The treatment plan is the overall management strategy for treating people with alcohol and other drug (AOD) problems. Ideally, the plan incorporates, to some extent, the World Health Organization's five dimensions of health: physical, social, mental, spiritual, and intellectual.
Treatment planning should develop from the assessment process and embrace the importance of appropriate client-treatment matching. Matching clients to treatment can be difficult in small communities with limited resources, or even in larger communities where funding is an issue. But matching a client with the first empty slot is generally not the best way to meet his or her needs -- or the community's needs.
The difficulty of addressing these needs is underscored by the debilitated nature of many AOD clients in the criminal justice system. Many have never had a stable home, are functionally illiterate, and have had few employment experiences. An AOD- abusing client may come from a family with generations of AOD abusers. The treatment plan must address not only the need for rehabilitation, but also for "habilitation." Rehabilitation emphasizes the return to a way of life previously known and forgotten or rejected; habilitation is the client's initial socialization into a productive and responsible way of life.
The treatment plan is based on each client's identified needs, problems, and resources. It seeks to match the client with what the assessment process has identified as the best level and modality of intervention. The good treatment plan is a comprehensive set of tools and strategies that address the client's identifiable strengths as well as her or his problems and deficits. It presents an approach for sequencing resources and activities, and identifies benchmarks of progress to guide evaluation.
Two key concepts guide the development of every treatment plan for every client:
The plan should be individualized.
The plan should be participatory.
The counselor does not devise the treatment plan for the client. Instead, the counselor and client prepare it together. The counselor's values should not be superimposed on the process. The client should have part ownership of the treatment plan, and she or he should be able to honestly look at the plan as a shared effort to work toward a common goal, not as something imposed from without. Other professionals from the treatment agency may also have input into the plan. Ideally, the final version of the plan will include the collective wisdom of the agency staff and contributions from referring and supervising criminal justice personnel, as well as from the counselor and client.
The treatment plan should have clearly stated goals and objectives. Goals should be realistic end points. There should not be too many goals, and goal-setting should be ongoing. An unnecessarily ambitious treatment plan is nearly as likely to fail as an inadequate one.
Goals should be specific, measurable, and quantitative. For example, the goal of "having a better life" is inadequate. Rather, a goal should be specific: "Find an apartment to live in," "Get back with my wife," "Stay away from my dealer friends," or "Exercise four times a week." The treatment plan should help the client establish a positive sense of self and self-esteem. Abstinence-based therapeutic goals are customary in most AOD treatment programming today (except in methadone maintenance programs), but the treatment plan should have some flexibility to accommodate some relapses or slips during treatment. It can be therapeutic to set realistic early goals, such as, "Fewer dirty urines a month, for the next 3 months." For some clients, merely getting to an appointment sober is the most realistic goal that can be set.
However, goals must conform to limitations imposed by the court, by the parole or probation department, or by any other criminal justice agency with jurisdiction over the client. The client participates in the process of setting goals, but does not dictate them. For example, if the halfway house that the client is living in requires proof that he or she is drug-free, then abstinence must be an immediate goal. However, it is important that criminal justice officials understand the incremental nature of change and the necessity of individualized objectives for the AOD-abusing offender.
Incorporated into these goals and objectives should be examples for the client regarding the handling of life and relationships without AOD in a variety of arenas, including friends, fun, family, sex, employment, and problem-solving. The client must be shown illustrations of successful living, especially positive examples in his or her own life, if any are identifiable.
Therapeutic goals must translate to behavioral indicators. Measures of improvement to be considered include changes in appearance, making different friends, and abstinence from or cutbacks in AOD use. Goals and objectives can also encompass elements that address the client's spiritual and social life. Examples that can be considered include attending Alcoholics Anonymous, Narcotics Anonymous, other self-help groups, or church; having healthy friends; or taking part in activities, hobbies, or volunteer service.
