Treatment Continuity

1. Treatment Continuity Treatment Planning from Assessment Through Completion

2. Synchronicity – Not just another Police album • Synchronicity is the experience of two or more events that are apparently unrelated, yet are experienced as occurring together in a meaningful manner. It was first described by Carl Jung in the 1920s. (Wikipedia)

3. In treatment, we want to have a synchronicity, or a continuity from beginning to end, related to the assessment, the treatment plan, and the treatment that is provided.

4. How do these all fit together? • Sometimes, however, we get a limited perspective of the program, the clients, and the treatment process. It’s good to see the whole picture. This lets us know where our part fits in with the other parts. This training will give some examples and insights into the individual parts to give a better understanding of the whole.

5. What’s your problem? • To provide treatment, we have to first identify the problems or areas that need improvement. That’s where assessment comes in.

6. Assessment • Correctional Treatment usually requires at least 2 kinds of assessments. • The ORAS is a risk assessment. It gives us basic information related to the risk of the client recidivating. This is good, and we need to use this information to develop treatment plans, but it does not cover a number of other issues that a client may have. Therefore, the State requires us to also use a secondary, or responsivity, assessment.

7. Assessment • The secondary assessment is usually a biopsychosocial assessment which addresses further issues related to health, family, more in-depth substance use, mental health, etc. It also gives us information on diagnosis, which is required by OhioMHAS for certified treatment programs. In addition to the ORAS domains, we are required to address any issues identified in the biopsychosocial through treatment planning.

8. Complications! Assessing humans can get complicated. For instance, during a substance use assessment, a client might begin talking about mental health issues. What do we do then?

9. Substance use can look like mental health Because mental health issues often involve a “chemical imbalance”, and drugs cause a brain to become imbalanced, it is difficult, if not impossible, to tell if someone who is actively or recently using is actually mentally ill.

10. Cross-check In a recent review of clients at CTF, it was found that, in the sample of the clients identified with mental health issues,100% of them also had a substance use issue, and that in 95.3% of these clients, substance use issues or some sort of trauma or family issue was present when the mental health issues were identified.

11. Corroborative Information One of the first things we want to do is to find out if the client’s substance use issues are causing or contributing to the mental health “symptoms”. Getting releases of information for any other agencies the client has worked with can help with this.

12. Monitor and Evaluate In many corrections agencies, we have the ability to have 24-hour a day observation of the client. If a client is experiencing mental health symptoms, we should see those consistently, not just when treatment staff are looking.

13. Tolerance and Withdrawal • As an individual uses substances (not just illegal ones) for a period of time, two processes begin to occur; tolerance and withdrawal. Let’s say that the Average Joe who is walking down the street having a good day has a certain level of positive brain chemicals operating in his system. For argument’s sake, we’ll call these “happy faces”. Happy faces represent brain chemicals that effect aspects of your life that influence quality, like affect.

15. For anything we do artificially that our bodies and brains are intended to do naturally, there is a consequence. Our bodies and brains like the balance that they are in naturally. This is called homeostasis. As Joe’s brain adjusts to, or tolerates, having the drugs in his system, his body and brain adapt to the changes the drugs are creating. His brain then cuts its natural production of these brain chemicals.

16. When Joe comes down from the high, he will not come back down to the same level he was at before. Then, when he goes to get high again, he will be seeking the same high, but in many cases will not be able to get the same high as the first time. Many addicts call this “Chasing the Dragon”.

17. As Joe continues this cycle, he will go through ups and downs in his moods, may experience physical conditions, and show mental health symptoms. By the time Joe finally gets incarcerated or goes to treatment, he will likely no longer be using to get high but just to feel normal.

18. As Joe’s brain no longer has those chemicals being artificially placed in his system, and since his brain is no longer naturally producing them at correct levels, Joe will experience effects from this. We call this withdrawal.

19. What many people don’t know is that there are 2 kinds of withdrawal. Acute withdrawal is what occurs in the first hours to around 2 to 4 weeks after last use. This varies based on the individual, the substance that was used, how long and how much was being used, as well as other things.

20. The other kind of withdrawal is post-acute, or protracted, withdrawal. These are the long-term side effects of what the drug has done to the system. Just like a diver cannot come to the surface quickly after a deep dive, the brain cannot quickly re-balance the chemicals that allow it to function normally.

21. Because most people do not know about post-acute withdrawal, however, they believe that the withdrawal is over after a few months. It can actually last around 2 years. Yep, that’s right. 2 YEARS!!! So when they experience long-term symptoms as their brain is trying to rebalance itself, they believe that there is something physically or mentally wrong with them, and the symptoms often look the same as a physical or mental condition. When the client goes for “help”, since the doctor or psychiatrist is probably not aware of post-acute withdrawal either, they often mistakenly diagnose the individual with a physical or mental illness.

