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Roadmap to Recovery: the Treatment Plan
NAMI MD Annual ConferenceSheppard Pratt Conference Center
October 17 & 18, 2014
Planning a Journey
• I want to travel
• Is this enough information for a travel agent?• Where do they need to start and what do they
need to know?
This may help the travel agent
• Where• When• What to do when you get there• How will you finance• Who will go with you• How long do you want to stay• How will you get there
The Treatment Plan GOAL
• Is what the consumer wants, not what the clinician “knows” he/she needs
• What if the consumer doesn’t have a goal?• What if the consumer says:– I want to be happy– I want to watch TV– I want to play video games
OBJECTIVES or Short-term Goals
• Written to overcome MH Barriers which interfere with Goal: to address symptoms/functional impairments as a result of diagnosis
• Reflect a change in behavior/status/level of functioning to improve; beyond maintenance
INTERVENTIONS
• Paid/professional services to help person achieve the specific objective
• Document WHO provides WHAT service WHEN (frequency/duration/ intensity) and WHY (individualized purpose/intent as it relates to the linked objective)
• Natural support/self-directed supports to help person achieve the specific objective
How does the clinician gather the necessary information?
• Comprehensive assessments across multiple domains
• History from records, consumer, family• Double check the information• Observation
Definition of an Assessment
• Evaluating a person’s life from a strengths perspective• Determining stage of change• Initiates helping relationships– An ongoing process
• It is the process of gathering information across life domains to determine– Eligibility – Extent of need– Direction of services
Why Strengths ?
• Critical component of PCP because focusing solely on deficits/barriers ignores the resources a person has on which to build their efforts towards recovery
• Focusing on strengths may help the individual to form a goal• Provides the practitioner with the WHOLE view of the
individual• Point of engagement with the focus person
Strengths
Identified by the person, the provider, and also natural supporters/collaterals where appropriate• environmental factors that will increase the likelihood
of success• identifying the person’s best qualities/motivation• strategies already utilized to help• competencies/accomplishments• interests and activities, i.e. sports, art
Strengths shouldn’t sit on a shelf!• use them constructively in the development of the
plan
Examples of Strengths
• Motivated to change• Has a support system –friends, family• Employed/does volunteer work• Has skills/competencies: vocational, relational,
transportation savvy, activities of daily living• Intelligent, artistic, musical, good at sports• Has knowledge of his/her disease• Sees value in taking medications• Has a spiritual program/connected
to church• Good physical health• Adaptive coping skills• Capable of independent living
Importance of Understanding
• Data collected in assessment is by itself not sufficient for service planning
Definition of a Goal
• Goals express the personal hopes and dreams of the person for a high quality life in recovery
• Goals identify the hoped-for destination to be arrived at through the services provided.
Long term, global, and broadly stated
Life changes as a result of services
Ideally expressed in person’s own words
Written in positive terms
Consistent with desire for self-determination
may be influenced by culture and tradition
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Goals
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What Do People Want?
Quality of Life Education Work Housing Health / Well-being Valued roles
Manage their own lives Social opportunity Accomplishment Transportation Spiritual fulfillment Satisfying relationships
To be part of the life of the community…
Some of What We See…
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POWER OVER
Challenges in Goal Setting
• Not all consumers can easily articulate personal goals/desired results– It’s OK to make a suggestion to get the ball rolling!
• The process of goal development takes time• Goals often unfold through reflective listening that
highlights key things of importance to the consumer• Consumers are ambivalent about some goals• A consumer’s goals may change• Goal formulation is a developmental process
Lives in subsidized housing
“0” psych hospitalizations last 12 mo.
Good hygiene & grooming
Eats 3 meals a day
Exercises regularly
Medication compliant
Sees dentist & PCP at least 1x/year
Anthony Turner, 46, doing 25 to life at Men’s state prison in Chino.
Stability Mistaken for Fulfillment
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The Right Balance
Let client do what he/she wants
Get client to do what I want
Recovery Zone
Neglect Control
Source: Advocates, Inc. (2001) International Care Standards
Barriers = Challenges
• What is getting in the way of the person achieving their goal?– Why can’t they do it tomorrow?– Why can’t they do it themselves?
• Our job is helping the individual to identify and then remove/reduce/resolve/overcome barriers that occur as a result of the mental health challenges– symptoms – functional impairments– distress
Barriers/Assessed Needs
• What’s getting in the way?– need for skills development– intrusive symptoms– lack of resources– need for assistance / supports– problems in behavior– challenges in activities of daily living– threats to basic health and safety– challenges/needs as a result of a mental/ alcohol and/or
drug disorder
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Objectives• Expected near-term changes to meet long-term goals
– “overwhelming” big chunks broken into manageable little ones
• Essential features– behavioral– achievable– measurable– time framed– understandable for the person served
• Services are not an objective!!
