Clinical application Clinical application Why use the ASI? Why use the ASI? � Prompts clinician to focus session on Prompts clinician to focus session on � important problems, goals, and important problems, goals, and objectives objectives � Basis for reviews of progress during Basis for reviews of progress during � treatment and documentation treatment and documentation � Basis for discharge plan Basis for discharge plan � 27
Clinical application Clinical application Why use the ASI? Why use the ASI? NIDA Principle 3: NIDA Principle 3: “To be effective, treatment must address the To be effective, treatment must address the “ individual’ ’s drug use and any associated s drug use and any associated individual 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. 28
29 application application Clinical Clinical
Clinical application Clinical application Clinical use of ASI improves rapport Clinical use of ASI improves rapport “. . . If patients . . . If patients’ ’ problems are accurately problems are accurately “ assessed, they may feel ‘ ‘heard heard’ ’ by their by their assessed, they may feel counsellor, potentially leading to the , potentially leading to the counsellor development of rapport and even a stronger development of rapport and even a stronger helping alliance.” ” helping alliance. 30 (Sources: Barber et al., 1999, 2001; Luborsky et al., 1986, 1996)
Clinical application Clinical application Using ASI to match services to client Using ASI to match services to client problems improves retention. problems improves retention. “. . . 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) 31
Evaluation uses Evaluation uses For Programme Programme Directors: Directors: For � Identifies types of client problems � Identifies types of client problems not addressed through the not addressed through the programme’ ’s s treatment services treatment services programme � Quantifies client problems � Quantifies client problems � Identifies trends over time � Identifies trends over time Continued 32
Evaluation uses Evaluation uses For Programme Programme Directors: Directors: For � Assists with level � Assists with level- -of of- -care choices care choices � Provides measure of � Provides measure of programme programme success success � Documents unmet client service � Documents unmet client service needs needs � Includes data needed for reports to � Includes data needed for reports to various stakeholders various stakeholders Continued 33
Evaluation uses Evaluation uses For Programme Programme Directors Directors For � Positions � Positions programmes programmes for for increased funding though increased funding though participation in clinical trials and participation in clinical trials and other research opportunities other research opportunities 34
Evaluation uses Evaluation uses For Clinical Supervisors For Clinical Supervisors ASI data can be used to ASI data can be used to � Identify Identify counsellor counsellor strengths and strengths and � training needs training needs � Match clients to Match clients to counsellor counsellor � strengths strengths � Identify trends in client problems Identify trends in client problems � 35
Workshop 2: Treatment plans Workshop 2: Treatment plans Programme-Driven versus Individualized 36
Biopsychosocial Model Biopsychosocial Model Biological Psychological Sociological 37
Biopsychosocial Model example ... Biopsychosocial Model example ... Does the client have a car? Can they access public How available transportation? are drugs or alcohol in the Sociological home? How close do they live to the treatment centre? 38
ASI problem domains and the ASI problem domains and the biopsychosocial model model biopsychosocial Biological Psychological (e.g., medical (e.g., psychiatric status) status) Sociological (e.g., family & social status) 39
Field of substance abuse treatment: Early work Field of substance abuse treatment: Early work Programme- -Driven Plans Driven Plans Programme “One size fits all One size fits all” ” “ 40
Programme- -driven plans driven plans Programme � Client needs are not important as the client is Client needs are not important as the client is � “fit fit” ” into the standard treatment into the standard treatment programme programme “ regimen regimen � Plan often includes only standard Plan often includes only standard programme programme � components (e.g., group, individual sessions) components (e.g., group, individual sessions) � Little difference among clients Little difference among clients’ ’ treatment treatment � plans plans 41
Programme- -driven plans driven plans Programme Client will . . . Client will . . . 1. “ “Attend 3 Alcoholic Anonymous meetings Attend 3 Alcoholic Anonymous meetings 1. a week” ” a week 2. “ “Complete Steps 1, 2, & 3 Complete Steps 1, 2, & 3” ” 2. 3. “ “Attend group sessions 3 times / week Attend group sessions 3 times / week” ” 3. 4. “ “Meet with Meet with counsellor counsellor 1 time / week 1 time / week” ” 4. 5. “ “Complete 28 Complete 28- -day day programme programme” ” 5. “Still don’t fit right” 42
Programme- -driven plans driven plans Programme � Often include only those services Often include only those services � immediately available in agency immediately 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?” 43
Treatment planning: A paradigm shift Treatment planning: A paradigm shift Individualised Treatment Plans - Many colors / styles available - - Custom style & fit - 44
Individualised plan plan Individualised “Sized” to match client’s problems and needs 45
To individualise individualise a plan, what a plan, what To information is needed? information is needed? 1. What does a What does a counsellor counsellor need to need to 1. discuss with a client before developing discuss with a client before developing a treatment plan? a treatment plan? 2. Where do you get the information, Where do you get the information, 2. guidelines, tools, etc.? guidelines, tools, etc.? 46
