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LEADER FOCUS
Workshop 2
EMPHASIS AREAS:
FOCUS
Programme-Driven vs.
Individualised Treatment Plans
Old Methods and New Methods of
Treatment Planning
Biopsychosocial Model
Treatment Plan Components
KEY CONCEPTS
Distinction between Programme-
Driven vs. Individualized
Treatment Plans
Old Methods and New Methods of
Treatment Planning
Trainer Guide
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Workshop 2
Recap of Workshop 1
Introduction to the treatment planning process,
the Addiction Severity Index (ASI), and the
ASI/DENS software
ASI applications in treatment planning
Workshop 2 will focus on introducing and (for some)
reviewing:
History of treatment planning
Differences between programme-driven and
individualized treatment plans
Biopsychosocial model of addiction
Treatment plan components
Participants will practise writing non-judgemental and
jargon-free problem statements.
Leader Note:
Workshop 1 introduced the importance of “marrying”
two ingredients of client care: assessment and
treatment planning. Treatment planning begins during
the assessment process, and the “union” of treatment
planning and assessment is a natural process.
Workshop 2 Handouts
1. ASI Narrative Report – John Smith
2. ASI Master Problem List
3. Treatment Plan Form - Alcohol & Drug
4. Treatment Plan Form – Medical
5. Treatment Plan Form – Family
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Workshop 2: Treatment plans
Programme-Driven
Individualised
versus
Treatment Plans
In the next section, we will focus on understanding the
differences between programme-driven plans and
individualized treatment plans. This difference is key in
the treatment planning process being taught in this
training.
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Introduce Biopsychosocial Model
The Biopsychosocial Model of medicine, developed in
1977 by a psychiatrist named George Engel, is widely
used as a backdrop for explaining substance abuse and
mental health disorders. By most standards, the model is
comprehensive and supports several different theories
and practises.
Engel viewed a disease as having numerous,
interconnected causal factors. For example, an individual
with the disease or condition of hypertension may:
Be predisposed to developing the condition due to
a family history of hypertension (biological).
Have an eating or mood disorder which
exacerbates hypertension (psychological).
Be living below poverty level and not have the
income to buy healthy and nutritious food and or
medicines (social).
The disease or condition of hypertension is not treated
without focusing on all three perspectives.
The strength of the biopsychosocial model is that one
theory is not necessarily discounted in favour of another
theory. The model allows for differing views. Theories
can be organized in such a way that they actually
complement one another and yet highlight differences in
explaining the complexity of treating multiple disorders.
Biological
Psychological
Sociological
Biopsychosocial Model
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Sociological
Biopsychosocial Model example ...
How close do
they live to the
treatment
centre?
Does the client
have a car? Can
they access public
transportation?
How available
are drugs or
alcohol in the
home?
The Biopsychosocial Model serves as a reminder to
include problems related to biological, psychological, and
social aspects of addiction in the treatment plan. For
example, a client’s environment (social) must be
considered when planning their treatment:
How close does the client live to the clinic?
Do they have a car or can they access public
transportation?
How available are drugs and alcohol in the client’s
home?
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ASI Problem Domains
The seven ASI problem domains (Medical Status,
Employment and Support, Drug Use, Alcohol Use, Legal
Status, Family/ Social, and Psychiatric Status) help
support the importance of viewing clients and their
problems from a biopsychosocial perspective.
Biological
(e.g., medical
status)
Psychological
(e.g., psychiatric
status)
Sociological
(e.g., family & social
status)
ASI problem domains and the
biopsychosocial model
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Field of Substance Abuse Treatment:
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Field of Substance Abuse Treatment:
Early Work
Field of substance abuse treatment:
Early work
Programme-Driven Plans
“One size fits all”
Early Work – “One Size Fits All”
Historically, the field of substance abuse treatment
operated from a “one size fits all” treatment philosophy.
The focus was on a limited number of tools and
strategies that had worked with some
consistency.