The treatment plan must be custom-tailored to the client, as much as resources and time will allow. A good plan is organic, dynamic, evolving, and flexible. Events occur over time that necessitate altering goals and objectives. A good plan is designed to address three types of potential problems:
Attrition
Noncompliance
Inadequate progress.
Mechanisms should be built in to handle these problems. For example, noncompliant clients could be required to report back to the supervisory criminal justice authority, experience some kind of sanctions, be reevaluated and referred to more appropriate services, or be terminated from the treatment program. In some cases, flexibility must work the other way.
Sometimes the client responds so well that treatment can be accelerated or streamlined. This can lead to reduced supervision from criminal justice agencies.
It is important to note here that not all treatment failures or examples of inadequate progress are the responsibility of the client. In some cases, inadequate assessment, poor planning, or inappropriate services may be the primary cause. Therefore, each client failure should provide the program with an opportunity to evaluate itself and its services, in order to identify areas for improvement.
Just as clients must be allowed to help design the treatment plan, so must they be responsible to it and accountable to its rules. Clients must know what the results of noncompliance and poor progress are and must understand the penalties for breaking rules that are intended to guide behavior. Clients must understand that treatment programs have certain unbreakable rules (for example, no violence or intimidation), and that penalties for breaking rules can include dismissal from the program, return to court, and incarceration.
These penalties should be specifically spelled out, so there is no room for rationalizations later. There should be no doubt in the client's mind regarding the consequences of specific misbehavior. Accountability also includes objective measures and monitoring as a basis for measuring the client's progress and determining the need for reassessment.
The answer to this question depends on the jurisdiction and the resources available to the system. Ideally, a treatment team should consist of whatever specialists are necessary to address the client's problems and deficits. These may include a drug and alcohol counselor, a clinical director, a licensed social worker, a case manager, and whatever medically trained personnel are necessary to address acute or chronic illnesses that have been diagnosed at assessment. A registered nurse is a valuable member of a good treatment team.
Short of this ideal, at minimum the team needs a case manager and counselor who are certified and experienced in providing AOD treatment. The criminal justice system should be represented on the team. Members of the treatment team need to be culturally and ethnically sensitive, and some of them should be members of the same group as the client being treated. There should be no linguistic barriers.
As noted briefly in Chapter 2 of this TIP, there is the potential for conflict between treatment and criminal justice agencies. This conflict can be anticipated and avoided, to a certain extent, if certain points are made clear from the beginning of the treatment planning process. Criminal justice officials need to understand that the treatment system does not coddle the client and that the goals of treatment are consistent with the aim of getting the client out of the criminal justice system. Treatment providers need to understand the legal obligations of criminal justice personnel -- to ensure public safety and to protect the rights of the offender.
It is best to spell out these points in a memorandum of understanding (MOU) between the two agencies. This is a formal agreement between two parties that specifies expectations, roles, communication procedures, decision-making processes, and action steps to be taken in response to clearly delineated unacceptable behavior. The MOU should list specific actions of the client that can result in dismissal from the treatment program or a change in supervisory status. It should spell out expectations, definition of terms, methods of communication, deliverables, roles, grievance procedures, and crisis management. The MOU can also answer the following questions.
How often should details of treatment be communicated to the criminal justice system?
What access to treatment and assessment records should the probation or other criminal justice officer have, and to what level?
How is client confidentiality to be respected?
Which members of the treatment team are to have contact with the criminal justice system?
What sanction mechanisms begin on the criminal justice side in the case of noncompliance and relapses?
The client should be also aware of the details of the MOU so that the consequence of relapse or noncompliance does not come as a surprise. And, in a similar vein, criminal justice officials must understand that the treatment process is not a linear function to be interrupted or declared a failure by a single relapse. Rather, it can be viewed as a graph to be plotted over time; success occurs over an overall upward slope, regardless of sporadic, noncritical dips.
Another TIP, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System, discusses the conflicts between the treatment and criminal justice systems, and how they can be resolved.