To individualise individualise a plan, what a plan, what To information is needed? information is needed? Possible sources of information Possible sources of information might include: might include: � Probation reports Probation reports � � Screening results Screening results � � Assessment scales Assessment scales � � Collateral interviews Collateral interviews � 47
Case A assessment information: Jan Case A assessment information: Jan � 27 27- -year year- -old, single Caucasian female old, single Caucasian female � � 3 children under age 7 3 children under age 7 � � No childcare available No childcare available � � Social companions use drugs / alcohol Social companions use drugs / alcohol � � Unemployed Unemployed � � Low education level Low education level � � 2 arrests for possession of 2 arrests for possession of meth meth & & � cannabis plus 1 probation violation cannabis plus 1 probation violation 48
Case B assessment information: Dan Case B assessment information: Dan � 36 36- -year year- -old, married African old, married African- -American male American male � � 2 children 2 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 problems High severity family problems � 49
The “ “Old Method Old Method” ”: : The (Programme Programme- -Driven) Problem Statement Driven) Problem Statement ( “Alcohol dependence Alcohol dependence” ” “ � Not Not individualised individualised � � Not a complete sentence Not a complete sentence � � Doesn Doesn’ ’t provide enough information t provide enough information � � A diagnosis is not a complete A diagnosis is not a complete � problem statement problem statement 50
The “ “Old Method Old Method” ”: : The (Programme Programme- -Driven) Goal Statement Driven) Goal Statement ( “Will refrain from all substance use now Will refrain from all substance use now “ and in the future” ” and in the future � Not specific for Jan or Dan Not specific for Jan or Dan � � Not helpful for treatment planning Not helpful for treatment planning � � Cannot be accomplished by Cannot be accomplished by � programme discharge discharge programme 51
The “ “Old Method Old Method” ”: : The (Programme Programme- -Driven) Objective Statement Driven) Objective Statement ( “Will participate in outpatient Will participate in outpatient “ programme” ” programme � Again, not specific for Jan or Dan Again, not specific for Jan or Dan � � A level of care is not an objective A level of care is not an objective � 52
The “ “Old Method Old Method” ”: : The (Programme Programme- -Driven) Intervention Statement Driven) Intervention Statement ( “Will see a Will see a counsellor counsellor once a week and once a week and “ attend group on Monday nights for 12 attend group on Monday nights for 12 weeks” ” weeks � This sounds specific, but it describes This sounds specific, but it describes � a programme programme component component a 53
Why make the effort? Why make the effort? Individualised Treatment Plans: Treatment Plans: Individualised � Lead to increased retention rates, Lead to increased retention rates, � which are shown to lead to improved which are shown to lead to improved outcomes outcomes � Empower the counselor and the client, Empower the counselor and the client, � and give focus to counseling sessions and give focus to counseling sessions 54
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 “ “fits fits” ” the client well the client well plan ASI: ASI: � Like measurements, the ASI Like measurements, the ASI � items are used to “ “fit fit” ” the the items are used to client’ ’s services to her or s services to her or client his needs his needs 55
What is included What is included in any treatment plan? in any treatment plan?
Treatment plan components Treatment plan components 1. Problem Statements 2. Goal Statements 3. Objectives 4. Interventions 57
Treatment plan components Treatment plan components 1. Problem Statements Problem Statements are based on are based on 1. information collected during the information collected during the assessment assessment 2. Goal Statements Goal Statements are based on the are based on the 2. problem statements and are problem statements and are reasonably achievable in the active reasonably achievable in the active treatment phase treatment phase 58
Problem statement examples Problem statement examples � 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 effect desired effect � Meghan* is currently pregnant and requires Meghan* is currently pregnant and requires � assistance obtaining prenatal care assistance obtaining prenatal care � Tom Tom’ ’s* psychiatric problems compromise s* psychiatric problems compromise � his concentration on recovery his 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. 59
Goal statement examples Goal statement examples � Van will safely withdraw from alcohol, Van will safely withdraw from alcohol, � stabilise physically, and begin to establish a physically, and begin to establish a stabilise recovery programme programme recovery � Meghan will obtain necessary prenatal care Meghan will obtain necessary prenatal care � � Reduce the impact of Tom Reduce the impact of Tom’ ’s psychiatric s psychiatric � problems on his recovery and relapse problems on his recovery and relapse potential potential 60
Treatment plan components Treatment plan components Objectives are what the client will do to 3. Objectives are what the client will do to 3. meet those goals meet those goals Interventions are what the staff will do to 4. Interventions are what the staff will do to 4. assist the client assist the client Other common terms: • Action Steps • Measurable activities • Treatment strategies • Benchmarks • Tasks 61
