SW 510 Integrated Health Care
SW 510 Integrated Health Care
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Date Created: 09/26/13
instructor ECKEL SFL13OODl00301O We assure campiiance with 115 Gavemment ccgtpyright39 Eaw Pe39rmissiltsn ta duwiczate any mamr ais ccwered by mpyright iaw has been seaured Treatment Plcmningfor PersonCentered Care Th e R0 a d to b en tczl fl and Addiction p p etc Very Mapping the journey for Individuals Families and Providers N cal Adams MD MPH Diane Grieder MEd ELSEVIE ACAD IC PR AMSTERDAM 0 BOSTON HEIDELBERG 39 LONDON NEW YORK 39 OXFORD PARIS SAN DIEGO SAN FRANCISCO SINGAPORE SYDNEY TOKYO Elsevzer Academic Hess 30 Corporate Drive Store 400 Burlington MP9 01803 USA 525 B Street Suite 1900 San Dlego Califorma 9210l 4495 USA 84 Tl1eobald s Road London WCIX SRR UK Tins book rs prmted on ac1dfree paper Copynght 3 2005 E39lsev1er lnc All rrghts reserved No part of tlns pubhcatron may be reproduced or transmxtted 111 any form or by any means electronxc or mechzmrcal 1nclud1ng photocopy recordmg or any mformatron storage and retrreval system wrthout perz11ss1on 1n wntmg from the pubhsher l ermiss1ors may be sought directly from Elsev1er s SC1 11C 63 Technology Rrghts Department in Oxford UK phone 44 1865 843830 fax 44 1865 853333 e ma1l pernnss1ooselsev1er coullt You may also complete your request on l1r1e V18 the Elsevier homepage http39 elsevtercom by selectmg Custor11er Support zmd then Obtammg Perolissioiis Library of Congress Cata1oging in ublication Data Application subnntsed British Library Cataloguing in Publication Data A catalogue record for this book 15 available from the Brmsh Llbrary ISBNI3 98 G 12044 l55 6 ISBNI0 G i2 O44l55 1 For informatron on all Elsevrer Academac Press publ1cato11s V1311 our Web szte at vvwwbooks t3lS V1E139COI1 Prtnted In the Umted States of An1er1ea O8 O9 9 8 7 6 5 Acknowledgments As all autlxors note this book could not have been written Without the ess1st2r1ee and support of many people Similar to the team assisting the Lndjv ual 150 aclueve lus or her goals in the persoo centered approach We L P p 1 Levy who Warned us vvnting 21 book will be the lmrdest thing you ever do and she was right M3I1Y th311kS 0 Our colleagues who were Willing to read offer comm n1e11ts ancl support and even edit portions of the bookuas it evolved Ed Drrksa Wrlsna Toxvnsend Nzrbay Sn1ghjohn Morris Lesa Yawn Nikki Mxgas Wer1dy Graddison Yana Jacobs Penny Knapp Sherry Kjmbrough and James W Batef Thanks are also due to the many individuals receiving services we 113 t in our professional careers who have been a source ofi11spiration to us ey have taught us how to hsten to have hope and to believe in them Most importantly thar1llts to our respective families who joined us on this road tr1p sometimes willingly sometimes 11o39t a11d were the foam ta1Ils of support encouragement unde1quotstar1d391ng and forgiveness that made vvr1t1r1g th1s book possible To our spouses Lucy and llarioo and to our Il1ilClIquot 11 Alyssa Caleb Parris and Zachary we will be forever grateful O w enigma 5 NE E 5535 3 mccm Emcmmou 960 mrwmb hm mz mEaampL xmwmwdu mo REG ummwe 5 ummm 3 Enema mode Eucm m ow BEL mwuom euv wm wax m maow mi ma 94 we 385com u QEFS gtwH um a on 28 Hm gt usonm mwE was we 338 muEgtoamp 93 m1wsEgt any we wgt uumu up K03 Esu mm m 150 m 2 253 2 wmm Uumwsmou kwmmmo wm uoduom mm 350 so mmzwma 5 Em ubu uw HBHE EgtuBo damn mama 2 w wES5mmuE kmmu mwuan ca PE 380 O Sw 3 at m m 2 HOE S oda mmo uvm 2amp3 3 om Hum nm ums wan mwmm omm Baou E hu mo zo omua you Eco om 6 mum mmmoa 933 wzmm mmwEgtE 95 mmamaoumu E505 umwam ma Row EH awuum Em 5393 hung mo cou om 23 Buummu wmw EB wa eom E o mgt oE H63 3 wows wzmu mm 6uEuwm w b unz mom 35 53 m mmdos aw wmmcmau wuumnwu mm M s mam msEgtuE Bu mo am m 2amp5 w S m uEw u mom E su kr aw GEE man 03 3505 Gem 4 Ho gtgtO 35 3 wuu mmu gtmuE 6gt imam E HQ H gtO was uwmmau Mom muhmm mmgmm mdw mm3gtE u mmmmummxu E5 Eummuu m d mwm umo5 m on 3505 wow m sawa mB gt cam wv uumou 1umoamp lt muu m 338 mam Eu mm uum 50 Rbouuso Hwdpsao u iico mn mmm any we conagugm wmBmuu mz b cam mmsEgtmu w Swami E505 dwow 09 3amp3 Q3 a mo 50338 H8 2 amp H33ngtumw was HO wow 5 w mm E mmltu MWHH UZHHltHm g ESE c Q m wc r ragga Es 30 uuumm ouusm H ENm 33 as 35 33 N23 ER sm Eu ask w 53 xcab 80 MEmm 120 On the Road ment with the individual and family and becomes the focus of further collaboration If the plan is thought of as a contract between the individual and the provider the goal is the deliverable speci ed in the contract For the most part goals are not necessarily time framed but may be if the time frame is meaningful and relevant to anchor their attainment to some point in the future This is often in uenced by a number of factors ranging from the service setting eg inpatient or residential as compared to outpatient the acuity of the individual and family s needs externally imposed tirne factors deadlines or requirernents and the speci city of the goal itself When there are multiple goals clarifying priorities and sequen cing by setting time ames can help to provide clarity and organization to the development of the plan Types of Goals Three different levels of goals can be identi ed life goals service or treatment goals and quality of life enhancement goals however not every plan has to specify all three types Often these three goals are closely related if not one in the same depending in part on the circumstances and service setting Goals described as li e goals may include aspects of the individual s life where they have hopes for overall improvement and may include aspirations such as I Want to be married or I Want a job Such goals may or may not appear to have an immediate relationship to service needs and are less likely to be time framed Yet the difference in the power and momentum of the plan that occurs when I Want a job becomes l want to be Working fulltime Within 9 months cannot be ignored Re gardless the recognition and acknowledgnient of the individual in identi fying and setting life goals can be a critical part of building and maintaining an effective collaboration Service or treatment goals address the resolution of the needs and concerns that are a barrier to discharge or transition om services These goals are often closely linked to the issues and needs that prompted the individual and family to seek help and are responsive to the immediate circumstances Treatment goals may be setting speci c or address concerns for a particular episode of care or a particular level of service In an inpatient or residential care setting these goals are typically the positive re arning of the discharge criteria and the removal of the barriers for a transition to a lower level of care These goals are often quite succinct and may be more speci c or rneasurable For example an individual may have a life goal of a career as a Setting Goals 121 teacher but is currently living in a clean and sober housing program The life goal might be I want to become a teacher While the treatment goal in the current setting is I Want to return to living With my fainily In some settings or circumstances as in the previous egttan1ple treatment goals may be a subset of larger and broader life goals The more non specific and larger the life goals the greater the likelihood that there will be important more speci c or immediate service goals to identify and achieve Admittedly this can be confusing and blur the distinction between objectives short terrn intermediate steps and goals At some level the distinction between the two is qualitative and subjective and needs to be considered in the context of an individual plan One could argue that returning home from a clean and sober housing program could be Viewed as a short ter1n goal or objective an intermediate step on the road to getting one s life back on track and pursuing the dream of becoming a teacher This is part of the art of individual plan11ing lltnoWing how to organize a strategy that is most effective in helping the individual and family A goal will typically have multiple barriers or steps that need to be resolved through a series of very specific objectives in contrast an objective is one of several efforts to focus on a measurable and targeted change in behavior or capacity Within a specified time frame that helps the individual and family to attain their larger goals There are typically few goals and many objectives Goals are tied to discharge and transition objectives are tied to the attainrnent of goals E39tl1a2sretncr1tgoals include those other needs not expressly or inirnediately linked to seeking services or specific life changes but typically reflect quality of life concerns for the individual and family These goals may be fairly non speci c and may speak to human needs and concerns ranging from the mundane and material to a desire for some form of self actualiaation Often these goals will not be a succinct focus of the individual plan Rather the individual and family are able to build upon their success in attaining