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| The Rubik’s Cube of Addiction Counseling: Treatment Planning – Recovery Tools, Recovery Contracts |
| Feature Articles - Treatment Strategies or Protocols | |
| Saturday, 30 September 2006 | |
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The first article of this series explored setting the stage and orienting the client to addiction counseling, and the second outlined considerations for screening and assessing to help them determine their options. The third installment of this series explores strategies and considerations for aligning treatment planning, recovery tools, and recovery contracts based on the client's needs and readiness. The first two articles set the stage for this part of the process that often occurs in the first session. Intake, screening, and assessment of persons with a potential addictive disorder need to balance rigor and action to get them moving in the right direction as quickly as it makes sense. Rarely is it of value to have a client go through hours and hours of clinical measures and assessment. Clinical measures and assessment tools need to facilitate the process, not dominate it. The goal is to get clients engaged in an action plan that meets their needs and wants. Addiction counselors use clinical measures and screening tools to ensure the assessment conclusions have efficacy. Different agencies and providers navigate assessment processes differently. I teach my students that we want to get to action planning as soon as possible so the client is focused on new actions to instill the confidence they need to make a change and take charge of his/her life. The treatment plan evolves from the formal or informal assessment. It is aimed at defining the goal and objectives, and determines the kinds of addiction recovery tools that will be used to guide the client along the change continuum. Our role as addiction counselors in the treatment planning process is to help the client discover opportunities. Often in the early stages of treatment, especially during the assessment and treatment planning phase, our role may require us to help the client to take actions. In these situations, clients benefit from the use of Motivational Interviewing. (For more information on this recovery tool go to http://www.motivationalinterview.org/.) Regardless of the methodology, the goal of the assessment process is the same: to facilitate the development of the client's treatment plan by setting priorities and actions. Before developing the treatment plan, the counselor must keep in mind that all actions must be aligned with the client's current level of motivation and capabilities. For example, Ries (1994) reports that nearly one-third of patients with psychiatric disorders experience substance abuse and more than one-half of substance-abusing clients have met the diagnostic criteria for a psychiatric disorder. A dual diagnosis may influence a client's capabilities. Being in tune with the client's level of motivation helps reduce the risk of false compliance, which is when a client agrees to a treatment plan but has no intention of really following it (Craig, 2004). For treatment to be successful, the client must not only agree with their treatment plan, they must be committed to the actions that go with it. An impressive, well thought out treatment plan is of little value if the counselor is the only one excited about it. All treatment plans must be aligned to the client's level of motivation and capabilities (e.g., level of functioning). Miller and Rollnick (2002) point out examples of interventions that can be used, depending on the client's level of motivation Developing the treatment plan Once the counselor has rapport and an agreement with the client on critical areas, and defines the current level of motivation and capabilities, the counselor and client work collaboratively to develop the treatment plan. Like solving a Rubik's cube, it often takes patience and creativity to find the right treatment plan for a client. Treatment planning matching (selecting an intervention to help the client make a change) never follows the rule that one size fits all. The treatment must match the client's current needs or the result is like trying to put a square peg into a round hole. There are many wonderful and proven recovery tools that have helped millions but may not be appropriate for every client. Counselors need to be careful not to try to fit every client into the same treatment plan. Every client's treatment plan needs to be designed and aligned to their individual needs and situation. Counselors need to be open to the fact there is more than one road to recovery and their role is to help the client draw the map for his or her journey. An exception to when the treatment planning process is not a collaborative one is when the client is threatening suicide and/or homicide. If you believe a client is a danger to themselves or others, you need to take action and report this risk to appropriate authorities and persons involved. I teach my students to err on the side of caution and whenever in doubt to get a second objective opinion from a peer or supervisor. Saying, "I did not think this was a real threat" is not defensible. You must be able to defend all your actions, and remember that taking no action is no defense. Treatment planning The ATTC National Curriculum Committee (1998) points out that the main goal of a treatment plan is to help the client overcome their addiction disorder. The plan addresses areas of the client's life that need to be put back in order, such as family, employment, health, and money.
