Engaging the Addicted Client in Case Planning

1. October 17, 2007 Engaging the Addicted Client in Case Planning Sustaining CalWORKs and Child Welfare Collaboration in Times of Transition Rose Marie Wentz

2. General rules for visits with parents who are addicted: • Substance abuse, by itself, is not child abuse or neglect. • It is highly recommended that the substance abuse treatment professional be a part of the case planning team. • The vast majority of children removed from substance abusing parents are removed for neglect. These parents are not likely to abuse their child during a visit. Page 1

3. General rules for visits with parents who are addicted: • Generally, the parent should be in substance abuse treatment before the level of supervision is lowered. • There should be a safety plan for the child and a relapse plan for the parent, shared with all parties, which will ensure that child will be safe even after a parent appears to be maintaining sobriety. • Most of these children will be reunited with their parents. There is never a guarantee that an addicted person will never relapse. Thereby, Progressive Visitation Planning allows us to assess if the safety and relapse plan will work.

4. Myths versus Facts of Addiction • Drug addiction brings out many emotions and bias. • What do you think about a pregnant mother who: • Smokes • Versus one who drinks alcohol • Versus one who uses meth • Take the test on page 1 without looking at the next pages of handouts.

5. Test Your Knowledge • Failing a UA (urine analysis) means that a parent cannot be safe during a visit. YES or NO

6. NOUA’s - What they CANNOT tell us Page 2 • The current level of intoxication – some drugs will test positive days and weeks after the last use • Whether a parent with a dirty or clean UA is able to be safe or appropriate during a visit. • Whether the person is actually drug free • Many ways to cheat the test • Even medical doctors often fail at performing the test correctly • Whether the person took the drug after the test but before or during the visit • The person may have taken a drug you are not testing for Source: Kim Sumner-Mayer, PhD, LMFT Children of Alcoholics Foundation

7. Test Your Knowledge • Meth is the most common form of addiction in the US. YES or NO

8. NO -- Treatment Admissions by Primary Substance Source: Treatment Episode Data Set (TEDS) – Highlights 2004

9. Test Your Knowledge • As the number of meth users has risen, there has been a corresponding increase in the number of children placed in foster care. YES or NO

10. NO -- Persons who Initiated Substance Use by Year compared to FC placements Source: Nancy K. Young, Ph.D., Director National Center on Substance Abuse and Child Welfare, May 8, 2006

11. Test Your Knowledge • The percent of pregnant women’s admissions for methamphetamine has tripled over the last 10 years. YES or NO

12. YES --Trends in Primary Substance UseTreatment Admissions for Pregnant Females by Primary Substance 1994-2004 Percent of Pregnant Women’s Admissions forMeth/Amphetaminehas tripled over the last 10 Years Source: Analysis of Treatment Episode Data Set (TEDS) Computer File

13. Test Your Knowledge • Meth babies are born addicted and with birth defects YES or NO

14. NO and Maybe • Babies are NOT born addicted to Meth. • David C. Lewis, M.D., Professor of Community Health and Medicine Donald G. Millar Distinguished Professor of Alcohol & Addiction Studies Brown University • Research shows mixed results on whether babies will be born with permanent defects. The problem is that most mothers are multi drug users and drugs such as alcohol and tobacco do lead to birth defects. • Babies can be born with multiple problems due to mother’s meth use. Similar symptoms to other prenatal drug exposure.

15. Mother Uses Meth While Pregnant • Risk to child depends on frequency and intensity of use, and the stage of pregnancy. • Risks may include birth defects, growth retardation, premature birth, low birth weight, brain lesions. • Problems at birth may include difficulty sucking and swallowing, hypersensitivity to touch, excessive muscle tension (hypertonia). • Long term risks may include developmental disorders, cognitive deficits, learning disabilities, poor social adjustment, language deficits. • Early diagnosis and treatment of these problems can prevent long term negative impacts. All Drug Exposed babies should have specialized medical care. Sources: Anglin et al. (2000); Oro & Dixon, (1987); Rawson & Anglin (1999); Dixon & Bejar (1989); Smith et al. (2003); Shah (2002)

16. Test Your Knowledge • Hundreds of children have been medically harmed or died in meth labs in the last five years. YES or NO