Programmes used the same tools, in the same
way, with everyone regardless of their specific
problems.
Unique aspects of client problems and treatment
needs were not reflected in treatment planning.
Most of the time, treatment plans were developed
without client involvement and “put in the chart”
for the duration of treatment.
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z Client needs are not important as the client is “fit”
into the standard treatment programme regimen
z Plan often includes only standard programme
components (e.g., group, individual sessions)
z Little difference among clients’ treatment plans
Programme-driven plans
What is a Programme-Driven Plan?
The client must fit into the programme’s regimen.
A Programme-Driven Treatment Plan reflects the
components and/or standard activities and
services available within the treatment
programme.
There is little difference among clients’ treatment
plans.
This type of plan will be referred to as the old
method of treatment planning.
Leader Notes:
Often, programmes are required to offer specific
services to all clients. These required services are
considered programme-driven components which
are different than a programme-driven treatment
plan.
Example: All clients in the outpatient programme
participate in a weekly relapse prevention group.
Many issues are addressed in the relapse
prevention group. Certain topic areas may be
more specific to the client’s situation; these topics
can be reflected in the treatment plan.
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Programme-driven plans
Client will . . .
1.“Attend 3 Alcoholic Anonymous meetings
a week”
2.“Complete Steps 1, 2, & 3”
3.“Attend group sessions 3 times / week”
4.“Meet with counsellor 1 time / week”
5.“Complete 28-day programme”
Programme-Driven Plans
Most counsellors have either written or have read similar
statements in treatment plans (i.e., old method).
Programme-Driven Plans – Other Common Problems
“Only wooden shoes?”
Programme-Driven Plans . . .
Identify only those services or programme
elements immediately available and readily
delivered in the agency.
Based on the client’s assessment, additional
services may be necessary. Programme-driven
plans often do not reflect referrals to community
service providers such as psychiatric clinics,
training programmes, or HIV testing clinics.
Paradigm Shift to Individualized Treatment Plans
What caused the shift?
Clinicians and researchers wanted to:
Improve treatment outcomes.
Effectively target clients’ needs.
Reflect the variety of techniques and medications
used in treatment today.
In addition, payers wanted to contain costs of care by
using the lower (less expensive) levels of care when
justifiable (Kadden & Skerker, 1999).
“Still don’t fit right”
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Programme-driven plans
z Often include only those services
immediately available in agency
z Often do not include referrals to community
services (e.g., parenting classes)
“ONLY wooden shoes?”
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Individualised Treatment Plans
- Many colors/styles available -
Treatment planning: A paradigm shift
- Custom style & fit -
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Individualised plan
“Sized” to
match client’s
problems and
needs
Individualized Treatment Plan is “Sized” to Match
Client Problems and Needs
Not all clients have the same needs or are in the
same situation.
The individualized treatment plan is made to “fit”
the client based on her/his unique:
Abilities
Goals
Lifestyle
Socioeconomic realities
Work history
Educational background
Culture
When treatment programmes do not offer
services that address specific client needs,
referrals to outside services are necessary.
Group Discussion
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To individualise a plan, what
information is needed?
1. What does a counsellor need to discuss
with a client before developing a
treatment plan?
2. Where do you get the information,
guidelines, tools, etc.?
What does a counsellor need to discuss with a
client before developing a treatment plan?
Where does a counsellor get the information to
identify client problems?
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To individualise a plan, what
information is needed?
Possible sources of information might
include:
z Probation reports
z Screening results
z Assessment scales
z Collateral interviews
Possible sources of information might include:
probation reports (may not be relevant in
some countries)
screening results
assessment scales
collateral interviews
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Programme-Driven Plan Activity
Instructions:
1. Two case studies will be presented.
2. Sample problem statements, treatment plan
goals, objectives, and interventions follow.
Leader Note:
Even though the specific steps in the treatment
planning process will not be introduced until
Workshop 3, participants will begin to view
different styles of problem statements, goals,
objectives, and interventions.