service goals or life goals and pursue these enhancement goals on their own Examples of life enhancement goals might include such things as I want to be able to travel morequot or l Want to have more friends a better job live near the beach and so on Life enhance ment goals are often of real importance to the individual and family but they are not as tightly linked to the needs challenges and barriers that result from the mental health and addictive disorders that are the focus of the plan a 003 a om m 0035 ru 02 Emma mom lt Sm20080m cam 0m00 omnuom 0 0200030 Sw 043 PL0E 05 05 8033 w 305 2 0 lt 3000 853 E mmsmmh 003030 3m 30 mm 33 aw m r amouoi m mm m 05 m0 300 23 0HE5m0m msoimm 03 39 000 8 E5 wom 00 wom Wain 000 mswwmmw 000 00303 wmm 3000000 005 m0 0 gt a0 00 m5EgtE 0 mo 00038 0 m0Bmm0 man How 000 30 ugtm 00 u ampoamp mwmswam 305 00 2 amnmo 3 Emom W w 000 505 mama 0mm 00 1230 00 mm mm doumuwm 3 E3 00 mown m m 000 0 Eo3 5020000 m H gt0u 030050 R m ummnm 000 BR 0 mom mqmsu om 0303 mm m mmmaiw HE3 HwEgt0 0 005 mom 06305 00m 0003 00 3352 E m 0amp 3 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Hgt0amp 00 05 E wm05 ER 33 m0m0mS 0 00mB no mommupmxe 083 00 mmmw um 3 852 500 wmmuummmm Ew00 mE0Egt0 05 mo u0EEw 00 ma um wow d ummwwm can mm uom Jamugu c 0003 m0 muium a Mom w wum m m aa 0m 0305 3 Row 03 ampm E mam 0m0wEwa m 00mE5 EH Q m lm o B05 3 005230 mE lmmo mam mm0 850 00 nmm0 m 0E00wugt0 00 wmv og 000 HmEgtm0E 0 05 Baum aw ww wmm 0000 8m 0000 00 05000 00 E33 03 2 WEB 0003 0 was 000 on 22 mow 000530 was mom WE 004 8005 03 083 emwm cmww 0 5 wom we 009050 0 mam 50 05 M0 mmu mamou 05 5 0303050 03 0300 39 mmmmwzmau can 000 mgmoa mo 3063500 warm Rom Br 0 N3 124 On the Road goal Written as I will be able to complete employment applications is probably best treated as an objective Not being able to complete a job application is likely a barrier to successful ernployrnent and therefore should be treated as an objective rather than a goal If job application becomes the goal then vvriting an objective for this goal can become tedious and the plan soon becomes a tangled Web of unnecessary details that confounds rather than facilitates the individual s recovery if there are too many goals managing the plan for both the individual and the provider becomes overwhelming and renders it a fairly useless document Providers are encouraged to carefully evaluate any plan that contains more than one goal and to question whether or not the plan is enhanced and strengthened by having multiple concurrent goals The other most common error is the inclusion of goals that reflect provider concerns and needs rather than those of the individual and family Sometimes this is driven by the provider s sense of values and what is correct or most important Other times this reflects a lack of meaningful involvement by the individual and family in the problem solving and identi cation processes it can be an early sign of trouble in the individ ualprovider partnership The standard of good practice is that goals are expressed and documented in the individual s own Words Goals developed by a provider should not be subsequently translated into the individual s Words in an attempt to give them authenticity Rather as much as possible goal statements should capture in a short phrase or sentence What individuals and families seeking services see as their needs and expected outcomes from the plan It is perfectly acceptable for the provider to suggest language or ideas to facilitate the process if an individ ual or family is unable to articulate goals then the first task in the service process is to provide them the comfort safety tools and supports necessary for them to be able to identify a goal After all it is their journey their destination the provider merely serves as guide facilitator and n 1apmallter along the Way There are states and service delivery systems that continue to have requirements oftentirnes tied to provider reimbursement for services for goals to be elaborated for each domain of an assessment Such require rnents run the risk of creating detours on the road to successful planning they create unnecessary complexity that confounds the service process and potentially dilutes the effectiveness of the plan Yet realistically these expectations and regulations cannot be ignored One practical solution is to identify some goals as active and inactive or primary and secondary allovving the team to focus on a few more immediate and critical needs Setting Goals 125 Developing Goals Goals are developed from the information gained in the assessnient and the understanding derived from the narrative summary The assessment process helps to identify the unique attributes of each individual and farnily including needs and problems strengths resources barriers and priorities in reaching the goals In a personcentered approach the provider s re sponsibilities are 1 to help the individual and family identify and express those issues and needs and 2 to help to frame the resolution of those needs as goals to be included in the individual plan Providers must guard against the temptation to step in and assert their 6Xp 139l 11C Wisdom and or values in stating goals that reflect the provider s concerns or priorities rather than those of the individual and family The provider s obligation is to respect the individual s and fan1ily s choices and preferences and to assist them in achieving those goals The link between goals and anticipating transition or discharge from services is often neglected but essential Goals should reflect the resolution of the problems or needs that initially led the individual and family to seek services The treatment goals speci ed in the plan can be used as a yardstick to measure readiness for discharge or transition from services If the indim vidual achieves the goals and there are no other goals that emerge it is probably time for transition or new goals need to be identi ed However clarity about discharge or transition criteria is often missing from mental health and addictive disorders service plans In many instances it seems not even to be a consideration the implication is that the relation ship with the provider is forever and there is no exit for the individual and family This implies fostering a codependency and a process with no end that lacks any accountability An important function of the individual plan is to prevent this from happening through the identification of goals and the articulation of discharge or transition criteria linked to the goals The power of the goal statement is often in its simplicity It is not necessary for goal statements themselves to reflect a sophisticated or highly developed understanding of the problem and needs this typically occurs in the task of developing objectives or specifying interventions Oftentimes the most effective statements of goals reflect the everyday basic concerns Wants and needs of individuals and families They might include such things as managing one s own life and being free of external control wanting a better quality of life with greater comfort or ease 126 On the Road improved housing improved access to transportation and mobility the ability to Work pursuing an education access to specific activity or accornplishinents social opportunities and more satisfying relationships sexual satisfaction spiritual ful llrnent better health and well being wanting to feel better and be happy the ability to have fun and enjoy things I U I G O 4 0 While these are goals that may well be affected by mental health and addictive disorders services they are not treatment or disorder specific Recovery and rehabilitation are concerned with helping people lead their lives to the fullest potential These concerns and needs are at once mundane and profound However it is important not to lose sight of the need to understand and link these challenges to the barriers created by the rnental health and addictive disorders that have led the individual and family to seek help Culture can also play a role in identifying goals and can affect both real and perceived priorities The interplay of personal experience culture society and the service delivery system is complex Awareness of and sensitivity to this interaction is critical Stigrria and culture are often linked in intricate Ways and may also play a role The potential for an individual or family to self lirnit their expectations for a better life in the face of the challenges resulting from rnental illness and addictive disorders is real Providing education about the potential for recovery resilience and Well ness is part of supporting the process of goal identification and definition The providefs task is to help people to see beyond What was to What can be by removing the blinders of fear ignorance and misunderstanding For e2ltan1ple individuals and their family inernbers may have a limited vision about an individual s ernploylnent potential They are resigned to a life of disability and unernployrnent based on old beliefs