17. NO -- Number of Children in Meth Labs *The 2003 figure for the number of incidents is calendar year, while the remaining data in the column are for fiscal year**Data for 2000 and 2001 may not show all children affected Source: El Paso Intelligence Center *The 2003 figure for the number of incidents is calendar year, while the remaining data in the column are for fiscal year**Data for 2000 and 2001 may not show all children affected

18. Test Your Knowledge • Children whose parents are addicted to meth are less likely to go home than children whose parents are addicted to other drugs. YES or NO

19. NO -- 24-Month Child Placement Outcomes by Parent Primary Drug Problem Source: Nancy K. Young, Ph.D., Director National Center on Substance Abuse and Child Welfare, May 8, 2006

20. Test Your Knowledge • Meth addicts are less likely to recover than other types of drug addicts. YES or NO

21. NO --Treatment Discharge Status by Primary Drug Problem*** ***p<.001 Source: Nancy K. Young, Ph.D., Director National Center on Substance Abuse and Child Welfare, May 8, 2006

22. Different Risks to Children Based on Type of Parental Involvement Page 2 • Parent uses or abuses methamphetamine • Parent is dependent on methamphetamine • Mother uses meth while pregnant • Parent “cooks” small quantities of meth • Parent involved in trafficking • Parent involved in super lab Progressively more risks Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

23. Risks most commonly related to meth use are: • Parental behavior under the influence: poor judgment, confusion, irritability, paranoia, violence • Chronic neglect – supervision, food, lack of medical care, lack of utilities • Inconsistent parenting - lack of attachment activities and setting of appropriate boundaries • Chaotic home life – moving, changing schools, no safety system • Exposure to meth, chemicals, needles and second-hand smoke • Higher possibility of physical and sexual abuse by parents and others Page 2

24. Risks most commonly related to meth use are: • Parent is incarcerated - trauma of arrest and separation • Pre-natal exposure may lead to hypersensitivity, difficulty sucking and other problems that will need special care and addicted parent is less likely to be able to provide this care • It is common for meth users to be using multiple drugs. Pre-natal exposure to alcohol can cause birth defects, i.e. fetal alcohol syndrome • Contact with other adults who may be abusive to the child • All of these risks can and must be addressed. Page 2

25. What predicts longer Abstinence for Meth Addicts • Longer time in treatment, e.g. those with 4 or more months of treatment • More sessions per month of individual counseling (or sexual recovery groups) • Treatment, intervention and case planning that account for short-term effects, especially cognitive deficits and verbal communication • Drug Court involvement • Family involvement in treatment, including visits Page 2

26. Other Meth Facts • Meth is dangerous and does impact the user • Impacts are reversible • Meth is decreasing in most Western States but is increasing in some Eastern States • We need more treatment programs for meth addicts

27. What is a Relapse ? Page 3 • Triggers • Warning Signs and THEN • Relapse • What are precursors to relapse? • Life changes • Stress • Return home of their child Relapse is an opportunity for growth and an indication that treatment could be in jeopardy. Pay attention to the circumstance surrounding the event.

28. What is a Relapse Plan? • ID – triggers, warning signs and who is in a position to notice these signs • After care services • Good communication between everyone • Support network • Coordinate service and treatment plans • INCLUDE treatment professional in case planning team!

29. Indicators of Significant Recovery • Staying in treatment • Clean Urinalysis Assessment (UA’s) • Has a relapse plan and uses it • Building a sober support system; family is involved in treatment • Taking responsibility • Participation in the treatment – does not matter why • Participate in visits and other services related to their children • Parents and children learning to relate without substances • Maintaining relationships with treatment providers • Using new healthy coping mechanisms to deal with life stresses • Reporting a dramatic change in the way they feel and see things • Responding cautiously to questions about the future • Being able to relate to their own life concepts learned in treatment and 12-step groups • Creating and using a safety plan for the child, in case relapse should occur • Re-entering treatment quickly if there is a relapse Pg 4-5

30. Change Process Goal Barriers Activities crisis Status Quo

31. Abraham Maslow’sHierarchy of Needs Match your interview technique to the customer’s needs and focus at this point … at this time Self- Actualization Personal growth and fulfillment Esteem Needs Achievement, status, responsibility, reputation, etc. Love Needs Family, affection, relationships, work groups, etc. Safety Needs Protection, security, order, law, limits, stability, etc. Physiological Needs Basic life needs – air, food, drink, shelter, warmth, sex, sleep, etc. Adapted from Alan Chapman www.businessballs.com

32. CDSS Mission • The mission of the California Department of Social Services is to serve, aid, and protect needy and vulnerable children and adults in ways that strengthen and preserve families, encourage personal responsibility, and foster independence.

