Engaging the Addicted Client in Case Planning

Rose Marie Wentz

October 17, 2007

Sustaining CalWORKs and Child Welfare Collaboration in Times of Transition

General rules for visits with General rules for visits with parents who are addicted:parents who are addicted:

Substance abuse, by itself, is not child abuse or neglect.

It is highly recommended that the substance abuse treatment professional be a part of the case planning team.

The vast majority of children removed from substance abusing parents are removed for neglect. These parents are not likely to abuse their child during a visit.

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General rules for visits with General rules for visits with parents who are addicted:parents who are addicted:

Generally, the parent should be in substance abuse treatment before the level of supervision is lowered.

There should be a safety plan for the child and a relapse plan for the parent, shared with all parties, which will ensure that child will be safe even after a parent appears to be maintaining sobriety.

Most of these children will be reunited with their parents. There is never a guarantee that an addicted person will never relapse. Thereby, Progressive Visitation Planning allows us to assess if the safety and relapse plan will work.

Myths versus Facts of AddictionMyths versus Facts of Addiction Drug addiction brings out many

emotions and bias. What do you think about a pregnant

mother who:• Smokes• Versus one who drinks alcohol • Versus one who uses meth

Take the test on page 1 without looking at the next pages of handouts.

Test Your KnowledgeTest Your Knowledge

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

YES or NO

NONOUA’s - What they CANNOT tell usUA’s - What they CANNOT tell us

The current level of intoxication – some drugs will test positive days and weeks after the last use

Whether a parent with a dirty or clean UA is able to be safe or appropriate during a visit.

Whether the person is actually drug free • Many ways to cheat the test • Even medical doctors often fail at performing the

test correctly• Whether the person took the drug after the test but

before or during the visit• The person may have taken a drug you are not

testing for Source: Kim Sumner-Mayer, PhD, LMFTChildren of Alcoholics Foundation

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Test Your KnowledgeTest Your Knowledge

2. Meth is the most common form of addiction in the US.

YES or NO

NO -- NO -- Treatment Admissions by Treatment Admissions by Primary SubstancePrimary Substance

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2,000,000

1992 1994 1996 1998 2000 2002 2004

Alcohol Opiates Cocaine

Marijuana/hashish Methamphetamine

Source: Treatment Episode Data Set (TEDS) – Highlights 2004

Test Your KnowledgeTest Your Knowledge

3. As the number of meth users has risen, there has been a corresponding increase in the number of children placed in foster care.

YES or NO

NONO -- -- Persons who Initiated Persons who Initiated Substance Use by Year compared to Substance Use by Year compared to

FC placementsFC placements

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Children in Foster Care New Cocaine Users

New Crack Users New Methamphetamine Users

New Heroin Users Source: Nancy K. Young, Ph.D., DirectorNational Center on Substance Abuse and Child Welfare, May 8, 2006

Test Your KnowledgeTest Your Knowledge

4. The percent of pregnant women’s admissions for methamphetamine has tripled over the last 10 years.

YES or NO

0%

5%

10%

15%

20%

25%

30%

35%

40%

1994 1996 1998 2000 2002 2004

Cocaine Alcohol Heroin/Opiates Marijuana Meth/Amphet/Stimulants

YES --YES -- Trends in Primary Substance UseTrends in Primary Substance UseTreatment Admissions for Pregnant Females by Primary Treatment Admissions for Pregnant Females by Primary

Substance 1994-2004Substance 1994-2004

Percent of Pregnant Women’s Admissions for Meth/Amphetamine has tripled over the

last 10 Years

Source: Analysis of Treatment Episode Data Set (TEDS) Computer File

Test Your KnowledgeTest Your Knowledge

5. Meth babies are born addicted and with birth defects

YES or NO

NO and MaybeNO and Maybe

Babies are NOT born addicted to Meth.• David C. Lewis, M.D., Professor of Community

Health and Medicine Donald G. Millar Distinguished Professor of Alcohol & Addiction Studies Brown University

Research shows mixed results on whether babies will be born with permanent defects. The problem is that most mothers are multi drug users and drugs such as alcohol and tobacco do lead to birth defects.

Babies can be born with multiple problems due to mother’s meth use. Similar symptoms to other prenatal drug exposure.

Mother Uses Meth While Mother Uses Meth While PregnantPregnant

Risk to child depends on frequency and intensity of use, and the stage of pregnancy.

Risks may include birth defects, growth retardation, premature birth, low birth weight, brain lesions.

Problems at birth may include difficulty sucking and swallowing, hypersensitivity to touch, excessive muscle tension (hypertonia).

Long term risks may include developmental disorders, cognitive deficits, learning disabilities, poor social adjustment, language deficits.

Early diagnosis and treatment of these problems can prevent long term negative impacts. All Drug Exposed babies should have specialized medical care.