about benefits treatment options prognosis and so on or are unaware of the established success of supported ernploynient programs for individuals with even the most severe mental health and addictive disorders challenges Providers need to inform the individual of options and share their professional judgrnent about What they believe would be most effective Providers need to help the family and individual move beyond disability labels Setting Goals 127 1 it eg can t work low productivity won t stay on task and instead build on their hopeful vision for a different future Priorities Priorities are an important consideration both for establishing goals as well as for setting objectives but they differ in significance for each individual and each phase of the service process Priority in goal setting is really driven by the wishes and desires of the individual and f3II1ilY WiCi1 appropriate help from the provider as needed in clarifying those preferences and priorities If multiple goals are identified it is important that their priority order or sequence be identi ed Addressing the issue of priorities is perhaps one of the more difficult and potentially conflictual aspects of the plarinirig process There are times when the priorities of the individual and family are very different than those of the provider Sonietimes this is simply a matter of values and perspectives At other times providers must give priority to protecting and preserving the basic health and safety of the individual family or conimunity Abraham Maslovvl elaborated a hierarchy of needs that helps to shed some light on the perspective of many providers lvlaslow identified five levels of human need as follows Physiological Needs These biological needs are the strongest needs because if a person were deprived of all needs the physiological ones would come first in the person s search for satisfaction Safety Needs When all physiological needs are satisfied and are no longer controlling thoughts and behaviors the needs for security can become active Adults have little awareness of their security needs except in times of emergency while children o en display the signs of insecurity and the need to be safe Needs of Love Affection and Belongingness When the needs for safety and for physiological vvell being are satisfied the next class of needs for love affection and belongiugriess can emerge as people seek to over come feelings of loneliness and alienation This involves both giving and receiving love affection atnd the sense of belonging Needs for Esteem Wheii the first three classes of needs are satisfied the needs for esteem can become dorninant These include needs both for S lf St I1T and for the esteem a person gets from others Ilurnans have a 128 O n the Road need for a stable firmly based high level of self respect and respect from others When these needs are satisfied the person feels selfcon dent and valuable as a person in the world Wheii these needs are neglected the person feels inferior vveak helpless and Worthless Needs for SelfActualization When all of the foregoing needs are satisfied then and only then are the needs for selfactualization activated ilaslovv describes self actualization as a person s need to be and do that which the person Was born to do A musician must make music an artist must paint and a poet must write These needs make themselves felt in signs of restlessness The person feels on edge tense lacking something in short restless If a person is hungry unsafe not loved or accepted or lacking self esteem it is very easy to know what the person is restless about It is not always clear What a person Wants when there is a need for self actuali2ation Provider Perspectives lllfhen the individual or family has signi cant physiological and or safety needs providers may have both moral as well as legal mandates and obligations that guide or direct their sense of priorities In some instances the provider may have requirements to le reports with various welfare or law enforcement agencies or seek the involuntary confinement and treat ment of the individual Wlieii the provider sees the individual and family as being at risk in a manner not recognized or acknowledged by them an impasse that threatens the recovery alliance and plan can occur This circumstance of irresolvable differences seems to occur most fre quently when there are differences between the provider individuals and families in the recognition of the impact of substance use and dependence on their needs The challenge for the provider in such instances is to nd a way to remain true to their professional moral and legal obligations and at the same time prevent a rupture or breach in the relationship This often requires the most artful negotiation and ability to cornproniise and some willingness to take risks There is much in the literature to suggest that these are risks well Worth taking For example numerous past efforts to help people who are mentally ill and homeless whose problems are complicated by substance use have I10f succeeded because they have made shelter and housing a reward condi tioned on good behavior drug and alcohol abstinence and compliance with medications This is an instance of providers placing their OWF1 priorities above and beyond those of individuals Recently new initiatives Setting Goals 129 and programs have demonstrated Success with a different model The alternative approach has been to offer and provide food clothing and shelter without the expectation of sobriety or treatment acceptance This has not only helped to remove individuals from living on the streets but it has often been a first step in building a trusting and safe relationship that over time has allowed the individuals to feel safe and able to consider their medical psychiatric and addictive disorders treatment needs This is an excellent example of how critical the issue of priorities can be and how success can be achieved when the individual s and family s priorities are allowed to direct the process Children and Adolescents The process of identifying and agreeing upon goals raises some issues unique for Working with children and adolescents and their families as compared to adults Sornetimes the goals that are identified are more those of the family rnen1bers than the child or adolescent Too often the child s or adolescent s voice gets lost in the crowd of other interested parties parents social service personnel guidance counselors probation officers and so on If the goals of the plan do not reflect the child s or adolescents views input and desires in a significant way the plan is not likely to succeed Children and adolescents deserve care that is both family and person centered Providers Working with youths need to spend the time necessary to build a trusting relationship that allows children and adolescents to engage and express their own perspectives about the issues and concerns that have brought them to the service setting For the child too young or otherwise unable to understand it is often appropriate for the provider to play a more active role Suggesting that the provider is there to help the child or adolescent improve their relationship with their parents succeed at school stay out of trouble with the law or help them overcome a painful loss or trauma is quite appropriate Offering and suggesting goals that the child can agree upon acknowledge and accept often helps to assure success in planning and services Even if the individual is a reluctant participant in the service program as may be the case when schools welfare agencies and so on refer children and adolescents the provider can use the principles of motivational inter viewing to help build the youth s cornmitrnent to change During the initial assessment phase the child may not be able or willing to 3CCept responsibility for the behaviors leading to the referral and will tend H mmoa Sade aw smusmmi u 550 mam mzommmm Eeamp6 nfum wummsm co muwmmm mEmD 332 um Emu 5amp3 mu sumwmw BE mmomm J95 momma wax Saga 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umsm u 3 woos E595 H33 u aumuw 3 mE mam 1u gtmuE may 33 k g nm Egtoamp w Q33 E 5Em m on 8 m uu u o3nm mum mwgmcum m tmm aa E a a 2 as E wan cm 95 E m EEWBU an 350 528 mo mcmus 5 umwmxu Eamp 93 possum n mmuuopm 33 E mmum m 3 Eaa mogmmm xum aummu mam wEa5m swok ua ME m zu m gtmoE uH m EmgtmumuuuwgtEm w gommu ogtuumuww mam 33 mBm E Uumoomohao MO muLomom cmamo mmm m ms mw mumu umxo Qod cou use sown amic m am 2amp3 maE2m sonammb 5 umuwnummw mag mam Emc w ou mm H mamammm mamumm wah aw uwuwaumm imam mo mum 35 mm B uow 8 S39 65 u o u u mam E 8 mzmow was no 8 m 923 8 13 80 mcnsem H33 an 28 S EoE3u0 SEQ ma 5 m w oumm M5 3 mom mom wag we 803 u mmu o mmuw om mc mvm nmsou mwmo umm an E3 wsa Em w mam REgtsd may Edam Tgt gtuE o 3 m u g owmumu 328 3 mom 5 ma wow 5 E53 umomw 3 3 EsEgtE Rm Him 8 3mmuum ampsm 5 28m Scuwmmucmmmu ummmo Emwsw was Jd m umu ummh imam 2 cmmab a mo usmmmu 2 mo Em m an ns 3Egtoem Em Eo muwm E ma u oEEouum um mcnmmuum 69 a5 on 3 Egtoamp on