engaging the addicted client in case planning rose marie wentz october 17, 2007 sustaining calworks...
TRANSCRIPT
Engaging the Addicted Client in Case Planning
Rose Marie Wentz
October 17, 2007
Sustaining CalWORKs and Child Welfare Collaboration in Times of Transition
General rules for visits with General rules for visits with parents who are addicted: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
General rules for visits with General rules for visits with parents who are addicted: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.
Myths versus Facts of AddictionMyths 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.
Test Your KnowledgeTest Your Knowledge
1. Failing a UA (urine analysis) means that a parent cannot be safe during a visit.
YES or NO
NONOUA’s - What they CANNOT tell usUA’s - What they CANNOT tell us
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, LMFTChildren of Alcoholics Foundation
Page 2
Test Your KnowledgeTest Your Knowledge
2. Meth is the most common form of addiction in the US.
YES or NO
NO -- NO -- Treatment Admissions by Treatment Admissions by Primary SubstancePrimary Substance
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2,000,000
1992 1994 1996 1998 2000 2002 2004
Alcohol Opiates Cocaine
Marijuana/hashish Methamphetamine
Source: Treatment Episode Data Set (TEDS) – Highlights 2004
Test Your KnowledgeTest Your Knowledge
3. 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
NONO -- -- Persons who Initiated Persons who Initiated Substance Use by Year compared to Substance Use by Year compared to
FC placementsFC placements
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Children in Foster Care New Cocaine Users
New Crack Users New Methamphetamine Users
New Heroin Users Source: Nancy K. Young, Ph.D., DirectorNational Center on Substance Abuse and Child Welfare, May 8, 2006
Test Your KnowledgeTest Your Knowledge
4. The percent of pregnant women’s admissions for methamphetamine has tripled over the last 10 years.
YES or NO
0%
5%
10%
15%
20%
25%
30%
35%
40%
1994 1996 1998 2000 2002 2004
Cocaine Alcohol Heroin/Opiates Marijuana Meth/Amphet/Stimulants
YES --YES -- Trends in Primary Substance UseTrends in Primary Substance UseTreatment Admissions for Pregnant Females by Primary Treatment Admissions for Pregnant Females by Primary
Substance 1994-2004Substance 1994-2004
Percent of Pregnant Women’s Admissions for Meth/Amphetamine has tripled over the
last 10 Years
Source: Analysis of Treatment Episode Data Set (TEDS) Computer File
Test Your KnowledgeTest Your Knowledge
5. Meth babies are born addicted and with birth defects
YES or NO
NO and MaybeNO 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.
Mother Uses Meth While Mother Uses Meth While PregnantPregnant
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)
Test Your KnowledgeTest Your Knowledge
6. Hundreds of children have been medically harmed or died in meth labs in the last five years.
YES or NO
Source: El Paso Intelligence Center
NO -- Number of Children in Meth Labs
2000 2001 2002 2003*
Number of incidents
8,971 13,270 15,353 14,260
Incidents with children present
1,803 2,191 2,077 1,442
Children residing in labs
216 976 2,023 1,447
Children affected**
1,803 2,191 3,167 3,419
Children exposed to toxic chemicals
345 788 1,373 1,291
Children taken into protective custody
353 778 1,026 724
Children injured
12 14 26 44
Children killed 3 0 2 3*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
Test Your KnowledgeTest Your Knowledge
7. 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
NONO -- -- 24-Month Child Placement 24-Month Child Placement Outcomes by Parent Primary Drug Outcomes by Parent Primary Drug
ProblemProblem
0
20
40
60P
erc
en
t
Reunification Adoption Guardianship ContinuedReunification
Services
Long-TermPlacement
Other
Alcohol Heroin Cocaine/crack Marijuana Methamphetamine
Source: Nancy K. Young, Ph.D., DirectorNational Center on Substance Abuse and Child Welfare, May 8, 2006
Test Your KnowledgeTest Your Knowledge
8. Meth addicts are less likely to recover than other types of drug addicts.
YES or NO
NO --NO -- Treatment Discharge Treatment Discharge Status by Primary Drug Status by Primary Drug
Problem***Problem***
***p<.001
49.7
71.4
65.661.6 61.5
50.3
28.634.4
38.4 38.5
0
20
40
60
80
Per
cen
t
Satisfactory Unsatisfactory
Heroin Alcohol Methamphetamine Cocaine/Crack Marijuana
Source: Nancy K. Young, Ph.D., DirectorNational Center on Substance Abuse and Child Welfare, May 8, 2006
Different Risks to Children Different Risks to Children Based on Type of Parental Based on Type of Parental
InvolvementInvolvement
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
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
Page 2
Progressively m
ore risks
Risks most commonly related to meth Risks most commonly related to meth use are: 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
Risks most commonly related to meth Risks most commonly related to meth use are: 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
What predicts longer Abstinence What predicts longer Abstinence for Meth Addictsfor 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
Other Meth Facts 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
What is a Relapse ?What is a Relapse ?
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.
Page 3
What is a Relapse Plan?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!
Indicators of Significant RecoveryIndicators 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
Abraham Maslow’sAbraham Maslow’s Hierarchy of NeedsHierarchy of Needs
Physiological Needs
Safety Needs
Love Needs
Esteem Needs
Self-
Actualization
Personal growth and fulfillment
Achievement, status, responsibility, reputation, etc.
Family, affection, relationships, work groups, etc.
Protection, security, order, law, limits, stability, etc.
Basic life needs – air, food, drink, shelter, warmth, sex, sleep, etc.
Adapted from Alan Chapman www.businessballs.com
Match your interview technique to the customer’s needs andfocus at this point … at this time
CDSS MissionCDSS 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.
Adoption and Safe Families Act Adoption and Safe Families Act (ASFA) 1997(ASFA) 1997Safety
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.
Temporary Assistance for Needy Temporary Assistance for Needy Families (TANF)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.
Job of the Case ManagerJob of the Case Manager To find an overlap between the
agency goal and the client’s goal.
Agency goal Client’s goal
The overlap area is developed into the joint case planning goal.
DefinitionDefinition
“MOTIVATIONAL INTERVIEWING is a directive, client-centered, style for eliciting behavior change by helping clients explore and resolve ambivalence.”
~Miller & Rollinick, 2000
page 6
DefinitionDefinition
“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
Motivational InterviewingMotivational 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 POVPg 1
Confrontation ApproachesConfrontation ApproachesArgue that the client has a problem
that needs to be changedOffers direct advice or prescribes
solutionsUses authoritative stance – client is
passiveDoes most of the talkingImposes a labelBehaves in punitive or coercive
manner
OARSOARS Open-ended questions Affirmation Reflective listening Summary
Roll with Resistance Reflection Shifting focus Emphasizing personal control and choice Reframing Engaging the client
10 Strategies for Evoking Change 10 Strategies for Evoking Change TalkTalk
1.Ask Evocative Questions2.Explore Decisional Balance3.Ask for Elaboration4.Ask for Examples5.Look Back6.Look Forward7.Query Extremes8.Use Change Rulers9.Explore Goals and Value10.Come Alongside
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
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…”
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