelLow education level2 arrests for possession of 2 arrests for possession of methmeth & & cannabis plus 1 probation violationcannabis plus 1 probation violation

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Case B assessment information: DanCase B assessment information: Dan

3636--yearyear--old, married Africanold, married African--American maleAmerican male

2 children2 children

2 arrests and 1 conviction for DUI (driving 2 arrests and 1 conviction for DUI (driving under the influence of alcohol)under the influence of alcohol)

Blood alcohol content at arrest Blood alcohol content at arrest -- .25.25

Employed Employed

High severity family problemsHigh severity family problems

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The The ““Old MethodOld Method””::((ProgrammeProgramme--Driven) Problem StatementDriven) Problem Statement

Not Not individualisedindividualised

Not a complete sentenceNot a complete sentence

DoesnDoesn’’t provide enough informationt provide enough information

A diagnosis is not a complete A diagnosis is not a complete problem statementproblem statement

““Alcohol dependenceAlcohol dependence””

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Not specific for Jan or DanNot specific for Jan or Dan

Not helpful for treatment planningNot helpful for treatment planning

Cannot be accomplished by Cannot be accomplished by programmeprogramme dischargedischarge

““Will refrain from all substance use now Will refrain from all substance use now and in the futureand in the future””

The The ““Old MethodOld Method””::((ProgrammeProgramme--Driven) Goal StatementDriven) Goal Statement

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Again, not specific for Jan or DanAgain, not specific for Jan or Dan

A level of care is not an objectiveA level of care is not an objective

““Will participate in outpatient Will participate in outpatient programmeprogramme””

The The ““Old MethodOld Method””::((ProgrammeProgramme--Driven) Objective StatementDriven) Objective Statement

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This sounds specific, but it describes This sounds specific, but it describes a a programmeprogramme componentcomponent

““Will see a Will see a counsellorcounsellor once a week and once a week and attend group on Monday nights for 12 attend group on Monday nights for 12 weeksweeks””

The The ““Old MethodOld Method””::((ProgrammeProgramme--Driven) Intervention StatementDriven) Intervention Statement

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Why make the effort?Why make the effort?IndividualisedIndividualised Treatment Plans:Treatment Plans:

Lead to increased retention rates, Lead to increased retention rates, which are shown to lead to improved which are shown to lead to improved outcomesoutcomes

Empower the counselor and the client, Empower the counselor and the client, and give focus to counseling sessionsand give focus to counseling sessions

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Why make the effort?Why make the effort?

Individualized Treatment Individualized Treatment Plans:Plans:Like a good pair of shoes, this Like a good pair of shoes, this plan plan ““fitsfits”” the client wellthe client well

ASI:ASI:Like measurements, the ASI Like measurements, the ASI items are used to items are used to ““fitfit”” the the clientclient’’s services to her or s services to her or his needs his needs

What is included What is included in any treatment plan?in any treatment plan?

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Treatment plan componentsTreatment plan components

1. Problem Statements

3. Objectives

2. Goal Statements

4. Interventions

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1. 1. Problem StatementsProblem Statements are based on are based on information collected during the information collected during the assessmentassessment


2. 2. Goal StatementsGoal Statements are based on the are based on the problem statements and are problem statements and are reasonably achievable in the active reasonably achievable in the active treatment phasetreatment phase

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Van* is experiencing increased tolerance for Van* is experiencing increased tolerance for alcohol as evidenced by his need for more alcohol as evidenced by his need for more alcohol to become intoxicated or achieve the alcohol to become intoxicated or achieve the desired effectdesired effect

Problem statement examplesProblem statement examples

Meghan* is currently pregnant and requires Meghan* is currently pregnant and requires assistance obtaining prenatal careassistance obtaining prenatal care

TomTom’’s* psychiatric problems compromise s* psychiatric problems compromise his concentration on recoveryhis concentration on recovery

*You may choose to use client*You may choose to use client’’s last name instead, e.g., Mr. Pierce, Ms. Hunt.s last name instead, e.g., Mr. Pierce, Ms. Hunt.