Sea M Rom u ma mm an uopwm 5 m3gt5 2 Eu Wow www moamm us an 33 Mu poum 23 H33 8 kgwsmou m3 w b m r axum mm uum E mcwmgtuoE wan uumou hung 8 Emma gs RWQFH 355 min E u mu 3 Mom Bm y uw wax m mmvmw BwwEEM Fi ag Q1 33 E wsmmnmumu Em H85 mmom EMF Ewom own uum 3 93 3m 5 HE wmwuoa 33 wmo m xmmomm 83 vim aw d w or mou Emu Kmm mm u Ba 8 u now mn5Egtoamp ip agsun ma 15 omws u Mnmumomumm NR5 mmwo 2 ugtommmw 8 33 a mm m mum H dwsmaumo ummmu was mm mwnsm m uEBm uom8m wow we 06 M 3mmmE um um OH mmm5 w moEgtm 35 wmmzbzu gem wna a mx mwu m E MoHmgtonE Em N mHAU H5030 ts Rt 3 dsmuu E gtoE Ear uwmm Jo HmIH U wEu HG wow 33 uua asa mwzm 55 5EuE E imgtm mwB m we mmmuusm mam mmgom o mo uusummm us M 33 am mosmmou mam Rom wmpwam m 5055 uwuusm 0298 339 lt vPgtgtmm mu nE 3 ma 55 cmmaumm dm mSEgtcn we mdwom 05 wa mmu mam Bmn3mmm s uwns B m m m mm 3gtoamp was 2 J m am as Esau mmuuoum P au u I1vumG Emamsmu ma Hmom wan mo umw uuwmm mm uwuzm m oHm mam cnmms 4wEgtw m cwup ua mowm w u m m we mouG way we 59 ENE Ewamwuumm ECL mEmum aw mama H35 gtE 55 Ems 8 wmm Ammamp can Rs tmu mat w m umms man Q33 3 Mn wmuumw v EH mmEwm as O uo SmEB 95 15 Mwmnxu as B mmhwum vim mwuwc E50 3 HO QE u m am 8 Em m mmu3gtom 2 5 mu 5 EEgtmu 33 we 35 Room 5 3 St imam mmuuwamunsomamm mcnS 3 Q0332 EB ZOLDAOm may UZHHltmdU 5 523 850 ub om m we mEm may wan umummummmuu dm dmuwm mo m 93 as man How a mom Hmuacummww wmuzmdmm 03 musum EBmmomm3 m mwamm Eowz p 5Mgtm oD hos mo muusu wumdou was mm mw odxum 392 3 Emma mzu w Box 9 Mam mmSEgtoamp u mu wnmom m o u a B Eod 2 so 5 132 On the Road for people to reconnect with an earlier sense of hopefulness and purpose in their life Xhen they were in high school for exarnple what were their goals and how did they see their life unfolding What happened that prevented attaining the goal Wliat would it take to resume even with some rnodifcation that original dream Witliiii the answers to these questions may Well he the goals of the service plan Revisiting this history can be painful but it can also commu nicate a message of hope joining with the individual and family in acknovvledging what was special exciting compelling and satisfying about their earlier vision can be empowering and has the potential to carry with it a message of caring hope and possibility In this way creating a service plan is not just the completion of a form and satisfaction of an intrusive administrative requirement Rather it a powerful healing inter vention that assures a personcentered approach to services and sets the stage for successful outcomes Addictive Disorders Goals The challenge of prioritizing and agreeing upon goals is often greatest in working with individuals whose needs and concerns are complicated by ongoing substance abuse or dependence In such circumstances it has not been unconimon for providers to quickly identify abstinence as the goal Sometimes sobriety becornes a condition of treatment instead of an out come This may occur especially when rnental health and addictive dis orders services are not provided in an integrated fashion Regardless this is not acceptable Such actions unnecessarily force a set of priorities that often push the individual away rather then engaging them Following Maslow s hierarchy some form of harm reduction and assurance of safety should be a priority over demands for sobriety This is particularly a problem when individuals corne seeking services in a less than voluntary fashion It is not unusual for many people to initially seek addictive disorders services under a court order or other legal rnandate They often feel angry resentful and lack awareness of the impact of alcohol and or other drugs on their lives As a result they have little real interest in being abstinent from these substances A goal of abstinence even in the face of a judicial mandate will not likely succeed It fails to recognize that recovery and effective addictive disorders treatment follows a stage vvise approach If the individual is in the pre conteinplation stage then the provider should focus on contemplation and engagement Setting goals Setting Goals 133 that have rneaning and relevance to the individual and their stage of change rather than imposing someone else s goals are part of creating a successful personcentered plan Rarely are sobriety and abstinence clearly stated goals of the individual at the outset of seeking help llany if not most individuals struggling with addictive disorders have tremendous ambivalence about relinquishing what has been at times a source of pleasure and enjoyment Rather they Want relief from the chaos and turmoil in their lives that is at least in part a result of the substance use Engaging the individual and family by agreeing to help them resolve the problems and challenges in their life is an appropriate approach to setting goals absti11ence and sobriety will likely become objectives in the plan as the individual comes to better understand that their goals cannot be realized if their substance use continues Goal setting especially for seeking help with a problem of substance use or dependence should be informed by an understanding of their stage of recovery and tlieir treatment readiness as well as their needs and prefer ences Questions that help to assess the person s Willingness to change and to participate in the planning process and treatment setting include What is your motivation for treatment What is your definition of addiction What experiences have you had with treatment programs either for yourself or family members Do you see any connection between your use of alcohol and or other drugs with this referral Every person with an addictive disorders problem is a unique individual with his or her own issues and needs Yet in practice it is not unusual to see sobriety become a onesize ts all goal with the program as the universal solution or service Instead each individual should have their own goal responsive to their life circtirnstances and needs Sobriety or even an initial reduction in use may be an objective along with several others and the program may be one of several services or interventions to help the individual attain the objective The Language of Goals Wlienever possible goals should be expressed in the words of the individ ual and Written in the person s primary language Some criteria for evaluat ing the appropriateness of goals are included in Table 61 Obviously not all criteria apply at all times not is the list in Table 61 intended to be complete Rather these suggestions are offered to provide a handy reference to use in developing goals statements 134 On the Road TABLE 6 The iniiguage of Goals Criteria Possible Goals Provlde a focus of engagementlife changes as a result of treatment Are consistent with a desire for recovery self deterrmnation and self rnanagcrnent Reflective of the person s values lifestyles and so on Culturally relevant in consultation with individuals and their families Appropriate to the 1ndiv1dualquots age Based upon the individual s strengths needs preferences and abilities Wntteii in positive terms which embody hope not negative in focus Appropriate to the stage of recovery AlE 139l i9t1V CO Cllfif iilt C1I CUI11Si39ElI1CCS I want to withdmw 39om drugs I want to have cl beyfiemi girlfriend I want to learn how to I want to be able to drive a car I want to open my own bcmle accotmt I want to work as Cl I want to live with my family I warzt myfcirnily to accept me I want to stop getting in Ifrozable with my pczrem 5 I want to be able to stay at home with myfczmily I want to get through the school year I want to nd out why I leeep relapsing I hope to live in my own apartment I want to leeep myjola I warm to get the judge of qf my bute ptecorztemplatiotz I want tofeel better by stopping gn39em39rzg over my lmsbrmd 3 wy e s death Parsimony Simplifying goal setting and resisting the temptation to elaborate too many goals is one of the secrets to success in developing effective individual plans It is possible that some plans will have three or more goals The intent of the plan is to make change a manageable process but identifying too many goals complicates and confounds the efforts of individuals farnili s Setting Goals 135 and providers Having too many goals in the plan is simply overvvhelming for everyone and underrnines the entire process Encouraging parsiirnony in setting goals for individual plans is one of the irnportant points of departure from common practice today Providers are encouraged to have only one or perhaps two goals at a time It is questionable Whether having more than one or two goals adds to the value of the plan and the effectiveness of service First goals should be global and XpEtI1SiVC l13Vl11g too many is an inherent contradiction Second goals linked to discharge and transition criteria should be a stable element of the plan as the recovery process unfolds l1aving multiple goals that are short term and narrow in focus means that this element of the plan will likely need frequent revision and render planning a burdensome chore