Additionally, trainers will need to adapt case
studies so that they are relevant to specific
populations or subpopulations treated by
participants in the training.
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Case A assessment information: Jan
z 27-year-old, single Caucasian female
z 3 children under age 7
z No childcare available
z Social companions use drugs / alcohol
z Unemployed
z Low education level
z 2 arrests for possession of meth & cannabis
plus 1 probation violation
Case A: Jan
Take a minute to read through Jan’s assessment
information.
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Case B assessment information: Dan
• 36-year-old, married African-American male
• 2 children
• 2 arrests and 1 conviction for DUI (driving under
the influence of alcohol)
• Blood alcohol content at arrest - .25
• Employed
• High severity family problems
Case B: Dan
Take a minute to read through Dan’s assessment
information.
Leader Note:
In debriefing these examples, be sure participants
include discussions of client strengths in addition
to the problem areas addressed on the slides.
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The “Old Method”:
(Programme-Driven) Problem Statement
z Not individualised
z Not a complete sentence
z Doesn’t provide enough information
z A diagnosis is
Problem Statement: The “Old Method”
“Alcohol Dependence”
This is a programme-driven problem statement.
It is not individualized.
It is not presented in a complete sentence.
It does not provide enough information.
A problem statement is NOT a diagnosis.
Goal Statement: The “Old Method”
“Will refrain from all substance use now and in the future.”
Goal is not specific for Jan or Dan.
This could be a goal for either Jan or Dan.
Goal could not be accomplished by discharge.
Leader Note:
The preceding goal is commonly overused in
programme-driven treatment plans.
Other examples__________________
Objective Statement: The “Old Method”
“Will participate in the outpatient programme.”
Objective is not specific for Jan or Dan.
Statement describes a level of care; a level of
care is not an objective.
not a complete problem
statement
“Alcohol dependence”
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z Not specific for Jan or Dan
z Not helpful for treatment planning
z Cannot be accomplished by
programme discharge
“Will refrain from all substance use now and
in the future”
The “Old Method”:
(Programme-Driven) Goal Statement
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z Again, not specific for Jan or Dan
z A level of care is not an objective
“Will participate in outpatient programme”
The “Old Method”:
(Programme-Driven) Objective Statement
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z This sounds specific, but it describes a
programme component
“Will see a counsellor once a week and
attend group on Monday nights for 12
weeks”
The “Old Method”:
(Programme-Driven) Intervention Statement
Intervention Statement: The “Old Method”
“Will see a counsellor once a week and attend group on
Monday nights for 12 weeks.”
Intervention is not specific for Jan or Dan.
This statement sounds specific but describes a
programme component.
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Why make the effort?
Individualised Treatment Plans:
z Lead to increased retention rates, which
are shown to lead to improved outcomes
z Empower the counsellor and the client,
and give focus to counselling sessions
Why Make the Effort?
Individualized treatment leads to increased client
retention, which has been shown to lead to
improved outcomes.
Why is retention important? Because about 50%
of the people that show up for treatment don’t
return and return to pre-treatment behaviours.
Empowers the counsellor and client, and focuses
counselling efforts.
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Why make the effort?
Individualized Treatment Plans:
z Like a good pair of shoes, this
plan “fits” the client well
ASI:
z Like measurements, the ASI
items are used to “fit” the
client’s services to her or his
needs
Treatment plans should pass the “first glance”
test. Ideally, you should be able to pick up a
client’s treatment plan like a pair of shoes and
recognize its uniqueness.
Example: “This particular plan must belong to
a client with children, hepatitis C, and no high
school diploma.”
In keeping with the shoes metaphor, data
collected from the ASI can be used as a
“measurement” to help “fit” the treatment plan to
the client’s individual needs.
The plan is individualized and customized to “fit
the client” just as shoes have unique sizes and
fit—high heal or flat, boots or slippers, etc.
