Transcript Effective Worker-Client Interactions

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.
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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
Alcohol
Opiates
Marijuana/hashish
Methamphetamine
2002
2004
Cocaine
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
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
0
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 19942004
40%
Percent of Pregnant Women’s Admissions
for Meth/Amphetamine has tripled over
the last 10 Years
35%
30%
25%
20%
15%
10%
5%
0%
1994
Cocaine
1996
Alcohol
1998
Heroin/Opiates
2000
Marijuana
Source: Analysis of Treatment Episode Data Set (TEDS) Computer File
2002
2004
Meth/Amphet/Stimula
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
Anglin et al. (2000); Oro & Dixon, (1987); Rawson & Anglin (1999); Dixon &
care. Sources:
Bejar (1989); Smith et al. (2003); Shah (2002)
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
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
Source: El Paso Intelligence Center
*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 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
Percent
40
20
0
Reunification
Adoption
Guardianship
Source: Nancy K. Young, Ph.D., Director
National Center on Substance Abuse and Child Welfare, May 8, 2006
Alcohol
Heroin
Cocaine/crack
Continued
Reunification
Services
Marijuana
Long-Term
Placement
Other
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
Percent
60
61.6
61.5
49.7
50.3
38.4
40
38.5
34.4
28.6
20
0
Satisfactory
Heroin
***p<.001
Alcohol
Methamphetamine
Unsatisfactory
Cocaine/Crack
Marijuana
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
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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:
 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 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
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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
SelfActualization
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 twoparent families, respectively.
Job of the Case Manager
 To find an overlap between the
agency goal and the client’s goal.
Client’s goal
Agency 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
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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.
2.
3.
4.
5.
6.
Expert Trap
Labeling Trap
Unsolicited Advice
Premature Focus
Question – Answer
Blaming Trap
Pg 10