Instead the focus for shortterm change should be found in the objectives It follows that prioritization of goals is a necessity The provider may have to help the individual brainstorm different approaches and options or choose the areas that are most immediately important and educate the person about the possibilities All of these activities are strategies for developing a partnership with the individual Even the individual involuntarily referred for services will be hard pressed to deny or rebuff the team s interests in his or her strengths preferences interests gifts and competencies Some organizations have used the tool of having a goal sheet wherein the individual is asked to Write down his or her goals or dreams in their own Words if they are capable of doing so Tliis worksheet is then utilized during the planning meeting as a mechanism to further de ne and priori tize A worlcsheet with topical headings such as What I want to do Wliere I want to work Friends I d like to make These are my hobbies favorite activities and so on may be useful for some people in helping them identify their goals Evaluation How can one tell if the goals on an individual plan are truly person centered The following criteria are useful for evaluating individual plans Upon review it should be clear that the findings from the assessment and formulation have been shared with the individual and family a planning meeting has occurred with the individual and perhaps others to discuss and develop the plan 805 SE no tosw z 98 Euzmu we eaom E83 mma owm mE Emma auumou m3 wan uun muuum mom mawc 3 vwm mgt o wmm um 35 33 21 swag Em Hcm Emso Sum 35 ummmm cm 3 c m zcsm m E 92 cm mm wumumeww Emo5m 0 m WE ems was amE 3 Era c 33 3 EE 2 E3 43 Ewamuumaa w mm m mom mm om 33 EB u5ogt w aosuom a3 32 m mmoa F50 mE BE m mm gm 3 as 35 cm m oni wm WE m wmmmmn NEE Eu mdm m E w m 30 Sam Jmm um ma a was m How mnBno mowmmawm xumamaum u 2 8 Eu ow MA Wow WEB mH usmmauwc Em Eoww moa 3 333 mam S Er wE 25 8 3 3 8 3 NC ms m c2sE Ewm qmom oE ubuoEum mi 53gt maxim wu mm 655 B an LE ma a m wouguo mm su zr 3 E 33 28 AS Euax wow um 54 mom u4 mHABE 035 md 0u 33553 Sam mo SW3 mws ahu SF Eam dsuom unm amub ES Eco 5 E wxiuw mm 6 m gomum a am mw M sou may wmwmmumm E952 mmuuomm umwmmmub 9 5 55mugtH EH5 mm cm om m uEumEPEoouamp w E 3 8 zmo s mom mam umuwammummm was 3 335 sonmagom may mo ugtUuwoa aw 53gt um mdou mTfnE 38 ma Na NSME 3 Kwwnmv Eiimow Em swub m r mm5cuE E Rom omo 30 o EmE 3 Sm 5 ua owm 8ampooE a5 33 5333 mo Wow um mm gt8 ugtoE 3 COHNMN 5 om amp 8 mmuum m gt muunummu 3 Wow m iimoElt wow mmsm Ewm 3 mo mo atmm 5Egtoamp 9 mo mirmmxm mm an ESL 5gtgt mm5 lt E oHr 0 E dupmspox 48 pwmuacuwmb m r 853 any we 6 21 35 8 uEgt2 30 5 1 m 6303 mg dowm mo Emuusou aw 63 muampcw 95 590 55 Ju umor m Em wgtuw ma aw Ema nmmummm new 50 303 5 mom u mumuu mam 3amp Sn mam mmogrw E c t 5 ea mam 8 2 How mm m ma a 6 ampEmmcNm cw MFE amp mx 8 5 Wow usu uusmnmw Sm a o3 ME 3 E wto 2 ma 3 ca m2 a w ma c w mN S w How Euw mub m N2 300 wmnmum EmuuE ow umuuuw u u 9 385 tBw5o moumxw we u ME 5 moam m2mE 3 w msozom was 3 some you mdwom mo 3352 wow Ea 2 3 Home 335 mumnmmNm BmB5 wsm 3E 3393 mo mwm mu mm 9 mmswumoa 5 maa E wouw uugmommum Ea 8 35cm Eu mu wmnw B mn mr maosmm amuo mam EmEgtoE mom uu osu 30 95 335 on 5 Ex 3338 umm b Scwcomasou wu wgmumw Ecombhou 550 mam mwwmm xmv o mmsummm mm 3 mu xmwm w2gt ww u Mo 0 aw 03 wm um mm awn hazy Mom um m i auoa ugtm 55 gtv3oE wozom 35 3833 unis 2 Em 335 E vim Eu u Ema aumu we mmm ouug was muww mumm Hm mom ak mmosugt tum mugtUum3o ow dmwguua mmo um mm Hwm u ou a wax m ss m 8 mmnumoammm wuuupduuado wm 80505 3 Eu EomwU 25502 an wmzmmo 38m 5530 ad 08 Hmu mu xao3gt wamuuou Sow uummwm acuom omoar 53 m mo mm uau mowgt BU mcwmwmmbm mam mc mhmsocu u as 2 Mm 3953 on 8 mgtoamp mmumuqwamm 9 E www u ms m BgtmuE ma m m wxm Eu How wum 250m 3 mgt95oI imam auuoudomx 2 E 9 you meow 3 awmoum u ma muuu op 20333 vmrw ZmnEltm PM UZHMAQJZ AZ Ema 56 mo Gxwom Q B so mw E8 muuwiwm mmg umm Emameuw Eud mam HmEgtE u uw E an no mega 2 E uup a wmm uw mum SEQ 23 no 28 was anew ammo Ea 3 Emma 33 wig nmE3 wax 32 now mum 55 mam nDOm 3 Emtomw amp Egon mBEw 2 B 5 8 2 5 E95 50 Bu B03 aw 53 mmo mmsv mom ammn mu H w u 33 3 maoumo Ee a b mum mo iom 50 m aomw mo mm 5 mm 22 50 ER an m am an an an S Q 53 L 4HmmH1 H om mm u m m w ow mam 355 wan auus omu Em smu w m awumm a mcubm mm wow mm w mam ma mu un mouummcoo w my 95 Em sm ugtmEn BE m E wmnxmumuw mam umu mwmm 23 E wm mm mou EomS may EB gamma Em m om Eom 9 a0 a 2 138 On the Road than perhaps he has been able to acknowledge Finding a Way to improve his relationsliip with his family is soniething that Sam Wants to focus on as he and his parents age As such is it not necessarily a key focus of services but soniething to attend to as his individual plan and recovery journey proceed Also tied to the setting of the goal and the identification of discharge transition criteria is the recognition of the barriers to attaining the goal and succeeding in transition The barriers listed in San391 s plan are a succinct sununary of issues and needs brought forward in the narrative summary Their distillation here will help to anie the objectives that follow next in the plan each objective and its interventions should build on the individ ual s strengths and resources to address relieve and remove barriers This plan identi es four separate but related barriers to Sanils housing success that are immediately related to his mental and addictive disorders and are the appropriate focus of a service plan Carrrien Carnien Suarez also has three different goals a life goal of I want to graduate from high school a treatment goal of resume regular classroom attendance c1 er school einvloyiiicr1t and social involvemer39zt and an enhancenient goal ofl want to lmve my old relatiorzslrnp lmtle wit H 1f1ll l iquot All three of these goals are readily identi ed in the assessment In the seminary of her strengths needs and abilities section of the assessnient document the provider notes that Carnierfs main interest is in graduating from high school and furthering her education She also realizes that she may not be able to have the kind of relationship with her father that she would ideally like the decision to focus on more immediate needs niakes the relationship issue an enhancernent goal By working on her treatinent goal of resuming her daily activities Carmen should also make progress in achieving her life goal although this may not actually occur during the treatment episode REFERENCES 1 Masioxv A i4osmsm zmrl Pe snnrrli39fy 2 Ed Harper lt3 Row 1970 2 O Brie11l Lyle O Brien C Responsive Systems Associates wwwsoewebsyreClU tliechprsapuohtrn Focusing on Change Specifying the Objectives You don 1 just luck into things you build step by step wlzetlrer r39t sfriendsl1ips or opportmiitzes Barbara Bush I STATING THE CASE Moving along the path to recovery and Wellness objectives can be thought of as the milestones and way posts along the route toward reaching the goal or destination point Sometimes objectives are called shortterni goals Building on the roadmap analogy objectives are the directions and route plan to reach the destination such as drive 30 miles to the town of Success meet me at the Recovery Center Post Officequot or when you come to the circle go hal lvay around and bear right and pull in to the We ness Lodge The individual moves closer to the nal destination or goal each time one of these rnidpoints is reached or a change in his or her mental health and addictive disorders status and needs is achieved Objectives are the sequential or concurrent near tern changes necessary to help the individual and family meet their long term goals Objectives identi r the immediate focus of treatment they are the incremental changes and manageable tasks the individual and family will focus on bit by bit as they move towards reaching their goal These are often seen as the real engine of the individual plan that drives overall progress The focus of objectives is the removal of barriers objectives should help the individual and farnily bring about changes in physical and psychological status function gle mquot quot39l pquot394quot1 F39Fgj399r lt tro Tcrermrd Cm Opyngi 2935 by Yilsevler inc All rights reserved Mm mam mS Em 53 550 can can 523 momksmn m m c a Ex uou oamzou Qt mm 95 mm wm sm mum mEgtE 2 mo mdwbm u com Eumza gtEumBo mo mmmuem HEP awzmt Bum gt3 min mmm 313 8 Em m no muuwonu mm m mum m1wwSuaM u Era Em kw Ho EEgtoamp ua Bw Ew om mm mm 3 mEH mouBgto E ugt3uuBm aw wuso mmxu Smdo 330 ES 8 330 was 339 odm mo muwmumuwmuuwds on Ed 350 5Eamp 9593 mix iumoo Jdmx dou Ewbouuu ao uo mmsou mm E bcwm was we 33 uw oma 35 5 may ww mag 03 Exam mm 5033 E503 EH dmumou mkuw umom u Em dmuuomm Et 3 mad Eu M3 was QPOHMHQH Eu 3 53 mmgtnom3O KS3 out an an 5 WBEE Er QMHMOUHMPO 5 58 u doEgtmu B293 5 En imam 5 doummumuw 5 wmE on aim as mic woman 550 B5 so mumcuzmau U d mmmum hu mmuxu w 3 333 wax 58 ugtgt E3 w uau ui hmm 2383 Q73 Mum muwm mm wan mmw mui 8EgtoHm may no msonmnensmcu 338 was we use