Sources: Anglin et al. (2000); Oro & Dixon, (1987); Rawson & Anglin (1999); Dixon & Bejar (1989); Smith et al. (2003); Shah (2002)

Test Your KnowledgeTest Your Knowledge

6. Hundreds of children have been medically harmed or died in meth labs in the last five years.

YES or NO

Source: El Paso Intelligence Center

NO -- Number of Children in Meth Labs

 2000 2001 2002 2003*

Number of incidents

8,971 13,270 15,353 14,260

Incidents with children present

1,803 2,191 2,077 1,442

Children residing in labs

216 976 2,023 1,447

Children affected**

1,803 2,191 3,167 3,419

Children exposed to toxic chemicals

345 788 1,373 1,291

Children taken into protective custody

353 778 1,026 724

Children injured

12 14 26 44

Children killed 3 0 2 3*The 2003 figure for the number of incidents is calendar year, while the remaining data in the column are for fiscal year**Data for 2000 and 2001 may not show all children affected

Test Your KnowledgeTest Your Knowledge

7. Children whose parents are addicted to meth are less likely to go home than children whose parents are addicted to other drugs.

YES or NO

NONO -- -- 24-Month Child Placement 24-Month Child Placement Outcomes by Parent Primary Drug Outcomes by Parent Primary Drug

ProblemProblem

0

20

40

60P

erc

en

t

Reunification Adoption Guardianship ContinuedReunification

Services

Long-TermPlacement

Other

Alcohol Heroin Cocaine/crack Marijuana Methamphetamine

Source: Nancy K. Young, Ph.D., DirectorNational Center on Substance Abuse and Child Welfare, May 8, 2006

Test Your KnowledgeTest Your Knowledge

8. Meth addicts are less likely to recover than other types of drug addicts.

YES or NO

NO --NO -- Treatment Discharge Treatment Discharge Status by Primary Drug Status by Primary Drug

Problem***Problem***

***p<.001

49.7

71.4

65.661.6 61.5

50.3

28.634.4

38.4 38.5

0

20

40

60

80

Per

cen

t

Satisfactory Unsatisfactory

Heroin Alcohol Methamphetamine Cocaine/Crack Marijuana

Source: Nancy K. Young, Ph.D., DirectorNational Center on Substance Abuse and Child Welfare, May 8, 2006

Different Risks to Children Different Risks to Children Based on Type of Parental Based on Type of Parental

InvolvementInvolvement

Parent uses or abuses methamphetamine Parent is dependent on methamphetamine Mother uses meth while pregnant Parent “cooks” small quantities of meth Parent involved in trafficking Parent involved in super lab

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

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Progressively m

ore risks

Risks most commonly related to meth Risks most commonly related to meth use are: use are:

Parental behavior under the influence: poor judgment, confusion, irritability, paranoia, violence

Chronic neglect – supervision, food, lack of medical care, lack of utilities

Inconsistent parenting - lack of attachment activities and setting of appropriate boundaries

Chaotic home life – moving, changing schools, no safety system

Exposure to meth, chemicals, needles and second-hand smoke

Higher possibility of physical and sexual abuse by parents and others

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Risks most commonly related to meth Risks most commonly related to meth use are: use are:

Parent is incarcerated - trauma of arrest and separation

Pre-natal exposure may lead to hypersensitivity, difficulty sucking and other problems that will need special care and addicted parent is less likely to be able to provide this care

It is common for meth users to be using multiple drugs. Pre-natal exposure to alcohol can cause birth defects, i.e. fetal alcohol syndrome

Contact with other adults who may be abusive to the child

All of these risks can and must be addressed.

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What predicts longer Abstinence What predicts longer Abstinence for Meth Addictsfor Meth Addicts

Longer time in treatment, e.g. those with 4 or more months of treatment

More sessions per month of individual counseling (or sexual recovery groups)

Treatment, intervention and case planning that account for short-term effects, especially cognitive deficits and verbal communication

Drug Court involvement Family involvement in treatment, including visits

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Other Meth Facts Other Meth Facts

Meth is dangerous and does impact the user

Impacts are reversible Meth is decreasing in most Western

States but is increasing in some Eastern States

We need more treatment programs for meth addicts

What is a Relapse ?What is a Relapse ?

Triggers Warning Signs and THEN Relapse

What are precursors to relapse?•Life changes

•Stress

•Return home of their child

Relapse is an opportunity for growth and an indication that treatment could be in jeopardy.

Pay attention to the circumstance surrounding the event.

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What is a Relapse Plan?What is a Relapse Plan?

ID – triggers, warning signs and who is in a position to notice these signs

After care services Good communication between

everyone Support network Coordinate service and treatment

plans INCLUDE treatment professional in

case planning team!