Examples of objectives Examples of objectives � Van will report acute withdrawal symptoms Van will report acute withdrawal symptoms � � Van will begin activities that involve a Van will begin activities that involve a � substance- -free lifestyle and support his free lifestyle and support his substance recovery goals recovery goals � Meghan will visit an OB/GYN physician or Meghan will visit an OB/GYN physician or � nurse for prenatal care nurse 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 relapse relapse 62
Intervention examples Intervention examples � Staff medical personnel will evaluate Van Staff medical personnel will evaluate Van’ ’s s � need for medical monitoring or medications need for medical monitoring or medications � 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 services for necessary medical services � Staff will review Tom Staff 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 feelings managing those feelings 63
Review: Treatment Plan Components Review: Treatment Plan Components 1. Problem Statements Problem Statements (information from assessment) 1. (information from assessment) 2. Goal Statements Goal Statements (based on problem statement) 2. (based on problem statement) 3. Objectives Objectives (what the client will do) 3. (what the client will do) 4. Interventions Interventions (what the staff will do) 4. (what the staff will do) 64
Treatment plan components Treatment plan components Other aspects of the client’ ’s condition: s condition: Other aspects of the client 1. Client Strengths* Client Strengths* are reflected are reflected 1. 2. Participants in Planning Participants in Planning* are * are 2. documented documented * The DENS Treatment Planning Software * The DENS Treatment Planning Software includes these components includes these components 65
ASI Narrative and ASI Narrative and Master Problem List Master Problem List
Master Problem List Master Problem List Refer to ASI Narrative Report Refer 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/drug domain domain � alcohol/drug � medical domain domain � medical � family/social domain domain � family/social � 67
ASI Master Problem List ASI Master Problem List Date Date Domain Domain Problem Problem Status Status Date Resolved Date Resolved Identified Identified Alcohol/Drug Alcohol/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. Medical Client has a chronic medical problem that interferes with Medical Client has a chronic medical problem that interferes with his/her life his/her life Family/Social The client is not satisfied with how he/she spends his/her free Family/Social The client is not satisfied with how he/she spends his/her free time time The client reports having serious problems with family The client reports having serious problems with family members in the past month members 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 treatments treatments Master Problem List 68
Considerations in writing Considerations in writing � All problems identified are included All problems identified are included � regardless of available agency services regardless 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 problem approach to addressing a problem Master Problem List 69
Tips on writing problem Tips on writing problem statements statements � Non Non- -judgemental judgemental � � No jargon, such as No jargon, such as… … � “Client is in denial Client is in denial” ” “ � � “Client is co Client is co- -dependent dependent” ” “ � � � Use complete sentence structure Use complete sentence structure � Problem Statements 70
Changing language Changing language 1. Client has low self Client has low self- -esteem. esteem. 1. 2. Client is in denial. Client is in denial. 2. 3. Client is alcohol dependent. Client is alcohol dependent. 3. 4. Client is promiscuous. Client is promiscuous. 4. 5. Client is resistant to treatment. Client is resistant to treatment. 5. 6. Client is on probation because Client is on probation because 6. he is a bad alcoholic. he is a bad alcoholic. 71 Problem Statements
Changing language: Pick two Changing language: Pick two � 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 non Rewrite those statements using non- - � judgemental and jargon and jargon- -free language free language judgemental Problem Statements 72
Changing language: Examples Changing language: Examples 1. Client has low self- -esteem. esteem. 1. Client has low self – Client averages 10 negative self Client averages 10 negative self- -statements daily statements daily – 2. Client is in denial. 2. Client is in denial. – Client reports two Client reports two DWIs DWIs (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 problem is not a problem 3. Alcohol Dependent. 3. Alcohol Dependent. – 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 use to alcohol use Continued Problem Statements 73
Changing language: Examples Changing language: Examples 4. Client is promiscuous. 4. Client is promiscuous. – Client participates in unprotected sex 4 Client participates in unprotected sex 4 – times a week with multiple partners times a week with multiple partners 5. Client is resistant to treatment. 5. Client is resistant to treatment. – In past 12 months, client has dropped out of 3 In past 12 months, client has dropped out of 3 – treatment programmes programmes prior to completion prior to completion treatment 6. Client is on probation because he is a bad 6. Client is on probation because he is a bad alcoholic. alcoholic. – Client has legal consequences because Client has legal consequences because – of alcohol- -related related behaviour behaviour of alcohol 74 Problem Statements
Case study problem statements Case study problem statements � Alcohol/drug domain Alcohol/drug domain � � Medical domain Medical domain � � Family/social domain Family/social domain � Write 1 problem statement for each domain. Write 1 problem statement for each domain. 75 Problem Statements