ma om 32 Jun mEgtmw Eu mam mamwmmm 3088 8 310 E5 33 30 Ea own van 5gtBuw3o mo mo oammw ESL gawk may we mom wEgtoom E E mam E woc wwxo PE mum mwmoumuiuucw uu suum 305 RE mo puum omo itmmmmau any mumemmu 33 80503 3 ow EB o c HO Egto Bu mEgt mo mo m umm w on eon Eno mu uuu 30 025 m um uwmmmo umo Eco E 5 mwwum m 305 Penuo o xumm a uumm BE uwuuusm maize ra uum mmu uvm Noam mwmauamzu oEou5gto B smmssm wunubmm wcm m5EgtE mmw mwm u we E om ma mc auuum can Jauwuwm an S8 mwmut E5 m msm ammuusm 39 En mugtnuoEO Umm mmEwH 2 3m u m m mw u smm z m mgtCotwHm 5 E m H2mltltHm an 350 mugt um o 5 93 udHO Gm G E33 4 9550 aw dmuEmoEgtow own mmEgtmmH 23 8 3aaoa nUDOUU4 mo wm m wax mumcmzmauxwm cmwvbgmnmmmu fmmg w mam 3 ugtmmommu mwmdmm umauumm ampTomgtm u E mu uwuouEm Se 8gt5um3O 95 mEsampm uwammU So wmmsuom Hm3gtow am 3 u mws iuwcs nmgtmEum w um Eu smob 23 E B ampoREm w nmmw v muommua 0Q 3505 mogt uoEO mmuduwunm kmevm 231 m3gtmm mmwaam an Egt9amp How 33 mum w moan us we mmo ma a gtuuu3o mmrmmommm gmwuoum mam 3 Han Ewm muwm 25b unn mE S mc E mmum mEm wmxmwQmaM an 9 33 MN MEG mam mmo cuh u n 5 muuviom 33 wummmsou up you 305 8gtnum E0 u om3 oEm oamp mo a 3 m3n wan EW dzEou Bu mo mwuwsomum magnum u mw m um 30 Bax z ummmw 8 ms wbmwmu 2 3 525m was m usagmw a xm ms ummu 0 M5 505 E3955 2 upnu 8o 8 09 Noam 053 59 Jumm u wmo muswwoamummm 8 0 om aw 62 mcu m msum MO mo mmsouo Juucmuwwmmcm 33 gnm uauou E mc5ummou m8 om6 ugtuumw aw cEm5 oumm mm 35 EH55 33 sc mmmoum wdO umB 50 mouwimm mo uwdi m u u 5 m ommu awash qmmmmwm Em m gtE m wmmum wn EmB u B FE mo mmonsmi ER uw ww n gtJsum mm gt2 wotommmm guuw o m we EmwEm lt m3wm m Rom uwmu u mm mmm n BmgtuoH wan dmmmmo Qmzom w Edomm mugt5uuEO dou nwmou 8 you ma a 955 a mm 85 mm mmuuusmmo Bsmmm m avian 350 vgt uuEo Q4 Anew Ema 95 man iu3H mmamgow w mm o u sm HO 33m dowwmaus E mmmm u dmu mug mum Emom mm m umnmumu mm 2 23 bm Hoxwcm Hms bmu EH u uz wpmum 31 ES Ewan 525 E505 wgtuuw3o 8bgt ampoamp 4 8033 go Emummu BUG Em mmw u u aza aw ucm omm Ht mo 9 mugtnumEO mb a 5 amp Sm ohm 55 w u mam mo um Eo m Em mogt uuEO 3m um o aw mwuus 36 8 momcommmn 923 otmw EOE mEmS E Su tom sm mac mw m m mix ma a gt5 M ummdQ B wZHGmH mam Tm3E B 9 3 35 mmc uu o wE lt wgtuuw3o w 5 umwdmww ma 3505 umw gowi 5 msummm uu sm 2 50 xsmog H33 monudsm 5 Ho bmaus an mmmswau du md do om wan Jawn p ma mSm5 m mQU E mumamsu uEcgtE cm 350 was mEogtgt douum E munmmumwm 3333 mum mwgtuum BO QEA meow 8 mo Mum ww mwauumoo aw mmwum own uiomuu 8 E03 HomEw was u 5 ndmum om aaoxrss Qorwmzwa god 23 ED 2 142 On the Road should reflect the mutual experience of dignity and respect for all partici pants The intermediate steps or objectives that an individual and family pursue to achieve their goals should be substantial and significant but at the same time manageable They should reflect valuable and meaningful change There is a tendency in current practice to trivialize objectives instead of making them meaningful and relevant For instance if the problem is depression and the goal is I want to feel happier merely stating Susan will keep a mood jonrna does not explain how that action or activity will help bring her happiness In fact this is a good example of how the differ ence between objectives and interventions can blur llteepir1g a rnoodjoup nal is much more of an intervention than a significant change in behavior or function Individuals seek help and receive services because they have reached an impasse and are unable to solve their own problems The team assists in helping to establish realistic responsive objectives that individuals can achieve as tangble steps towards meeting their goals Tirne Frames Specifying a time frame for attainment of an objective is a critical compon ent of the overall planning process Goals are longterm objectives are near ter1n The speci c time frame established in an objective carries with it a message for the provider as Well as the individual and family change is expected In many settings the time to accomplish an objective is auto matically tied to the minimum administrative requirement for review and update of a plan For example if the plan needs to be reviewed every 6 months or every year then all of the objectives have a 6 or 12month time frame for completion This typically does not comrnunicate a message of hope or change A person centered recoveryoriented approach to planning and services has time frames that are relevant to the scope of the objective the individuals and family s motivation and the resources available to support and facilitate the change More importantly setting extendecl time frames subtly connnunicates a message of low expectations and hop e i lessness TXIhile each objective must be individual and relevant to 535111quot person s goals as a general rule 90 days should be considered as an upi355 limit time frame in crafting objectives If nothing else 90 days is a reasoi1 f able period for review and reassessment and in many settings it is a standai of care d Focusing on Change Specifying the Objectives 143 Strengths Based Approach With much attention focused on the principles of a strengths based ap proach niany providers struggle with how to actually employ strengths in an individual plan Nowhere is the recognition and engagement of the individual s and family s abilities and resources more important than in specifying objectives Objectives should not focus on de cits rather they should describe positive clianges that build on past accomplishnients and existing resources There are times when it can be difhcnlt to recognize a person s strengths in the midst of their distress and need their Inotivation is often overlooked This alone can be a powerful strength upon which to build a plan and mobilize success Imagine trying to create an effective plan vvithout this resource to build upon In fact a lack of motivation is often a factor when individuals and families seek services only to satisfy the requirements of the courts school or other authorities In these instances providers could help individuals become motivated to change as a Way of supporting and sustaining personcentered strengths It could be appropriate to have a rst objective statement which anticipates the individual s and family s ability to recognize and own the need for services and change Such an objective might be Karen and her mother will be able to identify a self clefined goal and agree upon at least one objective that removes a barrier to that goal In this circumstance interventions would focus on the issues of awareness motivation and engagement As much as possible objectives should reflect an increase in functioning and ability along with the attainrnent of new skills rather than merely a decrease of symptoms In formulating an objective it is iinportant to ask What are the individual s strengths that can be utilized and enhanced to help bring about change Objectives that build upon these existing re Sources and abilities are far more likely to succeed and sustain the journey Objectives that merely ameliorate the current distress will inevitably lead to distractions and detours on the path to recovery and vvellness givoiding the Dead Man Standard and Other Pitfalls vs I creation of objectives that are simply the cessation of a particular g ffhayior or symptom is another cornrnonly observed error For example E 951d I the objective john will stop having temper tantrums The With this objective is that if john were to die he would meet 144 On the Road the objective by no longer losing control of his anger This is the dead man standard It should be immediately obvious that objectives must describe active positive change if they are to be meaningful midpoints as well as measures of progress and success A rewording of this objective might be John will remain calm when faced with frustration or john will express his anger using a normal tone of voice at least 80 of the time over the next 3 months An objective is not the mere removal of the barrier this runs the risls of reinforcing a de citfocused approach Rather the objective should cap cure the positive alternative to the current needs and challenges For example if an individual is struggling with thoughts of suicide the object ive should not be that Carla will report that she is free of suicidal thoughts within 30 days Instead the healthy alternative is that Carla will report enjoying at least two activities that help her to feel life is Worth living Wliile some might dismiss the difference as a trivial matter of semantics experience is that this type of refraining is empowering and leads to better outcomes Another pitfall is the use of activities that merely indicate attendance or participation in service activities as an objective Statements such as Bill will attend medication groups weekly Gayle s mother will participate in family psychoeducation groups every other vveekend or Juan will keep 70 of his cognitive behavioral therapy appointments are all examples of such objectives These statements should be considered a description of interventions They demonstrate