Addiction counselors who are doing treatment planning may review the Addiction Counseling Competen- All treatment plans need to include long-term goals in order of priority (primary, secondary, and tertiary) with short-term action steps for achieving each goal. It is important to include the following elements for all action steps:
Short-term action steps need to be SIMPLE - meaning the client has the Skills to implement them on his/her own; Immediate action can be taken; they are Measurable; are Plausible, so the client's chance of success is positive; and are Legal and Ethical.
To review 13 core principles for treatment planning that have been set out by the National Institute on Drug Abuse research, go to http://www.nida.nih.gov/PODAT/PODAT1.html I highly recommend the John Wiley's Treatment Addiction Planner (hard copy and electronic treatment planning tools), progress notes, and treatment planning homework resources. This tool may be viewed at http://ca.wiley.com/WileyCDA/WileyTitle/productCd-0471725447.html Recovery tools Recovery tools are strategies that an addiction counselor can draw upon to facilitate treatment plan success and reduce relapse. Each tool is independent of the other; however, the tools may be used interchangeably (e.g., disease model and peers support programs). The purpose of all recovery tools is to provide the client with a path to obtain new knowledge and skills. The tool chosen must be aligned to the treatment plan with a definable and measurable outcome. The more tools the addiction counselor researches and knows, the more opportunities he or she can offer the client. Recovery tools include:
A current resource providing an overview of many of the recovery tools that addiction professionals are using is Addiction Recovery Tools, edited by R. H. Coombs and published by Sage Productions Inc., Thousand Oaks, Calif. Recovery contract A written recovery contract is a strategy used to help clients develop ownership and responsibility for their own treatment plans. This is a measurable and definable agreement that outlines the actions and commitment of a client over a determined period of time. The recovery contract outlines the step-by-step actions that have been defined by the treatment plan, including times and dates for actions, support systems, progression of goals, and how progress will be measured. This enables the client to decide what he or she will and will not do, so that each day he or she can have a clear direction. Many of my clients report that a recovery contract acts like a lighthouse that provides direction. The recovery contract must also include agreements such as do no harm to self, crisis management plans, and relapse prevention plans. The recovery contract can be as simple as a one-page summary attached to a weekly timetable that a client can put on their refrigerator so they know each day what meetings and tasks they have. This contract must be reviewed and updated on a regular basis throughout treatment to integrate factors such as risk management and relapse prevention to ensure it is current. Recovery contracts can be used effectively in intensive outpatient, primary inpatient, and continuing care settings. They are most effective when the client's support systems are not only involved, but also are aware of the specifics of the contract and are supportive of its success. The last step is to complete a detailed review to ensure the client understands the contract and is motivated to honor it. The counselor should have the client sign the contract and then give him or her a copy. Let the client know this is not a legal agreement and what will happen if it is broken. It is important that the client know that if they break the contract they can feel safe to come back to you to pick up the plan and refocus. The Drug Addiction website provides information on recovery contracts. For more information visit http://www.drug-addiction-information.com/drug-addiction/. Conclusion The addiction counseling treatment process is like solving a Rubik's cube; it is done one side or one step at a time. So far we have explored the importance of orienting the client to counseling and assessment and using this information to build the treatment plan, which is supported by addiction recovery tools. The recovery contract aligns all the actions into a definable road map for the client to follow. However, just because the client is motivated, has a great plan, has excellent support strategies in place, and is following their recovery contract is no guarantee they will not end up in a crisis. The next article in this series will review important considerations for managing risk, such as safety, relapse, and crisis.
Addiction Technology Transfer Centers National Curriculum Committee (1998). Addiction counseling competencies: The knowledge, skills, and attitudes of professional practice. Treatment Assistance Publication #21. (DHHS Publication No. (SMA) 98-3171). Rockville, MD: Center for Substance Abuse Treatment. Craig, R. J. (2004). Counseling the alcohol and drug dependent client: A practical approach. Boston, MA: Pearson Education. Miller, W. R., & Rollnick, S. (Eds.) (2002). Motivational interviewing: Preparing people to change addictive behavior (2nd ed.). New York: Guilford.
Ries, R. K. (1994). Assessment and treatment of patients with coexisting mental illness and alcohol and other drug abuse. Treatment Improvement Protocol #9 (DHHS Publication No. SMA 95-3061). Rockville, MD: Center for Substance Abuse Treatment. This article is published in Counselor,The Magazine for Addiction Professionals, October 2006, v.7, n.5, pp.64-68.              |
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