The process of assessment does not end once a client has been classified, assessed, and assigned to a treatment program. Assessment is part of the ongoing treatment process, an essential tool that can determine:
The value of the course of treatment chosen
How that course should be adjusted
How realistic are the goals that have been set
What linkages need to be made to obtain services for the client from other agencies
When maximum benefit of the intervention has been achieved
The plan for further intervention.
The purpose of assessment during the treatment process is to determine how effective the treatment has been up to the assessment point, what kind of progress the client is making, the appropriateness of the present treatment, and what the next level of treatment should be. Assessment in the course of treatment is a dynamic, longitudinal process, not a single event. It is an objective, quantifiable measure of the progress achieved by the client and the treatment program.
Ongoing assessment of treatment progress using standardized criteria is a cost-effective procedure, revealing early in the treatment process such problems as inappropriate referral, misdirected treatment, or unrealistic goals.
Progress assessment is a clinical management tool focusing on the client already in treatment. In contrast to an intake assessment, which establishes a baseline for the client, progress assessment measures the client's response to the treatment that has been provided. It also measures change and degree of change, if any. This change may be either positive or negative. It is important that progress assessment be compatible with intake assessment, so that the treatment team will have a consistent continuum to use as a guide in considering a client's progress.
Goals set for progress assessments must be realistic, individualized, and determined through a participatory process that includes the client. As part of the assessment process, it should be made clear to the client and the criminal justice system that treatment is not punishment. This can be a very difficult concept for mandated clients to understand, particularly those who see themselves as controlled by the criminal justice system, often with treatment linked to their sentences. It is necessary to emphasize that treatment is not punishment, so that clients do not feel that "doing time" is all that is required of them in treatment. It is unlikely that a client with this attitude will be a participatory member of the process and reach the goals that have been set.
The assessment of treatment progress should be routinely performed by a clinician and the treatment team. It is important that the treatment team be equipped to handle linguistic and cultural diversity, as well as gender issues.
If security needs are an issue, a representative of the criminal justice system should inform the treatment team regarding matters of security. Criminal justice requirements must be considered, but they should not dictate the treatment agenda. This is discussed in more detail later in this chapter.
According to some involved in the treatment process, the answer to this question is, "As often as you can afford to." There are no set standards for the frequency of treatment progress assessments, and frequency is often dependent on financial resources and the availability of technical support. Different instruments also specify differing time periods between progress assessments. Different types of interventions -- long-term, short-term, residential, or outpatient -- may be needed at differing intervals.
The frequency of treatment progress assessment should be agreed upon by the client and the clinician at the beginning of treatment and adjusted, if necessary, as treatment continues. State licensing requirements often mandate treatment planning reviews at specific intervals. Thus, the treatment program may not have a choice regarding the frequency of assessment. Assessment can be part of the ongoing treatment plan.
The assessment instrument is a tool used to quantitatively measure progress. There is a need for valid, reliable, and widely recognized tools, and they must be standardized, understandable by both the AOD and the criminal justice systems, and culturally sensitive and appropriate. Whatever tool is used should be repeated to foster consistent measurement and reliability of data.
The most objective tools for measuring progress are urine and blood tests for the presence of AODs. These tests can be used beyond their obvious pass/fail connotations as therapeutic tools to measure progress. For example, treatment might be divided into three phases, with a goal of "clean" urine 50 percent of the time in Phase 1, 75 percent of the time in Phase 2, and 100 percent of the time in Phase 3. Another important consideration with respect to urine testing is the context within which it is done. A positive urine test from a client who has just begun treatment in a maximum security institution has considerably different implications than a test from someone who has received extensive treatment and is currently in a community-based residential program. Urine testing should not be employed independently as a measure of progress but, rather, used only in conjunction with other measures of progress.