how services and objectives can become conuningled and confused Attendance may be necessary to begin the process of change however it is not a meaningful change in function or behavior that helps move the individual and family closer to their goals Mere participation in services in no way indicates that any learning development or change has occurred Understanding insight or lltnow ledge alone are not suf cient objectives Instead there must be some active and measurable demonstration that the input and bene t of services has been incorporated and helped to cause positive and desired change The skill of developing an individual plan is to clearly articulate intermediate accomplishments in support of the larger goals and to understand how services such as medication groups family psychoeducation and case management all contribute to meeting objectives and promoting change All too often otherwise thoughtful and Well developed plans are under mined by the efforts to do too much at once There are no hard and fast rules about how many active objectives are required at any one time except for the expectation that there is at least one objective for every Focusing on Change Specifying the Objectives 145 goal There are circumstances when it may be perfectly appropriate to have only one active objective there may also be times when having two or three simultaneous and concurrent objectives is necessary and bene cial However as with goals there may be value in strategic parsimony ie having fewer objectives that are more targeted and therefore make the overall plan more manageable This alone may help to niake a plan more effective In general plans with more than two or three current active objectives are too complex and should be carefully reconsidered Object ives are the building blocks of successive learning and have an order and sequence For instance an individual may first need to be able to recognize and acknowledge his or her addictive behaviors before being able to demonstrate two alternatives to drug and alcohol use as a Way to relieve uncomfortable emotions Figure 1 is a reminder of the relationship between assessment point A goals point B objectives points B C and D and the services and interventions small arrows Although this diagram suggests that objectives are sequential there are many times when two or more objectives are concurrent From Barriers to Success The narrative surnrnary should include at least some description of the identified barriers to attaining the stated goals During the assessment process some attention should be focused on understanding what stands between the individual and family today and their hopes dreams and goals for the future For example in Figure 71 what hinders pursuit of the direct course between A and E3 The simple but powerful question Wl1at keeps you from doing blank tomorrow is often an effective entree into a discussion of barriers those that are a result of a mental health or addictive disorder as Well as those that are brought about by social ecoiiorriic and other challenges Objectives in the individual service plan should reflect the removal resolution or mediation of those barriers If the barriers are not 3 bC gtD A 4 E FIGURE 71 aw m000m 03 000303 mq000 00 Hmow 05 000300 0gt0E 500 50 005 00 u 00E 08 00300 E0000 005 500030 00 05EgtE 05 080 00 0000030 04 0mmnmmm00 00 00wm00 05 05000 00 00Ld0 0 E 0U3 gt 5 003000 300 000 00 mEm0w00m nosmumnmo w 1000003000 gt003 00m0mE 00 0mmgt0H00 00 000Em0amp9w 3 00350030 0050 00 005 3000 0 000 0 000005000 0n 0 02 000H 50 0mm cn00mm0 00000 05 0053 50 000500000 000m00EEW 00 03000 3000 m0gt300E0 0amp0 E00oa 00 Ewmuwm 0000 Eoauvm 0 E 00Egt0amp 0000 000 0001500 H 0203 0050 E m 00E0 009305 00 00 0amp0 000m0 0gt0H 03000 580000 0 E 000000300 09 0 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moamma 0008 0000 00 E0gt0m EH00 000 m0gtn00n0 no m00Em0m 0000000 00 00 000000000000 00003 lt ZODAOm 00 0234000 5 m0m0m0 000 0000 0005 0003 00 mm 03 0 m00000000m 0020 mm0ampw0 00 000230 000 m mm 30 E03 E05 0m0wgt0amp 305 000 mE00200E0 03 900 0030003 305 000 00300030 00 3 m0000M0O 0amp0 m 5ampm 00300 0 000000 20 000Hlt 100 0005 00 00030 0500 gt030 000 mE0E 0005 00500 05 00 Sm uunmm 00 030 000000 00000 000 005 mm0gtw000E0 w0E E m0 E 0Egt0amp 0 05 00 020 02000 0003 0055 33000 000 wEgtum0E 0amp5 0 0 E800 0 mo 0003 0ampgtgtn00m 00 000 0090090 0000000 00 0 gtp00gt00 0 00m v0 Sm0 03 05 030 Row 05 00 030000000 000 0035000 000 030 m0gtu00E0 302 0m 00 0gt0 0 Q0 m00 0 wax 0Snn B0300 400m 0 00m3mgt000 00 EE300mm0 um 00 S m0w00mn0 0 000 0000900000000 0003 Enmmmom 00 m0UE300nE0 30 000000 gt000 000 00035005 50 m0Egt0amp Em gt0E E00030 ap mm 003 mEgt0mw 05 00 S0mgt00 00m 053 0 mm 000000030 mo m0 0nm00 00 0009300000 Q um 00030 0000 30m m 02 000 0 0350 300 mm 0 0033 0000 HR 01 00 3 m0m50m 03 mo 02u0 05 00n0m0m 00 030000 m H m0 E00E0m 000 2 0300030 005 05 00 0n23mm0 0 30 05 0930 00 00 030300 03 00 000 00300030 05 m0 0 0oz 0wgt04m m0gt 00E0 0 mE0a03w0m wan m0u00M0 030 Q 000 0 gt03 0 300 02300 05 mm 0 mm 1Egtm0E 030 002 000 m00 0m00 00 32303 05 GEN mm Eu 00 d3gt0E 05 00 350 0amp0 m0 Sm 053 0000200000 06 030 23000 05 mo 0wx0EE00 050 000010 00000 3 00050 aw 000S0m00 5 30000000 00 350 m0gtm00E0 000 00 0030033 00 m0 00Egt00m 05 mm 03 mm wwa zw mum mwm vewwnm 05 mo 0 m 5m 00 00 2 0003 0050003 000amp 030 00 00500 100202000 BC mB0Wgt000E 000505 000 mmonmmmn a manu mmm E 00m0 0mm0E 000 900 00 mm0000gt0 00 EU 0 mEm0 0gt0m 00500 5 00000 00 003030 000 300303 0 mm0 0 3000 0300030 000000 4 000E01E0 0000300 000 0020 0 003 00 m0gt 00E0 00 000020 E 0000 00 030 02 0030 3000 wmm rw 0003 E E000 m m0nQm 00 omma 0005 wxr w0wm00a0 0005 0000000 030 m0 gt00m mam m00 00gtH00E 00 02 0 00303 330 0000203 m00E00m 00 00 03 0 030 00 305 00052 E 0 0000gt0 00 00 0000 8000030 mm 00505 0gt000000m00gt0 in 000 mE0E0amp mmE0H 4mEm0m0 3 000E0 03003 3000 w0mw00E mm muw m 0gtum00mm 00 E b0m00 05 35000 can gt000gt20m0 00 030 00 50 202 00 004 00 030 00 33 0008 30 om 03059 H03 300 0m00 0EE0 mEES 0 00 80 05 000300 m0gtn00E0 0003 0 00 000 03 em 0000 0 000 3 0E0 E00000 03550 10030 230 ma a 00 0000 m 000 0003 0050003 m0E 00mwcw0 m00w00amp 00 mu 0 02 Emum 0bn0HmE0 0300000 00 0053 0 01EmN0 00 03 o0 000 00 0mE0 03 EB m0gtE00E0 030000 000 m0Em0 wo 005005 05 05 4000000000 00 00005203 E0003 000 00 0 0 148 0 On the Road not appropriate to that setting Instead an objective focused on de veloping relapse prevention skills that prepares the individual to face the challenges of returrzing to the community is very appropriate to the setting Arkisvable The individual should have the capacity to actually meet the object ive sornetin39ies this is also about being reasonable Expecting a child to never have any disciplinary problems at school is not reasonable Instead expecting that jorge will reduce the frequency of aggressive outbursts at school from 3 to 1 per week may be attainable Achievable should also include some consideration of the number of objectives Having too many simultaneous active objectives for each goal is not realistic and probably not attainablel Urzdcrstandalvle Writing objectives in a language and style that is understandable to the individual and family is essential The objective should be practical simple and easy to recallafter all it is the individual s plan quotWriting in an excessively professional style does not meet the intent of a persomcentered plan An objective that seeks to restore etithyrnia for a depressed mother with a history of mood swings may not be particularly meaningful Instead an objective that states Sheila and her husband will report 7 consecutive days of emotional stability and Wellbeing Within 2 nioriths meets the criteria for a Well written objective Time sper39 it Time frames are speci c to the each objective and predict how long it will take the individual to achieve the change be it 60 days Within the next year or by a certain date Time frames are not necessarily all the same nor are they based on 9 progranfs established revievv dates for plans ie quarterly annually and so on Rather they should be specific to the individual s and family s needs strengths and desires for change Most people are responsive to deadlines and due dates they often motivate our actions and organize our energies While setting realistic expectations is important it is possible to create hope and inornentuin by establishing relatively shortterm expectations for success Written in acti0n0r139czrted and behavioral language Given the historic emphasis in the mental health eld on process over outcomes it is not unconirnon to nd objectives vvritten anticipating Focusing on Clharige Specifying the Objectives 149 that the individual will gain insight have understanding or be able to accept These are not actiomoriented changes that meet the criteria for an objective Instead the focus needs to be on what the individual and family will do differently with the insight understanding know ledge and acceptance that transpire through services Oftentimes these cognitive processes are cornponents