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Van will safely withdraw from alcohol, Van will safely withdraw from alcohol, stabilisestabilise physically, and begin to establish a physically, and begin to establish a recovery recovery programmeprogramme

Goal statement examplesGoal statement examples

Meghan will obtain necessary prenatal careMeghan will obtain necessary prenatal care

Reduce the impact of TomReduce the impact of Tom’’s psychiatric s psychiatric problems on his recovery and relapse problems on his recovery and relapse potentialpotential

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3. 3. ObjectivesObjectives are what the client will do to are what the client will do to meet those goalsmeet those goals

4. 4. InterventionsInterventions are what the staff will do to are what the staff will do to assist the clientassist the client Other common terms:

• Action Steps• Measurable activities• Treatment strategies• Benchmarks• Tasks


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Van will report acute withdrawal symptomsVan will report acute withdrawal symptomsExamples of objectivesExamples of objectives

Meghan will visit an OB/GYN physician or Meghan will visit an OB/GYN physician or nurse for prenatal carenurse for prenatal care

Tom will list 3 times when psychological Tom will list 3 times when psychological symptoms increased the likelihood of symptoms increased the likelihood of relapserelapse

Van will begin activities that involve a Van will begin activities that involve a substancesubstance--free lifestyle and support his free lifestyle and support his recovery goalsrecovery goals

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Staff medical personnel will evaluate VanStaff medical personnel will evaluate Van’’s s need for medical monitoring or medicationsneed for medical monitoring or medications

Intervention examplesIntervention examples

Staff will review TomStaff will review Tom’’s list of 3 times when s list of 3 times when symptoms increased the likelihood of symptoms increased the likelihood of relapse and discuss effective ways of relapse and discuss effective ways of managing those feelingsmanaging those feelings

Staff will call a medical service provider or Staff will call a medical service provider or clinic with Meghan to make an appointment clinic with Meghan to make an appointment for necessary medical servicesfor necessary medical services

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Review: Treatment Plan ComponentsReview: Treatment Plan Components

1.1. Problem StatementsProblem Statements (information from assessment)(information from assessment)

3.3. ObjectivesObjectives (what the client will do)(what the client will do)

2.2. Goal StatementsGoal Statements (based on problem statement)(based on problem statement)

4.4. InterventionsInterventions (what the staff will do)(what the staff will do)

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1. 1. Client Strengths*Client Strengths* are reflectedare reflected


2. 2. Participants in PlanningParticipants in Planning* are * are documenteddocumented

**The DENS Treatment Planning Software The DENS Treatment Planning Software includes these componentsincludes these components

Other aspects of the clientOther aspects of the client’’s condition: s condition:

ASI Narrative and ASI Narrative and Master Problem ListMaster Problem List

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Master Problem ListMaster Problem List

Refer to ASI Narrative ReportRefer to ASI Narrative Report(Workshop 2, Handout 1)(Workshop 2, Handout 1)

Review case study Review case study

Focus on problems identified in the: Focus on problems identified in the: alcohol/drugalcohol/drug domaindomainmedicalmedical domaindomainfamily/socialfamily/social domaindomain

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ASI Master Problem ListASI Master Problem List

Master Problem List

Date Date IdentifiedIdentified

DomainDomain Problem Problem StatusStatus Date ResolvedDate Resolved

Alcohol/DrugAlcohol/Drug The client reports several or more episodes of drinking alcohol The client reports several or more episodes of drinking alcohol to intoxication in past month.to intoxication in past month.

The client reports regular, lifetime use of alcohol to The client reports regular, lifetime use of alcohol to ““intoxication.intoxication.””

The client reports using heroin in past month.The client reports using heroin in past month.