There is disagreement within the treatment community regarding how standardized and objective assessment instruments should be. On the one hand, standardized, quantitative methods of measurement provide clear and easily accessible documentation of progress in treatment. But many treatment personnel resist what they see as the "robotization" of assessment and prefer assessments that are subjective and individualized. There are few assessment instruments designed specifically for measuring progress in AOD abuse treatment programs for a population referred from the criminal justice system. However, a number of existing instruments, such as the Addiction Severity Index, can be adapted for this purpose.
The treatment plan, developed as an important component of the clinical assessment, is reviewed, assessed, updated, and revised throughout the course of treatment. Ideally, the plan is adapted as intermediate goals are met successfully. Then, at the end of a successful process, the treatment plan evolves into a discharge plan. All treatment plans should address specific substantive issues. Among these are:
Employment, vocational, and educational needs
Housing in an environment that is free from AODs
Medical and psychological concerns
Recovery support
Self-esteem development
Relapse prevention
Stress management
Self-help resources
Abstinence or reduced AOD use.
Different issues will be addressed at different points of assessment, and individual issues should not be considered in isolation but, rather, in the context of the treatment process. For example, was the client successful in finding housing because of his or her own efforts, or because of the efforts of a counselor? The aim is not for the counselor to overly facilitate the solving of the client's problems. Rather, it is for the clients to make internal changes in the way they view the world and themselves. Internal changes in the way the clients view the world and themselves are desirable.
Obtaining information to assess progress is a pragmatic procedure that is dependent on a number of sources. The most obvious, of course, is the client. What must be emphasized, however, is something that every treatment professional knows: Clients often tell us what they think we want to hear, and unintentionally deceive themselves. What the client says must be considered within this context and verified whenever possible. Verification is discussed in greater detail later in this document.
The assessor should try to remain current with events in the client's life: where he or she is living, with whom, etc. This information can be gathered either through interview or through a self-administered form, if the client has sufficient literacy. Beyond this basic biographical information, the assessor should try to get the client to describe what he or she has learned throughout the treatment process. For example, what has the client learned about addiction? It cannot be assumed that clients are learning merely because information has been provided to them.
Observation of the client's appearance is another way the assessor can gather information. If clients are unemployed and wearing expensive clothes and jewelry, their denial of drug dealing is suspect. This kind of sensibility and sensitivity can be applied by the clinician to a wide range of clients' behavioral cues.
The counselor should also elicit information about the impact of treatment. For example, has the client moved away from a previous circle of drug-using friends? Is the client consciously exercising impulse control when confronted by a situation that a few weeks ago would have triggered a dangerous rage? What does the client think about treatment? Is the client satisfied with his or her progress? What does the client think the next stage of treatment should be? What are his or her complaints? There are sure to be complaints and they should be noted and considered seriously.
The assessor can also gather information from
family members and others close to the client. Input from these sources can corroborate information about the client's attitudinal and behavioral changes.
Contacts with sources in the criminal justice system can provide additional information about the client, as well as verify information received from other sources, such as a social services agency. This exchange of information can be specifically described in a memorandum of understanding between the two agencies, listing how and when the communication can take place.
Information shared between agencies should be written whenever possible, but other types of verification can be used. For example, if clients are attending self-help meetings, they should be able to describe the meeting format, their reactions to the meetings, and the issues that were addressed. This kind of verification is often more valid than the results of a standardized test, where there is no assurance that a client is responding truthfully.
It is important for the treatment and criminal justice systems to recognize each other's needs, and to understand each other's methods and goals. Sometimes these needs, methods, and goals may differ, but with the same clients passing through both systems, it is imperative that coordination, understanding, and synchronization be achieved if the best interests of the clients, the systems, and society are to be served.
Information must be shared between the two systems for mutual benefit. A treatment counselor needs to know if the client has had new encounters with the law or has been noncompliant with conditions of probation and parole, since these are indicators of serious behavior problems. If a probation officer learns that a client is compliant with treatment and is progressing well, he can adjust the level of supervision and better allocate the resources of an overtaxed agency. The two professionals can also work together to avoid duplication of effort in handling such things as Social Security and Medicaid eligibility.