ofbehavioral change but the focus of the objective is on the actual demonstration of new skills and abilities Respcmsive to the 1zdividuczl s uniqite needs challenge9 and recovery goals The development of objectives needs to be informed by the assessment process For example if an individual is in the pre contemplative stage about their use of alcohol and other drugs then an objective that expects that Jordan will meet with his narcotics anonymous sponsor Weekly for the next 10 weeks does not reflect an understanding of the individual s stage of recovery However if the individual has been in multiple treat rnent experiences has had several relapses has a sense of awareness of his or her addiction and is motivated to maintain sobriety then an objective which states Vitliiri 2 weeks Leroy will be able to identify three of his usual triggers e g people places and things to seeking heroin and develop a plan to avoid them may be quite reasonable and meaningful lppr 0priare to the age development and culture of the individrial cmdjirmily Objectives must be an individual match that not only builds on strengths and resources but also accounts for the unique qualities and attributes of each person and family These characteristics are often determined by factors such as age development race ethnicity and cultulfe Expectiiig a young single vvornan from a family centric culture to establish an independent residence may be an example of an inappropriate objective Instead an objective that focuses on resolution of crossgenerational differences and expectations of autonomy and self determination is consistent with a person centered approach sensitive to issues of accul turation Similarly an objective seeking fulltime ernploy1nent for a l6year old boy may not be consistent with his age and development An objective that focuses on his need to succeed in pre vocational education is more likely to be acceptable to both he and his parents Risk and Choice One of the more difficult challenges in setting objectives involves the questions of choice preference risk and failure Providers have an 150 On the Road inclination to be risk aversive advocates for vulnerable individuals and fa111Till S quottll y often try and steer individuals and aniilies towards choices and options that the provider feels are safe With the best of intentions providers often act in a controlling and limiting fashion offering a limited menu of choices for action that appear to be reasonable and protective This can lead to conflict between the individual family and provider especially when the individual has other preferences and priorities and feels constrained by the limited choices offered On the other hand providers can become slavish adherents to the notion of choice and stand by passively while individuals make poor decisions that put them in harm s way At some point leaving individuals and families to endure the natural consequences of their choices becomes a form of abandonment or neglect What is a provider to do in the face of disagree merit over individual preference and choice As nientioned in Chapter 4 Patricia Deeganl and her associates have developed Intentional Care Performance Standards to help bridge the gap between the principles of recovery and ernpovverrnent and the realworld application of these principles in the everyday Work of direct service staff and their supervisors These standards attempt to provide a franievvorllt to reconcile some of the differences and tensions that can occur Some of the principles of Intentional Care include the ideas that individuals and families deserve to have the dignity of risk and right of failure providers should always be advocates of individual choice over a wide range of options individuals should not be not abandoned to suffer the natnral conse qnences of their choices neither providers or individuals and families are failures if a choice results in failure Figure 72 depicts some of these ideas in a simple graphic The suggestion is that providers need to learn to comfortably exist in a conflict zone somevvhere between unacceptable provider control and unacceptable nsk by the individual and family Objectives need to be selected with awareness of and sensitivity to this underlying dynamic Most individuals learn and grow from taking risk and learning from both their successes and failures In a person centered approach individuals and families on the road to recov ery should not be unreasonably denied the same opportunities Focusing on Change Specifying the Objectives 151 Let client do what Get client to do heshe wants what i want Conflict Zone Neglect Control FlGURE 72 Ill MAKING IT HAPPEN As stated in the quotation at the beginning of this chapter opportunities are not created by luck they are built step by step Attaining goals is not a matter of luck Goals are reached by pursuing objectives and bnilding on each increment of success over time Objectives must be created in the context of each individuals assess ment re ect an understanding of their unique needs and challenges and respond to their speci c individual goals Yet there are many resources ranging from books and rnanuals to various software programs and service planning tools designed to help providers create service plans that do not follow these basic principles Instead these training and practice guides are often organized and driven by a predetermined inventory of problems largely determined by diagnosis In such approaches if the diagnosis is depression then the problem is predictably described as low mood the goal is to feel better and the objective is to reduce symptoms on an established rnood rating scale There is nothing in this method that recognizes the unique needs con cerns desires and qualities of the individual This is the antithesis of a person centered approach While these tools and resources may help pro viders nieet regulatory and administrative requirenients for planning they are unresponsive to the unique needs and abilities of each individual Objectives cannot merely be chosen from a pre delern1ined nienu of dl3gI1Squot3S problems and goals Rather they must always be responsive to the unique attributes and challenges of each person ogtcampamp muwmmuuwwadd mo Emodma wso aodm mm mm Bm wan u uuo o some Beam 8 Emmmuuum mmo 5gtBS 2 mo zm wuwmm 8 msumw mama mg mugtuumEo zcm 03 Ba 95 d uw m E Emu macaw E mmoucuim d u mmwwmmou E w 3330 mgt5uuwE sm wdum xom 305 us go mmur um can mco am was was J wp o nmwm m EOE g Egon as mm mu u o m dno mu 5 33 mummu w mum on EU mEmn m gtgtO mm WE numm 35 nmuuc m macaw E mco5wgtE ECO E85 5 umon sm 2 mamp samp o ou w om w was mw mmzm u Moos E E w mvowm wmwmmm Q Jumoummm 2 333 mBmm6 5 wunmvm k as Ewan swam E awgtnuuEo EOE m N3 mugtEm E 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amouusm gow ma a ESL 3 33 Bmmuunamh m5 can owmz u wo wwsoa QC 5 1 E 5 E58 35 muEom u 3 van Hoonom ME mm 25 mm 38 Huumow 2 vS Smumxu min 3 95 33 Eumm mmz E wmu m w ma mo Mm ES WM 2023 mm u uswm muwmuo m n 09 was was mm3ugt on 309 mz m mqmmmamm boom mnmmm a3 5 dmS m rm mmb 3 wmtw t mu uom o mugtuou3o vwu mc um am mueuusm on aw M5 mm SO34 5 ov immune mw mgt3uwEo 93 8 wma uu Eummw5m mwm cmmw um mnw was so 153 E m u mmgtUuu3o 05 dom www 3 imam EA 3 uum w BEE mum wu md RES 9 u3SmE 95w u mag mo m u uu Hmpouum 3 Emma mwgtEuw o atom 53 m3 39 35305 Eucwpmamm E3 m mmmu mam m uusnu E E ummmtmmmwww mm an E5 muwwomu C mm gum wd bw 0 m3 How ugmwgmoun oww Hob Luau oEvmE m an so dwgtOu 33 E ugtUum3o vacuum mam u uo m Shem mum Joo um mum 33gt mu mommwu 385 SE wvmsmu was u o Emgou Howwmzun ugtammW m uo m mwmmwum m mmoumxu Emwm moammw U d smE 8 wmwm is mommuhxum m uuu o EE MEH aanom WE mo 5amp2 E van mhmo mBu om98m Ehw u PE vumgom owlt mo mmgt uuEo om 034 A83 E wgt h Sm gem wu umEo wEmogtmm on 33 as 8 Aomowmmm mwwmumuuumomwum m mo ma a 9 mac 2 303 um m nu 3 W ms on o cw 3dgtoMm 83533 umum warm mammwm nmm Eon as 0 mm 154 On the Road Carmen The objective for Carmen Suarez is to attend school all day for 2 weeks without any absences This is directly tied to her goal of waziting to graduate from high school and addresses the barriers of social anxiety and symptoms of depression that inhibit her academic success The assessment information is clear in identifying Ca139men s piiimary aim to nish high school and attend college Her objective reflects that goal While Carmeifs story is rich with psylthody11amic themes and psycho logical uoderpimiings to her grief loss and depression these issues are not an inimediate focus OfEI39 21tII1C1 1t They do help to clarify the diagnosis and explain some causative precipitants But the focus of the plan is not on furthering that understanding or on 1 process of resolving her grie lnstead the emphasis is on behavioral and fu11lttional change and attairiment of her goals Psychotlierapy which brings an opportunity to resolve some of those feelings is one of several i11ter ve11tions not an end unto itself REFERENCE 1 wwwinten t1or1alcare org
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