22. Dual Diagnosis requires Dual Training If our clients are dealing with both of these issues, but we only have at best one half of the solution, we are not going to be effective. As professionals, we need to be well-educated and trained in both mental health and substance use issues. We’ll save that for another training.

23. Treatment Planning Once we know (or at least kinda know) what the heck is going on with the client, we can then begin to create a plan of attack on how the help the client improve. OhioMHAS says that we have to have a treatment plan done within 7 days of the assessment.

24. Why do I have to do this? • I mean the clients, not the staff. Unfortunately, many of our clients are mandated for treatment. Not all of our clients want help with all of the issues that have been identified. How do we handle these situations?

25. Motivation • It all comes down to motivation. Finding out what motivates the client is what makes a good treatment plan. While many of our clients may not want to change certain aspects of their lives, they are at least likely to not want to be incarcerated or have to deal with us longer than need be. Those are great motivators!

26. Treatment Planning What makes up a good treatment plan? What time frame should we be using for the treatment plans? Who does the burden of completing the treatment plan fall on?

27. Treatment Planning When completing treatment plans, a good place to start is with the problem. This may seem negativistic, but since the purpose of a treatment plan is to work on a problem or issue, then it makes sense to begin with identifying which problem you’re going to be working on.

28. Treatment Planning From the problem, identifying strengths is a good next option. Some people use the same strengths for each treatment plan, and that’s not wrong. If you look at strengths as things that may help the client overcome that specific problem, however, you would most likely get different strengths with each problem area. These help us look at things the client may have done in the past to find some improvement or make some progress with that issue.

29. Treatment planning From there, identifying past or potential barriers to change may be wise. If we can identify things that have tripped a client up before, we can look at ways they can avoid these pitfalls now.

30. GOOOOAAAALLLLL As the name suggests, the goal is something we are trying to accomplish. It’s the big picture, the ideal, or the final destination that the client wants to arrive at from the treatment. Goals should be personal to the client. That way the client has buy-in to the goal and makes it his/her own.

31. Objective The objective then becomes a step along the way to reaching the goal. We use SMART objectives, ones that are: specific, measurable, attainable, realistic, and time-sensitive.

32. Methods The methods are “where the rubber meets the road”. These are the actual steps taken by the client and the staff that move the client forward with the objectives and closer to the goal. While much of the treatment in a program may be general, the methods make the programming fit the individual client’s needs.

33. Practice Now it’s time for you to practice. Pair up and develop treatment plans for each other.

34. Autopilot – it’s not just for airplanes anymore. If you’ve ever flown on a commercial airliner, you know the pilot has 2 major jobs: takeoff and landing. In between, the jet is being navigated by autopilot. You need 2 things for autopilot to navigate a plane: where you’re at and where you want to go. The assessment helps us know where the client is at. The treatment plan lets us know where he wants to go.

35. Progress, not perfection While an airplane may be off course 95% of the time, 99.99% of the time, they arrive at their destination on time. So it may be with our clients, too. What autopilot does is, each time the plane is off course, it corrects the path of the plane. Until our planes (the clients) develop their own sense of direction, we need to help them to course-correct.

36. How do we do that? The reality is that our clients have been off course, many of them for their whole lives. It takes time and patience on both our parts to get these behavior patterns to change. It doesn’t happen over night. But with steady and persistent course-correction, we can help to put a client on track and give them the tools to stay that way.

37. Document, document, document To “chart the course” of the clients progress (or lack of), we have to document. There are several forms of documentation to help us track a client’s progress.

38. Individual notes Think of the individual note as the day-to-day documentation of the client’s progress. When we meet with our clients to work on their individual treatment plans, we then document what we’re doing in relation to the plan and if the client is making progress towards these goals and objectives or not.

39. Weekly notes The weekly note is a broader view of the client’s progress. It takes not only your work with the client but the work of all of the other staff who have input into a client’s treatment into account. This then helps us to see if a client is making progress, is off course, or is going backwards with the goals he/she is working toward.

40. Group notes Group notes are the most plentiful notes we produce. It was estimated that a CD counselor with 5 groups per day could theoretically produce around 39,000 notes in a year. Luckily the state now accepts electronic signatures. Group notes reflect a client’s general programming. The individual note and the weekly note need to connect how the groups are meeting the client’s individual needs.

41. Consistency There should be a consistency among the documentation. This should also get reflected in the clients’ other documentation, such as the phase movement application, the discharge summary, the continued stay criteria, etc.

42. Putting it all together So we can see how important the whole treatment process is from beginning to end. Without a good assessment, we nor the client knows where he’s at. Without a good treatment plan, one that the client helps to develop, we nor the client knows where he wants to go. Without proper documentation, we nor the client knows if progress is being made.

43. The End – or is it just the beginning? Questions?