ASI Treatment Plan Format ASI Treatment Plan Format Date Domain Problem Status Date Date Domain Problem Status Date Identified Identified Resolved Resolved 76
Workshop 3: Prioritising Prioritising problems problems Workshop 3: M A T R S 77
Now that we have the Now that we have the problems identified… …how do how do problems identified we prioritise prioritise them? them? we
Maslow’ ’s hierarchy of needs s hierarchy of needs Maslow 5 Self-actualisation 4 Self-esteem 3 Love & Belonging 2 Safety & Security 1 Biological/Physiological 79
Physical needs Physical needs • Substance Use • Substance Use • Physical Health Management • Physical Health Management • Medication Adherence Issues • Medication Adherence Issues 1 Biological/Physiological Biological/Physiological PHYSIOLOGICAL 80
Safety & security Safety & security � Mental health management � Functional impairments � Legal issues 2 Safety & Security Safety & Security 81
Love & belonging Love & belonging 3 Love & Belonging Love & Belonging � Social & interpersonal skills � Need for affiliation � Family relationships 82
Self- -esteem esteem Self 4 Self- -Esteem Esteem Self � Achievement and mastery � Independence/status � Prestige 83
Self- -actualisation actualisation Self 5 Self-Actualisation � Seeking personal potential � Self-fulfilment � Personal growth 84
Self- -esteem & self esteem & self- -actualisation actualisation Self 5 Self-actualisation 4 Self-esteem � Is “self-esteem” specific? 85
Relationship between ASI domains & Relationship between ASI domains & Maslow’ ’s hierarchy of needs s hierarchy of needs Maslow Self- -actualisation actualisation Self Self- -esteem esteem Self ASI Domain 5 – Family/Social Relationships Love & Love & Belonging Belonging ASI Domain 2 – Employment/Support Status ASI Domain 4 – Legal Status Safety & Security Safety & Security ASI Domain 1 - Medical ASI Domain 3 – Drug / Alcohol Use Biological/ Biological/ ASI Domain 6 – Psychiatric Status Physiological Physiological
Practise prioritising prioritising Practise � 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 � st , 2 nd , 3 rd , addressed 1 st , 2 nd , 3 rd , and why? and why? addressed 1 87
Writing goal statements Writing goal statements � Use ASI Treatment Plan Handouts Use ASI Treatment Plan Handouts � Alcohol / 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 � domain domain � Write in complete sentences Write in complete sentences � 88
Check- -in discussion in discussion Check � 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? 89
Treatment M.A.T.R.S. objectives and interventions Treatment M.A.T.R.S. objectives and interventions A M Attainable Measurable T R S Time-limited Specific Realistic 90
M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions Measurable Measurable M � Objectives and interventions are measurable � Achievement is observable � Indicators of client progress are measurable � Assessment scales / scores � Client report � Behavioural and mental health status changes 91
M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions A Attainable Attainable � Identify objectives and interventions Identify objectives and interventions � attainable during active treatment phase attainable during active treatment phase � Focus on Focus on “ “improved functioning improved 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 another level of care to another 92
M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions T Time- -limited limited Time � Focus on time-limited or short-term goals and objectives � Objectives and interventions can be reviewed within a specific time period 93
M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions Realistic Realistic � Client can realistically complete objectives Client can realistically complete objectives � within specific time period within 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 functioning level of functioning � Progress requires client effort Progress requires client effort � 94
M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions S Specific Specific � Specific and goal Specific and goal- -focused focused � � Address in specific Address in specific behavioural behavioural � terms how level of functioning or terms how level of functioning or functional impairments will improve functional impairments will improve 95
M.A.T.R.S. clinical example M.A.T.R.S. clinical example Problem Statement: Client reports Client reports Problem Statement: 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. A M T R S 96
M.A.T.R.S. clinical example M.A.T.R.S. clinical example A M Example Goal: Client will safely reduce or Example Goal: Client will safely reduce or T discontinue alcohol consumption discontinue alcohol consumption R S Example Objective: Client will continue to Example Objective: 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 evaluation to medical staff for evaluation Example Intervention: Counselor / medical Example Intervention: 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. 97
Do examples pass M.A.T.R.S. guidelines? Do examples pass M.A.T.R.S. guidelines? M M What makes these examples measurable measurable? ? What makes these examples What makes these examples attainable attainable? ? What makes these examples A What makes these examples time time- -limited limited? ? What makes these examples T T What makes these examples realistic realistic? ? What makes these examples R R S S What makes these examples specific specific? ? What makes these examples 98
Workshop 4: Putting Treatment Workshop 4: Putting Treatment Planning M.A.T.R.S. into Practise Practise Planning M.A.T.R.S. into
The Stages of Change: Illustrated The Stages of Change: Illustrated Adapted from Prochaska & DiClemente, 1982; 1986 100
Recommend
More recommend