MedicalMedical Client has a chronic medical problem that interferes with Client has a chronic medical problem that interferes with his/her lifehis/her life

Family/SocialFamily/Social The client is not satisfied with how he/she spends his/her free The client is not satisfied with how he/she spends his/her free timetime

The client reports having serious problems with family The client reports having serious problems with family members in the past monthmembers in the past month

The client is troubled by family problems and is interested in The client is troubled by family problems and is interested in treatmentstreatments

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Considerations in writingConsiderations in writing

All problems identified are included All problems identified are included regardless of available agency servicesregardless of available agency services

Include all problems whether deferred or Include all problems whether deferred or addressed immediately addressed immediately

Each domain should be reviewed Each domain should be reviewed

A referral to outside resources is a valid A referral to outside resources is a valid approach to addressing a problemapproach to addressing a problem

Master Problem List

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Tips on writing problem Tips on writing problem statementsstatements

NonNon--judgementaljudgementalNo jargon, such asNo jargon, such as……

““Client is in denialClient is in denial””““Client is coClient is co--dependentdependent””

Use complete sentence structureUse complete sentence structure

Problem Statements

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1.1. Client has low selfClient has low self--esteem.esteem.2.2. Client is in denial.Client is in denial.3.3. Client is alcohol dependent.Client is alcohol dependent.4.4. Client is promiscuous.Client is promiscuous.5.5. Client is resistant to treatment.Client is resistant to treatment.6.6. Client is on probation because Client is on probation because

he is a bad alcoholic.he is a bad alcoholic.

Changing languageChanging language

Problem Statements

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Changing language: Pick twoChanging language: Pick two

Problem Statements

Think about how you might change the Think about how you might change the language for 2 of the preceding language for 2 of the preceding problem statements problem statements

Rewrite those statements using nonRewrite those statements using non--judgementaljudgemental and jargonand jargon--free languagefree language

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Changing language: ExamplesChanging language: Examples

Problem Statements

1. Client has low self1. Client has low self--esteem.esteem.

3. Alcohol Dependent.3. Alcohol Dependent.

2. Client is in denial.2. Client is in denial.

–– Client averages 10 negative selfClient averages 10 negative self--statements dailystatements daily

–– Client experiences tolerance, withdrawal, loss Client experiences tolerance, withdrawal, loss of control, and negative life consequences due of control, and negative life consequences due to alcohol useto alcohol use

–– Client reports two Client reports two DWIsDWIs (driving while (driving while intoxicated) in past year but states that alcohol use intoxicated) in past year but states that alcohol use is not a problemis not a problem

Continued

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Changing language: ExamplesChanging language: Examples

Problem Statements

4. Client is promiscuous.4. Client is promiscuous.

5. Client is resistant to treatment.5. Client is resistant to treatment.

6. Client is on probation because he is a bad 6. Client is on probation because he is a bad alcoholic.alcoholic.

–– Client participates in unprotected sex 4 Client participates in unprotected sex 4 times a week with multiple partnerstimes a week with multiple partners

–– Client has legal consequences because Client has legal consequences because of alcoholof alcohol--related related behaviourbehaviour

–– In past 12 months, client has dropped out of 3 In past 12 months, client has dropped out of 3 treatment treatment programmesprogrammes prior to completionprior to completion

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Case study problem statementsCase study problem statements

Problem Statements

Alcohol/drug domainAlcohol/drug domainMedical domainMedical domainFamily/social domainFamily/social domain

Write 1 problem statement for each domain.Write 1 problem statement for each domain.

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ASI Treatment Plan FormatASI Treatment Plan FormatDate Date IdentifiedIdentified

DomainDomain Problem Problem StatusStatus Date Date ResolvedResolved

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Workshop 3: Workshop 3: PrioritisingPrioritising problemsproblems

S

M A

RT

Now that we have the Now that we have the problems identifiedproblems identified……how do how do we we prioritiseprioritise them?them?