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What is included
in any treatment plan?
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What Is Included in any Treatment Plan?
Questions the counsellor and programme need to
consider:
What information is essential?
What does local policy require?
What does your state want?
If insurance or other third parties pay for services,
what do they require?
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Treatment plan components
1. Problem Statements
3. Objectives
2. Goal Statements
4. Interventions
What Components Are Found in a Treatment Plan?
Problems identified during assessment
Goals reasonably achievable in the active
treatment phase
The term objectives used in this training is
defined as what the client does to meet the goals.
The term intervention used in this training is
defined as what the staff will do to assist the
client.
This terminology is consistent with vocabulary
used in the DENS ASI Treatment Planning
Software.
Leader Notes:
The terminology used to convey the more specific
components of a treatment plan may vary by
profession, by programme, by agency, and by
region.
The participants may be familiar with other terms
such as action step, task, measurable goal,
treatment strategy, benchmark, milestone,
solutions, etc.
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1.
Treatment Plan Components
1. Problem Statements are based on the
information the counsellor collected during the
assessment.
2. Goal Statements are based on the problem
statements. Goals included in the plan should be
reasonably achievable in the active treatment
phase.
Problem Statement Examples
Take a minute to look at these problem statement
examples.
Notice how the examples are specific to a client’s
need.
You may choose to use the client’s last name in
place of the first name.
Examples of Goal Statement
Now, take a minute to look at these goal
statements.
Does Van’s goal relate to his problem?
Does Meghan’s goal relate to her specific
problem?
Leader Note:
Allow time for the participants to ask questions
and seek clarification of terms before proceeding.
Problem Statements are based on
information collected during the
assessment
Treatment plan components
2. are based on the
problem statements and are
reasonably
achievable in the active treatment phase
Goal Statements
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z Van* is experiencing increased tolerance for
alcohol as evidenced by his need for more
alcohol to become intoxicated or achieve the
desired effect
Problem statement examples
z Meghan* is currently pregnant and requires
assistance obtaining prenatal care
z Tom’s* psychiatric problems compromise
his concentration on recovery
*You may choose to use client’s last name instead, e.g., Mr. Pierce, Ms. Hunt.
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z Van will safely withdraw from alcohol, stabilise
physically, and begin to establish a recovery
programme
Goal statement examples
z Meghan will obtain necessary prenatal care
z Reduce the impact of Tom’s psychiatric
problems on his recovery and relapse potential
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3.
Treatment plan components
Treatment Plan Components
3. Remember objectives are defined as what the
client will do to meet those treatment goals.
4. Remember interventions are defined as what the
staff will do to assist the client.
Examples of Objectives
Take a minute to look at these examples.
How do the examples indicate what the client will
do?
You may choose to use the client’s last name in
place of the first name.
Examples of Interventions
Take a minute to look at these examples.
Notice what the staff will do to assist or follow-up
with the client.
Leader Notes:
Allow time for participants to discuss terminology
used in their agencies’ treatment plan formats.
Remind participants that terms frequently viewed in
treatment planning are not standardized nor
consistently defined.
Objectives
Interventions
ar
are what the client will do to meet
those goals
4. e what the staff will do to assist
the client
Other common terms:
• Action Steps
• Measurable activities
• Treatment strategies
• Benchmarks
• Tasks
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z Van will report acute withdrawal symptoms
Examples of objectives
z Meghan will visit an OB/GYN physician or nurse
for prenatal care
z Tom will list 3 times when psychological
symptoms increased the likelihood of relapse
z Van will begin activities that involve a
substance-free lifestyle and support his recovery
goals
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z Staff medical personnel will evaluate Van’s need
for medical monitoring or medications
Intervention examples
z Staff will review Tom’s list of 3 times when
symptoms increased the likelihood of relapse
and discuss effective ways of managing those
feelings
z Staff will call a medical service provider or clinic
with Meghan to make an appointment for
necessary medical services
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Review: Treatment Plan Components
1.