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Objectives Examples
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Client will reduce assaultive behavior. Learning Objective
• within 90 days, Amy will identify 3 triggers to behavioral outbursts with children
Behavioral Objective• Within 90 days, Amy will have a minimum of one
successful visit with her children AEB by report of Amy’s DCF Case Worker
• Client will decrease frequency & intensity of substance use. • Pre-contemplative / motivational
– Joe will identify a minimum of 2 adverse effects that substance use has on his/her recovery within 30 days
• Action-oriented / relapse prevention– Joe will be substance-free for 6 months as
evidenced by self-report/drug screens
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Objectives Examples
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Interventions: Action Steps
• Actions by staff, family, peers, other natural supports
• Specific to an objective• Respect recovery choice and preference• Specific to the stage of change/recovery• Availability and accessibility of
services may be impacted by cultural factors
• Describes medical necessity
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Important Considerations
• Wherever possible, include a task for the individual as well as family or other community or natural supports– Indicate the specific actions the person served will take
to support achievement of the objective– Indicate the actions/support the
parent/guardian/community/ others will provide
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Examples of Interventions
Psychiatrist will meet with Mary 1x per month for 30 minutes for the next 6 months to adjust medications. Purpose is to reduce symptoms, including Mary's tendency to isolate and avoid social situations.
PSC will meet with Mary at least 1x/week for the next 6 months. During these meetings, PSC will help Mary learn skills necessary to use ACCESS and go into the community by herself. Anxiety reduction techniques and social skills training will also be provided.
For the next 6 months, Mary will collect information from friends, family, and other sources about programs for senior citizens in her community.
Another Example…
• Barriers– panic attacks– anxiety,– hyper-vigilance around people sometimes
• Objective– Within 6 months Anne will be able to volunteer 2x per
week for one month at the local pet shelter without experiencing any panic attacks/anxiety
Another Example…• Interventions
1) Dr DoGood, psychiatrist, will provide medication management 1x per month for 6 months for the purpose of alleviating anxiety symptoms
2) Kelly Smith, LCSW, will provide individual rehabilitation therapy 1x per week for 6 mos. to help Sally develop coping tools to better manage her trauma symptoms
3) Susan, her partner, will accompany Anne to the dog shelter 1x per week for one month to help support her transition back to work
4) Anne will engage in weekly journaling to write about her fears and anxiety and new tools she is learning to use in therapy
• Greg reports he is very lonely and that he just wants a girlfriend. He used to go to the downtown jazz fests and meet lots of people, but now he feels like a “zombie.”
• He is not getting out of the group home to do much of anything other than come to the Center. He wonders if this is due to his meds
• Greg admits to being “terrified” to get out in community and meet women, and states that its been 10 years since he had a girlfriend. He wouldn’t know where to start
• He is currently unable to take the bus and is afraid to go anywhere alone
An Outpatient Example to Consider…
Goal• I want a girlfriend
• Strengths– motivated to reduce social isolation– supportive brother– Has interests and activities he enjoys in
the community (e.g., music, Chinese restaurants, bicycling)
– well-liked by peers– humorous
Greg’s Plan
• Barriers/Assessed-Needs/Problems – intrusive thoughts/paranoia increase in
social situations– possible negative symptoms of
schizophrenia and/or med side effects result in severe fatigue/inability to initiate
– easily confused/disorganized– need for skill development to • use public transportation/increase community
mobility• develop symptom management/coping
strategies• improve communication and social skill• attend to personal appearance
Greg’s Plan
• Objective:– Greg will effectively use
learned coping skills to manage distressing symptoms to participate in a minimum of 1 preferred social activity per week for the next 90 days
Greg’s Plan
Interventions
• John Smith, Peer Coordinator, will provide travel training 1X/wk. for 4 weeks to help him become independent with city bus (e.g., identifying most direct bus routes, rehearsing use of coping skills, role playing conversations if confused/lost, etc.)
• Greg’s brother, Jim, will accompany Greg to weekly social outings over the next 3 months.
• Greg will complete a daily medication side-effect log for the next 2 months while meds are evaluated and adjusted.
Greg’s Plan
Interventions Jane Roe, Clinical Coordinator, to provide CBT 2X/mos. for
next 3 mos. to increase Greg’s ability to cope with distressing symptoms in social situations teaching thought stopping, distraction techniques,
deep-breathing, visualization, etc. Dr. X to provide Med management, 2X/months for next 3
months to evaluate therapeutic impact and possible side effects to reduce fatigue and optimize functioning
Greg will complete a daily medication side-effect log for the next 2 months while meds are evaluated and adjusted
Greg’s Plan
Planning the Journey
• If the travel agent doesn’t know anything about me, how can he or she help me reach my destination?
• It may take time, but the dividends will be great, especially if I get to where I want to be!