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MaslowMaslow’’s hierarchy of needss hierarchy of needs

Biological/Physiological

Safety & Security

Love & Belonging

Self-esteem

Self-actualisation

1

2

3

4

5

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PHYSIOLOGICAL1 Biological/PhysiologicalBiological/Physiological

•• Substance UseSubstance Use

•• Physical Health ManagementPhysical Health Management

•• Medication Adherence IssuesMedication Adherence Issues

Physical needsPhysical needs

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Safety & SecuritySafety & Security2

Mental health management

Functional impairments

Legal issues

Safety & securitySafety & security

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3 Love & BelongingLove & Belonging

Social & interpersonal skills

Need for affiliation

Family relationships

Love & belongingLove & belonging

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4 SelfSelf--EsteemEsteem

Achievement and mastery

Independence/status

Prestige

SelfSelf--esteemesteem

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5Self-Actualisation

SelfSelf--actualisationactualisation

Seeking personal potential

Self-fulfilment

Personal growth

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4

5 Self-actualisation

Self-esteem

Is “self-esteem” specific?

SelfSelf--esteem & selfesteem & self--actualisationactualisation

Relationship between ASI domains & Relationship between ASI domains & MaslowMaslow’’s hierarchy of needss hierarchy of needs

ASI Domain 5 – Family/Social Relationships

ASI Domain 4 – Legal StatusASI Domain 2 – Employment/Support Status

ASI Domain 1 - MedicalASI Domain 3 – Drug / Alcohol UseASI Domain 6 – Psychiatric Status

Biological/ Biological/ PhysiologicalPhysiological

Safety & SecuritySafety & Security

Love & Love & BelongingBelonging

SelfSelf--esteemesteem

SelfSelf--actualisationactualisation

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Pick 3 ASI problem domains for Pick 3 ASI problem domains for John Smith that appear most John Smith that appear most critical.critical.

Which domains should be Which domains should be addressed 1addressed 1stst, 2, 2ndnd, 3, 3rdrd,, and why?and why?

PractisePractise prioritisingprioritising

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Writing goal statementsWriting goal statements

Use ASI Treatment Plan HandoutsUse ASI Treatment Plan HandoutsAlcohol / Drug Domain Alcohol / Drug Domain Medical Domain Medical Domain Family / Social Family / Social

Write at least 1 goal statement for each Write at least 1 goal statement for each domaindomain

Write in complete sentencesWrite in complete sentences

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CheckCheck--in discussionin discussion

Will the client understand the goal?Will the client understand the goal?(i.e., no clinical jargon) (i.e., no clinical jargon)

Clearly stated? Clearly stated? Complete sentences?Complete sentences?Attainable in active treatment Attainable in active treatment phase?phase?Is it agreeable to both client Is it agreeable to both client and staff?and staff?

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Treatment M.A.T.R.S. objectives and interventionsTreatment M.A.T.R.S. objectives and interventions

Measurable

Realistic

Time-limitedR

T

MAttainable

A

Specific

S

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MeasurableMeasurableObjectives and interventionsare measurable

Achievement is observable

Indicators of client progress are measurableAssessment scales / scores

Client report

Behavioural and mental health status changes

M

M.AT.R.S. objectives & interventionsM.AT.R.S. objectives & interventions

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AttainableAttainableIdentify objectives and interventions Identify objectives and interventions attainable during active treatment phaseattainable during active treatment phaseFocus on Focus on ““improved functioningimproved functioning”” rather rather than cure than cure Identify goals attainable in level of care Identify goals attainable in level of care provided provided Revise goals when client moves from one Revise goals when client moves from one level of care to anotherlevel of care to another

AM.AT.R.S. objectives & interventionsM.AT.R.S. objectives & interventions

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TimeTime--limitedlimited

Focus on time-limited or short-term goals and objectives

Objectives and interventions can be reviewed within a specific time period

T


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Client can realistically complete objectives Client can realistically complete objectives within specific time periodwithin specific time period

Goals and objectives are achievable given Goals and objectives are achievable given client environment, supports, diagnosis, client environment, supports, diagnosis, level of functioninglevel of functioning

Progress requires client effortProgress requires client effort

RealisticRealistic


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SpecificSpecific

Specific and goalSpecific and goal--focusedfocused

Address in specific Address in specific behaviouralbehaviouralterms how level of functioning or terms how level of functioning or functional impairments will improvefunctional impairments will improve

S


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Problem Statement:Problem Statement: Client reports Client reports regular alcohol use for a period of 15 regular alcohol use for a period of 15 years. For the past 7 years, he drank years. For the past 7 years, he drank regularly and heavily (5 or more drinks regularly and heavily (5 or more drinks in one day). He reports drinking heavily in one day). He reports drinking heavily 20 of the past 30 days. 20 of the past 30 days.