33. Adoption and Safe Families Act (ASFA) 1997 Safety • Children are, first and foremost, protected from abuse and neglect. • Children are safely maintained in their own homes whenever possible and appropriate. Permanency • Children have permanency and stability in their living situations. • The continuity of family relationships and connections is preserved for children. Well-Being • Families have enhanced capacity to provide for their children’s needs. • Children receive appropriate services to meet their educational needs. • Children receive adequate services to meet their physical and mental health needs.

34. Temporary Assistance for Needy Families (TANF) • To end the cycle of dependency on public assistance for families. • The CalWORKs program goal is to assist recipients to obtain employment while remaining on aid, as well as moving recipients from welfare to work. • CalWORKs WTW program is recipient self-sufficiency through employment. Rules ensure that individuals who work are better off financially than if they do not work. • Child well-being is defined as the provision of food, clothing and shelter, while ensuring educational progress, health and safety, and economic support for the child. • Reauthorization provisions of the federal Deficit Reduction Act of 2005, requires a significant increase in the number of recipients participating in activities that count toward the TANF work participation rate (WPR) requirements of 50 and 90 percent for all families and two-parent families, respectively.

35. Job of the Case Manager • To find an overlap between the agency goal and the client’s goal. Client’s goal Agency goal The overlap area is developed into the joint case planning goal.

36. Definition page 6 “MOTIVATIONAL INTERVIEWING is a directive, client-centered, style for eliciting behavior change by helping clients explore and resolve ambivalence.” ~Miller & Rollinick, 2000

37. Definition “AMBIVALENCE is a state of mind in which the person has coexisting but conflicting feelings about something. [They may]…experience severe conflict about engaging versus resisting [change]…working with ambivalence is working with the heart of the problem. One reason why brief interventions may work so well is that they help people to get ‘unstuck’ from their ambivalence—to make a decision and move on toward change.” ~Miller & Rollinick, 2000

38. Motivational Interviewing Change is not imposed from the outside • It is the client’s task to articulate and resolve ambivalence • Worker’s style is quiet and eliciting • Readiness to change is not a client trait, but a product of the interpersonal interaction • A partnership rather than expert/recipient roles • Seek to understand the person’s POV Pg 1

39. Confrontation Approaches • Argue that the client has a problem that needs to be changed • Offers direct advice or prescribes solutions • Uses authoritative stance – client is passive • Does most of the talking • Imposes a label • Behaves in punitive or coercive manner

40. OARS • Open-ended questions • Affirmation • Reflective listening • Summary Roll with Resistance • Reflection • Shifting focus • Emphasizing personal control and choice • Reframing • Engaging the client

41. 10 Strategies for Evoking Change Talk • Ask Evocative Questions • Explore Decisional Balance • Ask for Elaboration • Ask for Examples • Look Back • Look Forward • Query Extremes • Use Change Rulers • Explore Goals and Value • Come Alongside

42. Less “USEFUL” QUESTIONS • Begin with “Why?” implies blame; presumes insight into problem • Can be answered “yes” or “no” -- because then it’s your turn again already • End with a tag like “don’t you?” or “right?” “You want to be sober, don’t you?” No hand out page

43. Motivational General Principles & Best Practices  Express Empathy  Develop Discrepancy*  Avoid Argumentation  Roll with Resistance Support Self-Efficacy “On the one hand you say… yet I notice that you still… so please tell me more about…”

44. Motivational General Principles & Best Practices  Express Empathy  Develop Discrepancy  Avoid Argumentation  Roll with Resistance Support Self-Efficacy* *Hope. Optimism.The belief that they can be successful and that it’s their responsibility to take the steps

45. Traps to Avoid Avoid “Traps” • Expert Trap • Labeling Trap • Unsolicited Advice • Premature Focus • Question – Answer • Blaming Trap Premature Focus Pg 10