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Effective Worker Client Interactions

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Effective Worker Client Interactions Powered By Docstoc
					Engaging the Addicted Client in
        Case Planning
            October 17, 2007

                     Sustaining CalWORKs
                     and Child Welfare
                     Collaboration in Times
                     of Transition


                    Rose Marie Wentz
General rules for visits with parents who are
                  addicted:
                                          Page 1

     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.
General rules for visits with 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 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 Knowledge


1. Failing a UA (urine analysis) means
   that a parent cannot be safe during
   a visit.


              YES or NO
                          NO
                                                    Page 2


        UA’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, LMFT
                            Children of Alcoholics Foundation
       Test Your Knowledge
2. Meth is the most common form of
   addiction in the US.



             YES or NO
NO -- Treatment Admissions by Primary
             Substance
2,000,000

1,800,000

1,600,000

1,400,000

1,200,000

1,000,000

 800,000

 600,000

 400,000

 200,000

       0
            1992   1994   1996        1998         2000        2002         2004
      Alcohol             Opiates                          Cocaine

      Marijuana/hashish   Methamphetamine


                                 Source: Treatment Episode Data Set (TEDS) – Highlights 2004
        Test 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
NO -- Persons who Initiated Substance Use by Year
                    compared to FC placements

1,400,000

1,200,000

1,000,000

 800,000

 600,000

 400,000

 200,000

       0
          85

          86

          87

          88

          89

          90

          91

          92

          93

          94

          95

          96

          97

          98

          99

          00

          01

          02

          03
       19

       19

       19

       19

       19

       19

       19

       19

       19

       19

       19

       19

       19

       19

       19

       20

       20

       20

       20
            Children in Foster Care                                New Cocaine Users
            New Crack Users                                        New Methamphetamine Users
            New Heroin Users      Source: Nancy K. Young, Ph.D., Director
                                  National Center on Substance Abuse and Child Welfare, May 8, 2006
        Test Your Knowledge
4. The percent of pregnant women‘s
   admissions for methamphetamine
   has tripled over the last 10 years.


              YES or NO
                YES -- Trends in Primary Substance Use
Treatment Admissions for Pregnant Females by Primary Substance 1994-
                               2004
 40%

                                                Percent of Pregnant Women‘s Admissions
 35%
                                                 for Meth/Amphetamine has tripled over
                                                             the last 10 Years
 30%

 25%

 20%

 15%

 10%

  5%

  0%
            1994            1996             1998            2000         2002      2004
 Cocaine           Alcohol          Heroin/Opiates            Marijuana      Meth/Amphet/Stimula
Source: Analysis of Treatment Episode Data Set (TEDS) Computer File
       Test Your Knowledge
5. Meth babies are born addicted and
   with birth defects


             YES or NO
           NO 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 Pregnant
 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
                                           & Dixon, (1987);
  care. Sources: Anglin et al. (2000); OroShah (2002) Rawson & Anglin (1999); Dixon &
        Bejar (1989); Smith et al. (2003);
       Test Your Knowledge
6. Hundreds of children have been
   medically harmed or died in meth
   labs in the last five years.


             YES or NO
NO -- Number of Children in Meth Labs
                   2000               2001                            2002                            2003*

Number of
                   8,971              13,270                          15,353                          14,260
incidents
Incidents with
                   1,803              2,191                           2,077                           1,442
children present
Children
                   216                976                             2,023                           1,447
residing in labs
Children
                   1,803              2,191                           3,167                           3,419
affected**
Children
exposed to toxic   345                788                             1,373                           1,291
chemicals
Children taken
into protective    353                778                             1,026                           724
custody
Children
                   12                 14                              26                              44
injured
Children killed    3                  0                               2                               3
                                          *The 2003 figure for the number of incidents is calendar year, while the remaining
Source: El Paso Intelligence Center       data in the column are for fiscal year
                                          **Data for 2000 and 2001 may not show all children affected
        Test 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
        NO -- 24-Month Child Placement Outcomes by Parent
                                          Primary Drug Problem
                     60




                     40
           Percent




                     20




                      0
                          Reunification    Adoption        Guardianship    Continued      Long-Term   Other
                                                                          Reunification   Placement
Source: Nancy K. Young, Ph.D., Director                                     Services
National Center on Substance Abuse and Child Welfare, May 8, 2006


                     Alcohol       Heroin       Cocaine/crack             Marijuana       Methamphetamine
        Test Your Knowledge
8. Meth addicts are less likely to
   recover than other types of drug
   addicts.


              YES or NO
NO -- Treatment Discharge Status by Primary
                                   Drug Problem***
            80              71.4
                                   65.6
                                           61.6   61.5
            60       49.7                                  50.3
  Percent




                                                                                38.4   38.5
            40                                                           34.4
                                                                  28.6


            20


             0
                            Satisfactory                          Unsatisfactory

            Heroin   Alcohol       Methamphetamine        Cocaine/Crack          Marijuana
***p<.001
                       Source: Nancy K. Young, Ph.D., Director
                       National Center on Substance Abuse and Child Welfare, May 8, 2006
                               Different Risks to Children Based on Type of
                                           Parental Involvement
                                                                                                                          Page 2


                           
Progressively more risks




                                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
Risks most commonly related to meth use are:

                                                  Page 2


     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
Risks most commonly related to meth use are:

                                                      Page 2
  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.
What predicts longer Abstinence for Meth
                Addicts
                                                  Page 2


    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
        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 ?
                                           Page 3

  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.
     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 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
           Change Process

                                    Goal



                         Barriers
            Activities




crisis

   Status Quo
                                           Abraham Maslow’s
                                     Hierarchy of Needs
                      Match your interview technique to the customer’s needs and
                      focus at this point … at this time



                                                            Self-
                                                      Actualization
                                              Personal growth and fulfillment


                                                     Esteem Needs
                                    Achievement, status, responsibility, reputation, etc.

                                                        Love Needs
                                     Family, affection, relationships, work groups, etc.

                                                       Safety Needs
                                     Protection, security, order, law, limits, stability, etc.

                                                  Physiological Needs
                             Basic life needs – air, food, drink, shelter, warmth, sex, sleep, etc.

Adapted from Alan Chapman
www.businessballs.com
        CDSS 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 (ASFA) 1997
  Safety
   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 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 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.
              Definition            page 6




―MOTIVATIONAL INTERVIEWING is a
directive, client-centered, style for
eliciting behavior change by helping
clients explore and resolve
ambivalence.‖
                             ~Miller & Rollinick, 2000
                 Definition
―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 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 POV    Pg 1
 Confrontation Approaches
Argue that the client has a problem
 that needs to be changed
Offers direct advice or prescribes
 solutions
Uses authoritative stance – client is
 passive
Does most of the talking
Imposes a label
Behaves in punitive or coercive
 manner
               OARS
   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 Talk
   1.Ask Evocative Questions
   2.Explore Decisional Balance
   3.Ask for Elaboration
   4.Ask for Examples
   5.Look Back
   6.Look Forward
   7.Query Extremes
   8.Use Change Rulers
   9.Explore Goals and Value
   10.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
             Traps to Avoid
          Avoid “Traps”
1.   Expert Trap
2.   Labeling Trap
3.   Unsolicited Advice
4.   Premature Focus
5.   Question – Answer
6.   Blaming Trap
                              Pg 10

				
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