M.A.T.R.S. clinical exampleM.A.T.R.S. clinical example

R

T

M A

S

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Example Goal:Example Goal: Client will safely reduce or Client will safely reduce or discontinue alcohol consumptiondiscontinue alcohol consumption

Example Objective:Example Objective: Client will continue to Client will continue to take medication for alcohol withdrawal while take medication for alcohol withdrawal while reporting any physical symptoms (discomfort) reporting any physical symptoms (discomfort) to medical staff for evaluationto medical staff for evaluation

Example Intervention:Example Intervention: Counselor / medical Counselor / medical staff will meet with client daily to discuss staff will meet with client daily to discuss medication management and presence of medication management and presence of withdrawal symptoms.withdrawal symptoms.

M.A.T.R.S. clinical exampleM.A.T.R.S. clinical example

R

T

M A

S

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Do examples pass M.A.T.R.S. guidelines?Do examples pass M.A.T.R.S. guidelines?

MM What makes these examples What makes these examples measurablemeasurable??

A What makes these examples What makes these examples attainableattainable??

RR What makes these examples What makes these examples realisticrealistic??

TT What makes these examples What makes these examples timetime--limitedlimited??

What makes these examples What makes these examples specificspecific??SS

Workshop 4: Putting Treatment Workshop 4: Putting Treatment Planning M.A.T.R.S. into Planning M.A.T.R.S. into PractisePractise

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The Stages of Change: IllustratedThe Stages of Change: Illustrated

Adapted from Prochaska & DiClemente, 1982; 1986

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Consider Consider ““Stages of ChangeStages of Change””1. Pre-Contemplation

2. Contemplation

3. Preparation

4. Action

6. Relapse

5. Maintenance

(Source: Prochaska & DiClemente, 1982; 1986)

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Pre-contemplation“I don’t have a problem.”

Person is not considering or does not want to change a particular behaviour.

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Person is thinking about

changing a behaviour.Pre-

Contemplation

Contemplation

“Maybe I have a problem.”

Contemplation

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Person is seriously

considering & planning to change a behaviourand has

taken steps towards change.

Pre-Contemplation

Contemplation

Preparation“I’ve got to do something.”

Preparation

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Pre-Contemplation

Action

Person is actively doing things to

change or modify behaviour.

Contemplation

Preparation

Action“I’m ready to start.”

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Person continues to

maintain behavioural

change until it becomes

permanent.

Maintenance

Contemplation

Pre-Contemplation

Preparation

Action

Maintenance

“How do I keep going?”

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Pre-Contemplation

Contemplation

Preparation

ActionMaintenance

Relapse

Relapse

“What went wrong?”

Person returns to pattern of

behaviour that he or she had

begun to change.

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1.1. Conduct assessmentConduct assessment

2.2. Collect client data and informationCollect client data and information

3.3. Identify problems Identify problems

4.4. PrioritisePrioritise problems problems

5.5. Develop goals to address problemsDevelop goals to address problems

6.6. Write M.A.T.R.S.Write M.A.T.R.S.Objectives to meet goals Objectives to meet goals Interventions to assist client in meeting goalsInterventions to assist client in meeting goals

Treatment planning process reviewTreatment planning process review

DateDate Problem StatementProblem Statement

GoalsGoals

D/C CriteriaD/C Criteria ObjectivesObjectives

InterventionsInterventions ServiceServiceCodesCodes

TargetTargetDateDate

ResolutionResolutionDateDate

Participation in the Treatment Planning ProcessParticipation in the Treatment Planning Process

Participation by Others in the Treatment Planning ProcessParticipation by Others in the Treatment Planning Process

ASI Treatment Plan Format

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Write 2 objective statementsRequired or optional for discharge?