Indicators of Significant RecoveryIndicators of Significant Recovery

Staying in treatment Clean Urinalysis Assessment (UA’s) Has a relapse plan and uses it Building a sober support system; family is involved in treatment Taking responsibility Participation in the treatment – does not matter why Participate in visits and other services related to their children Parents and children learning to relate without substances Maintaining relationships with treatment providers Using new healthy coping mechanisms to deal with life stresses Reporting a dramatic change in the way they feel and see things Responding cautiously to questions about the future Being able to relate to their own life concepts learned in

treatment and 12-step groups Creating and using a safety plan for the child, in case relapse

should occur Re-entering treatment quickly if there is a relapse Pg 4-5

Change ProcessChange Process

Status Quo

crisis

Goal

Activities

Barriers

Abraham Maslow’sAbraham Maslow’s Hierarchy of NeedsHierarchy of Needs

Physiological Needs

Safety Needs

Love Needs

Esteem Needs

Self-

Actualization

Personal growth and fulfillment

Achievement, status, responsibility, reputation, etc.

Family, affection, relationships, work groups, etc.

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

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

Adapted from Alan Chapman www.businessballs.com

Match your interview technique to the customer’s needs andfocus at this point … at this time

CDSS MissionCDSS Mission The mission of the California

Department of Social Services is to serve, aid, and protect needy and vulnerable children and adults in ways that strengthen and preserve families, encourage personal responsibility, and foster independence.

Adoption and Safe Families Act Adoption and Safe Families Act (ASFA) 1997(ASFA) 1997Safety

Children are, first and foremost, protected from abuse and neglect.

Children are safely maintained in their own homes whenever possible and appropriate.

Permanency Children have permanency and stability in their living

situations. The continuity of family relationships and connections is

preserved for children.Well-Being Families have enhanced capacity to provide for their

children’s needs. Children receive appropriate services to meet their

educational needs. Children receive adequate services to meet their physical

and mental health needs.

Temporary Assistance for Needy Temporary Assistance for Needy Families (TANF)Families (TANF) To end the cycle of dependency on public assistance for

families. The CalWORKs program goal is to assist recipients to

obtain employment while remaining on aid, as well as moving recipients from welfare to work.

CalWORKs WTW program is recipient self-sufficiency through employment. Rules ensure that individuals who work are better off financially than if they do not work.

Child well-being is defined as the provision of food, clothing and shelter, while ensuring educational progress, health and safety, and economic support for the child.

Reauthorization provisions of the federal Deficit Reduction Act of 2005, requires a significant increase in the number of recipients participating in activities that count toward the TANF work participation rate (WPR) requirements of 50 and 90 percent for all families and two-parent families, respectively.

Job of the Case ManagerJob of the Case Manager To find an overlap between the

agency goal and the client’s goal.

Agency goal Client’s goal

The overlap area is developed into the joint case planning goal.

DefinitionDefinition

“MOTIVATIONAL INTERVIEWING is a directive, client-centered, style for eliciting behavior change by helping clients explore and resolve ambivalence.”

~Miller & Rollinick, 2000

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DefinitionDefinition

“AMBIVALENCE is a state of mind in which the person has coexisting but conflicting feelings about something. [They may]…experience severe conflict about engaging versus resisting [change]…working with ambivalence is working with the heart of the problem. One reason why brief interventions may work so well is that they help people to get ‘unstuck’ from their ambivalence—to make a decision and move on toward change.”

~Miller & Rollinick, 2000

Motivational InterviewingMotivational Interviewing Change is not imposed from the outside It is the client’s task to articulate and

resolve ambivalence Worker’s style is quiet and eliciting Readiness to change is not a client trait,

but a product of the interpersonal interaction

A partnership rather than expert/recipient roles

Seek to understand the person’s POVPg 1

Confrontation ApproachesConfrontation ApproachesArgue that the client has a problem

that needs to be changedOffers direct advice or prescribes

solutionsUses authoritative stance – client is

passiveDoes most of the talkingImposes a labelBehaves in punitive or coercive

manner

OARSOARS Open-ended questions Affirmation Reflective listening Summary

Roll with Resistance Reflection Shifting focus Emphasizing personal control and choice Reframing Engaging the client

10 Strategies for Evoking Change 10 Strategies for Evoking Change TalkTalk

1.Ask Evocative Questions2.Explore Decisional Balance3.Ask for Elaboration4.Ask for Examples5.Look Back6.Look Forward7.Query Extremes8.Use Change Rulers9.Explore Goals and Value10.Come Alongside

Less “USEFUL” QUESTIONS

• Begin with “Why?” implies blame; presumes insight into problem

• Can be answered “yes” or “no” -- because then it’s your turn again already

• End with a tag like “don’t you?” or “right?”“You want to be sober, don’t you?”

No hand out page

Motivational General Principles & Best Practices

Express Empathy

Develop Discrepancy* Avoid Argumentation Roll with Resistance Support Self-Efficacy

“On the one hand you say… yet I notice that you still… so please tell me more about…”

Motivational General Principles & Best Practices

Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance

Support Self-Efficacy*

*Hope. Optimism. The belief that they can be successful and that it’s their responsibility to take the steps

Traps to AvoidTraps to Avoid

Avoid “Traps”

1. Expert Trap

2. Labeling Trap

3. Unsolicited Advice

4. Premature Focus

5. Question – Answer

6. Blaming TrapPg 10

Premature Focus