There can be areas of tension between the treatment counselor and the criminal justice official. A counselor may be satisfied that a client is making good progress toward specific treatment goals. The criminal justice officer might respond, "Sure, treatment may be going well, but what about these other behavior problems? This guy is still testing the conditions of release and is hanging out with his undesirable associates."
There are inherent conflicts as well between the treatment community's need to factor cost into its decisions and the mandate of the criminal justice system to protect public safety and security. Cost considerations may lead to the least restrictive program that can be appropriate. A judge or other criminal justice official may not be willing to accept this recommendation. "We do our best to inform the criminal justice system of our assessment," said a Chicago-area counselor in the Treatment Alternatives for Special Clients program. "And when we recommend residential treatment, it's usually favorably received. But when we recommend outpatient treatment, the judge tells you where he thinks that client should go."
Somehow these conflicts must be resolved and the tensions used constructively. Ultimately, an offender's fate is in the hands of the criminal justice system, and AOD abuse is only one of a number of factors that must be considered in determining placement. Treatment personnel must consider the whole client in their dealings with the criminal justice system, or they will lack credibility with criminal justice personnel. Likewise, criminal justice staff can learn to understand that treatment involves many shades of gray. For example, just because a client is not in a residential program does not mean that she or he is not in an intensive treatment regimen. Residential treatment should not be viewed by the criminal justice system as punishment due to its restrictive nature.
Meetings should be set up between criminal justice representatives and AOD abuse treatment repre-sentatives to consider such issues as supervision, community protection, and treatment content and progress. It is important that judges understand that they should not sentence offenders to specific treatment plans. Rather, they should order clinical assessment at an early stage, and then mandate treatment based on the outcome of the assessment and under the supervision of the treatment provider and/or the probation department.
The problems of attrition and noncompliance should be anticipated early in treatment. If they are noted sufficiently early in the treatment process, it may be possible to avert them. Regarding issues of noncompliance, a proactive attitude is needed from the treatment counselor. The criminal justice representative should be alerted when noncompliance occurs, long before a client is actually expelled from a program, if it appears that a situation leading to this outcome is developing.
The client needs to know that there are certain nonnegotiable rules in treatment, and that breaking one of these rules can result in expulsion from the program. Some programs are more rigid than others. The criminal justice representative, as well as the client, needs to be informed about the specifics of these rules, so that if expulsion becomes necessary, the course of action will be understood. For example, if a client physically assaults a counselor, and assaulting counselors is specified in the rules as a cause for expulsion, an expulsion should be a surprise to no one. Obviously, any infraction such as this should be documented in writing and immediately communi-cated to the supervising criminal justice authority.
It is also helpful if the treatment counselor and criminal justice representative discuss certain general trends in advance. Such particulars as retention rates, the most likely dropout points, and relapse rates in various stages of treatment, can be used to alert case managers in other systems to potential problem periods and when they are be likely to occur.
Every clinician knows that the limits to reaching treatment goals can span a wide variety of circumstances, both predictable and unforeseen. The treatment may no longer be effective. The client may have other serious life problems that preclude successful treatment. The counselor may leave the program, and the client may feel he or she does not have the energy to start again with someone new.
Another limitation in reaching goals derives from the complex problems of the clients being seen today in the criminal justice system. Compared to problems seen in clients 10 or 15 years ago, the problems of today's generation of clients are far more complex and multilayered. In many cases, the issues are not simply poverty or AOD abuse, but problems stemming from generations of poverty and generations of AOD abuse. This population is more debilitated than previous generations. Clients may be illiterate and often lack a sense of family, structure, or purpose. They may not have any concept of the value of employment. They may need help in developing qualities that provide the underpinnings needed to be productive members of society. The treatment program can be an important part of the habilitative process.
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