Write 2 intervention statementsAssign service codes and target dates

M.A.T.R.S. objectives & interventionsM.A.T.R.S. objectives & interventions

1. Alcohol / Drug Domain1. Alcohol / Drug Domain

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Measurable? Attainable?Measurable? Attainable?Can change be documented? Is it achievable Can change be documented? Is it achievable within active treatment phase? Is it reasonable to within active treatment phase? Is it reasonable to expect the client will be able to take steps on his or expect the client will be able to take steps on his or her behalf?her behalf?TimeTime--Related? Realistic?Related? Realistic?Is time frame specified? Will staff be able to Is time frame specified? Will staff be able to review within a specific period of time?review within a specific period of time? Is it Is it agreeable to client and staff?agreeable to client and staff?Specific? Specific? Will client understand what is expected and how Will client understand what is expected and how programmeprogramme/staff will assist in reaching goals?/staff will assist in reaching goals?

M.A.T.R.S. objectives/interventions testM.A.T.R.S. objectives/interventions test

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2. Medical Domain2. Medical Domain3. Family/Social Domain3. Family/Social Domain

Write 2 objective statementsWrite 2 objective statementsRequired or optional for discharge? Required or optional for discharge?

M.A.T.R.S. objectives & interventionsM.A.T.R.S. objectives & interventions

Write 2 intervention statementsWrite 2 intervention statementsAssign service codes and target datesAssign service codes and target dates

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Other required elementsOther required elements

New, improved DENS Software (2005)New, improved DENS Software (2005)Guides Guides counsellorcounsellor in documenting: in documenting:

Client strengths Client strengths

Participants in planning processParticipants in planning process

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Documentation: Basic guidelinesDocumentation: Basic guidelines

Dated, Signed, Legible

Referral Information

Documented

Client Strengths/ Limitations in Achieving Goals

Source of Information

Clearly Documented

Client Name

on Each Page

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Entries should include . . . Entries should include . . . Your professional assessmentYour professional assessment

Continued plan of actionContinued plan of action


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Describes . . .Describes . . .Changes in client statusChanges in client status

Response to and outcome of Response to and outcome of interventions interventions

Observed Observed behaviourbehaviour

Progress towards goals and Progress towards goals and completion of objectivescompletion of objectives


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The clientThe client’’s treatment record s treatment record is a legal documentis a legal document

Clinical Example:Agency Trip


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Legal Issues & Recommendations:Legal Issues & Recommendations:Document nonDocument non--routine calls, missed sessions, routine calls, missed sessions, and consultations with other professionalsand consultations with other professionalsAvoid reporting staff problems in case notes, Avoid reporting staff problems in case notes, including staff conflicts and rivalriesincluding staff conflicts and rivalriesChart clientChart client’’s nons non--conforming conforming behaviourbehaviourRecord premature dischargesRecord premature dischargesNote limitations of the treatment provided to the Note limitations of the treatment provided to the clientclient


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Method of DocumentationMethod of Documentation

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SSubjective ubjective -- clientclient’’s observations or s observations or thoughts, client statementthoughts, client statement

OObjective bjective –– counsellorcounsellor’’ss observations during observations during sessionsession

AAssessment ssessment -- counsellorcounsellor’’ss understanding of understanding of problems and test resultsproblems and test results

PPlan lan –– goals, objectives, and interventions goals, objectives, and interventions reflecting identified needs reflecting identified needs

S.O.A.P. method of documentationS.O.A.P. method of documentation

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S.O.A.P. note exampleS.O.A.P. note example30 June 2007: Individual Session 30 June 2007: Individual Session S: S: ““My exMy ex--wife has custody of the kids and stands in wife has custody of the kids and stands in

the way of letting me see them.the way of letting me see them.””O: Tearful at times; gazed down and fidgeted with O: Tearful at times; gazed down and fidgeted with

shirt buttons. shirt buttons. A: Client has strong feelings that family is important in A: Client has strong feelings that family is important in

his recovery process. He has a strong desire to be his recovery process. He has a strong desire to be a father to his children and is looking for a way to a father to his children and is looking for a way to resolve conflicts with his exresolve conflicts with his ex--wife. wife.