Review: Components in a Treatment Plan
1. Problem Statements are based on the
information the counsellor gathers during the
assessment.
2. Goal Statements are based on the problem
statements.
3. Objectives are defined as what the client will do
to meet those treatment goals.
4. Interventions are defined as what the staff will do
to assist the client.
Treatment Plan Components
Other aspects of the client’s condition that should be
taken into account in the development of a
treatment plan include the following:
1. Client strengths: Most clients have strengths that
will assist them in their treatment process. Those
strengths are often documented and are a
required component of treatment plans.
2. Other participants in the planning process:
Note how family or others participated in the
treatment planning activities. Also note whether
significant others agreed with the plan.
The DENS ASI Treatment Planning Software
allows the counsellor to document:
Who was invited to participate in the
treatment planning process.
If they did not participate, why
(unavailable, refused, etc.).
If the client and other participants agreed
with the plan.
Problem Statements (
Objectives (
Goal Statements (
information from assessment)
3. what the client will do)
2. based on problem statement)
4. (what the staff will do)Interventions
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1. Client Strengths* are reflected
Treatment plan components
2. are
ted
*The DENS Treatment Planning Software
includes these components
Other aspects of the client’s condition:
Participants in Planning*
documen
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ASI Narrative and
Master Problem List
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Interactive Activity Instructions: Identify All Problems
The first step in the treatment planning process is to refer
to the client’s assessment information to develop a Master
Problem List.
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Master Problem List
Refer to ASI Narrative Report
(Workshop 2, Handout 1)
z Review case study
z Focus on problems identified in the:
z
Refer to Handout John Smith’s ASI Narrative Report
Leader Notes:
The John Smith example report was generated
from the DENS ASI Software.
Allow approximately 15 minutes for participants to
read the narrative and identify problems in the
alcohol/drug, medical, and family/social domains.
Common Participant Questions/Issues:
Participants may ask whether “problems” are from
the client’s or counsellor’s perspective.
Emphasise the collaborative efforts between client
and counsellor for this process.
Participants may work ahead, generating goal
statements, objectives, and/or interventions for
the client. Emphasise that this exercise is for
brainstorming a problem list at this point.
alcohol/drug
medical
family/social
domain
z domain
z domain
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ASI Master Problem List
Master Problem List
The client is troubled by family problems and is interested in
treatm
ents
The client reports having serious problems with family
members in the past month
The cl is not satisfied with how he/she spends his/her free
time
Family/Social
Client has a chronic medical problem that interferes with
his/her life
Medical
The cl reports using heroin in past month.
The cl reports regular, lifetime use of alcohol to
“intoxi ion.”
The client reports several or more episodes of drinking alcohol
to into cation in past month.
Alcohol/Drug
ient
ient
ient
cat
xi
Date ResolvedStatusDate
Identified
Domain Problem
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Leader Note:
The sequence of the slide presentation below is
intentional and recognizes principles for an adult learning
style.
For example, it is important for participants to be exposed
to the correct procedure for writing problem statements
rather than being corrected for writing incorrect
statements.
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Considerations in writing
z All problems identified are included
regardless of available agency services
z Include all problems whether deferred or
addressed immediately
z Each domain should be reviewed
z A referral to outside resources is a valid
approach to addressing a problem
Master Problem List
Considerations in Writing Problem Statements
All problems identified are included regardless of
services available at the agency.
Whether problems are deferred or addressed
immediately, all should be included on the Master
Problem List.
There should be a review of each problem
domain.
A referral to outside resources is an appropriate
approach to addressing a problem.
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Tips on writing problem statements
z Non-judgemental
z No jargon, such as…
z “Client is in denial”
z “Client is co-dependent”
z Use complete sentence structure
Problem Statements
Tips on Writing Problem Statements
Next, use John Smith’s Master Problem List to begin
writing problem statements. First, some tips on writing
problem statements.