P: Addressed Tx Plan Goal #4, Action Step 1. P: Addressed Tx Plan Goal #4, Action Step 1. Continue with Tx Plan Goal #4, Action Step 2 in next Continue with Tx Plan Goal #4, Action Step 2 in next session.session.

Mary Smith, CADACMary Smith, CADAC

S: S: ““My exMy ex--wife has custody of the kids and wife has custody of the kids and stands in the way of letting me see them.stands in the way of letting me see them.””

O: Tearful at times; gazed down and fidgeted with O: Tearful at times; gazed down and fidgeted with shirt buttons. shirt buttons.

A: Client has strong feelings that family is A: Client has strong feelings that family is important in his recovery process. He has a important in his recovery process. He has a strong desire to be a father to his children and strong desire to be a father to his children and is looking for a way to resolve conflicts with is looking for a way to resolve conflicts with his exhis ex--wife. wife.

P: Addressed Tx Plan Goal #4, Objective 1. P: Addressed Tx Plan Goal #4, Objective 1. Continue with Tx Plan Goal #4, Objective 2 in Continue with Tx Plan Goal #4, Objective 2 in next session. next session.

Tx Plan Reflected in Documentation?Client quote

Physiological observations?

Problem statements, test results, ASI severity ratings, non-judgmental professional assessment

Goals, objectives, interventions

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CClient Conditionlient Condition

HHistorical significance of client conditionistorical significance of client condition

AAction ction –– What action What action counsellorcounsellor took in took in response to client conditionresponse to client condition

RResponse esponse –– How client responded to actionHow client responded to action

TTreatment Plan reatment Plan –– How it relates to planHow it relates to plan

C.H.A.R.T. method of documentationC.H.A.R.T. method of documentation

(Source: Roget & Johnson, 1995)

Write a Documentation (Progress) Note

Case Note ScenarioYou are a case manager in an adult outpatient drug and alcohol treatment programme. You have an active caseload of 25 patients, primarily young adults between the ages of 18 and 25 who have some sort of involvement with the adult criminal justice system.Jennifer Martin is your patient.

Case Manager: “I am glad to see you made it today, Jennifer. I was starting to get worried about your attendance for the past two weeks.”

Jennifer: “I’ve just been really busy lately. You know, it is not easy staying clean, working, and making counsellingappointments. Are you really worried about me or are you just snooping around trying to get information about me to tell my mom and probation officer?”

Case Manager: “You seem a little defensive and irritated. Are you upset with me or your mom and your probation officer, or with all of us?”

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A treatment plan is like the hub in a wheel A treatment plan is like the hub in a wheel

SCREENING & SCREENING & ASSESSMENTASSESSMENT

ONGOING ONGOING DOCUMENTATIONDOCUMENTATION

DISCHARGE PLANDISCHARGE PLANTX

PLAN REFERRALSREFERRALS

INITIAL SERVICE INITIAL SERVICE AUTHORIZATIONAUTHORIZATION

LEVEL OF CARELEVEL OF CARE

TREATMENT PLAN TREATMENT PLAN REVIEWSREVIEWS

Continued Stay Continued Stay ReviewsReviews

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Other Other organisationalorganisational considerationsconsiderations

1.1. Information Information requirementsrequirements of funding entities / of funding entities / managed care?managed care?

2.2. Is there Is there duplicationduplication of information collected?of information collected?

3.3. Is Is technologytechnology used effectively?used effectively?

4.4. Is Is paperwork usefulpaperwork useful in treatment planning in treatment planning process?process?

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PostPost--assessmentassessment

Please respond to the postPlease respond to the post--assessment assessment questions in your workbook.questions in your workbook.

(Your responses are strictly confidential.)(Your responses are strictly confidential.)

10 Min.

Thank you for your time!Thank you for your time!