Statements are non-judgemental.
No jargon statements are included (e.g., “client is
in denial”; “client is co-dependent”).
Use complete sentence structure when writing
Problem Statements.
In general, it is easier to write treatment goals, objectives,
and/or interventions if the problem statement reflects
specific behaviours. Also, judgmental statements should
not be written on the treatment plan as this document is
shared with the client.
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Changing language
Problem Statements
1. Client has low self-esteem.
2. Client is in denial.
3. Client is alcohol dependent.
4. Client is promiscuous.
5. Client is resistant to treatment.
6. Client is on probation because
he is a bad alcoholic.
Practise Changing the Language of Problem
Statements
Change the language of these common judgemental and
jargon-based statements.
1. “Client has low self-esteem.”
2. “Client is in denial.”
3. “Client is alcohol dependent.”
4. “Client is promiscuous.”
5. “Client is resistant to treatment.”
6. “Client is on probation because he is a bad
alcoholic.”
Examine the problem statement, “The client is
promiscuous.”
What does promiscuous mean?
Does the term refer to the number of sexual
partners?
Does it refer to activities that include high-risk
sexual behaviours?
Does it refer to women or men or both?
Leader Note:
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Changing language: Pick two
Problem Statements
z Think about how you might change the
language for 2 of the preceding problem
statements
z Rewrite those statements using non-
judgemental and jargon-free language
Have participants select two problem statements and
write a non-judgemental and jargon-free statement.
Trainers may want to provide incentives at this point for
“correct” responses.
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Changing language: Examples
Problem Statements
1. Client has low self-esteem.
2. Client is in denial.
3. Alcohol Dependent.
– Client averages 10 negative self-statements daily
– Client experiences tolerance, withdrawal, loss of
control, and negative life consequences due to
alcohol use
– Client reports two DWIs (driving while intoxicated) in
past year but states that alcohol use is not a problem
Continued
Non-judgemental and Jargon-Free Statements
Introduce examples of responses to each statement:
1. Client averages 10 negative self-statements daily.
2. Client reports two DWIs in the past year but states
that alcohol use is not a problem.
3. Client experiences tolerance, withdrawal, loss of
control, and negative life consequences due to
alcohol use.
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Changing language: Examples
Problem Statements
4. Client is promiscuous.
5. Client is resistant to treatment.
6. Client is on probation because he is a bad
alcoholic.
– Client participates in unprotected sex 4
times a week with multiple partners
– Client has legal consequences because
of alcohol-related behaviour
– In past 12 months, client has dropped out of 3
treatment programmes prior to completion
4. Client participates in unprotected sex four times a
week.
5. In the past 12 months, the client has dropped out
of 3 treatment programmes prior to completion.
6. Client has legal consequences because of
alcohol-related behaviour.
Treatment Planning M.A.T.R.S.: Utilizing the Addiction Severity Index (ASI) –
Making Required Data Collection Useful
NIDA/ATTC ASI Blending Team Part 2.18
Worksho
p
2 Leader’s Guide
Overhead 75
Overhead 76
75
Case study problem statements
Problem Statements
z Alcohol/drug domain
z Medical domain
z Family/social domain
Write 1 problem statement for each domain.
Write John Smith’s Problem Statements
Individual Activity Instructions:
1. Refer to ASI Treatment Plan Format handouts
3 pages provided
Note where problem statement, goal statement,
objectives, and interventions appear.
Each practise page has the specific domain noted
in the upper right-hand corner. In an actual
written plan, such separation is not necessary.
Alcohol/drug domain (1 page)
Medical domain (1 page)
Family/social domain (1 page)
2. Write 1 problem statement for these domains.
alcohol/drug domain
medical domain
family/social domain
76
ASI Treatment Plan Format
Date
Resolved
StatusProblem DomainDate
Identified
3. REVIEW – Who wants to share a problem
statement?
