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ASSESSMENT AND TREATMENT PLANNING When a potential client contacts a substance use treatment service, an assessment process begins. The two most fundamental issues in assessment are the following: determining
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ASSESSMENT AND TREATMENT PLANNING When a potential client contacts a substance use treatment service, an assessment process begins. The two most fundamental issues in assessment are the following: determining the most appropriate treatment alternatives and developing a plan of care that is consistent with the client s particular needs and preferences. For the counsellor in an MMT service, these issues may be restated as: Is MMT the right service for this client, and if so, what issues need to be addressed in the MMT process? This chapter outlines procedures for determining eligibility for MMT, and describes the process of formalizing a commitment to participating in MMT and developing a detailed plan of care. (Included in Appendix B are a series of treatment-planning forms that can be used and/or adapted to help you with your treatment planning.) We set the scene by outlining some of the challenges of engaging clients in MMT. Initial Challenges for Clients and Counsellors Clients presenting for other substance use treatments are typically on a continuum from moderate to severe dependence, irrespective of the drug. In contrast, clients seeking MMT are virtually all severely dependent. Many have a long history of chronic injection drug use. Upon entry to methadone treatment many clients feel desperate about their circumstances. Their lives are often chaotic and disorganized as a consequence of their substance use. They commonly present with a wide range of problems including C H A P T E R 7 Methadone Maintenance: A Counsellor s Guide to Treatment some or all of the following: housing problems, dysfunctional social relations, occupational difficulties, legal and psychoeducational problems and/or health and family concerns (Ball & Ross, 1991). Typically, they have in the past tried treatment to overcome their substance use problems without success. Therefore, they may feel skeptical about their chances of benefiting from further treatment. Clinicians working with these people must be knowledgeable about the various issues that affect their clients well-being. These issues also include the effects of various psychoactive substances, safe health practices, and symptoms associated with mental health problems common among people dependent on opioids. Early dropout from methadone treatment is high. Approximately 50 per cent of people who use heroin can be expected to drop out of treatment within the first three months of initial contact (Condelli & Duntemen, l993). This high dropout rate raises concerns about how best to engage clients upon initial contact. Many clients enter into treatment feeling highly ambivalent about making changes as well as feeling guarded and vulnerable to criticism. How a counsellor engages a client often determines whether the client will succeed in treatment. It is critical during the initiation phase that counsellors convey an attitude of understanding, respect, concern and hope toward clients. Counsellors should examine their own attitudes to their clients subculture, which are often viewed as deviant by those who have little contact with a drug-using population (Woody et al., l994). A non-accepting attitude by a caregiver can easily result in the client turning away from treatment. The orientation and assessment of a client can be viewed as the first line of intervention. Whether or not a client s needs are responded to by the treatment team during the orientation process can determine her or his further engagement in treatment. It has been shown that using this client-centred approach results in superior treatment retention (Brands et al., 2002). Assessment Process Assessment is an ongoing process. The process described here involves four main components, three of which are systematically addressed at the outset of treatment. crisis intervention determining appropriateness of MMT developing a comprehensive treatment plan monitoring and revising the treatment plan. 86 Assessment and Treatment Planning Chapter 7 Crisis Intervention The primary goal of crisis intervention at the beginning of treatment, and throughout the treatment process, is to determine whether there are acute needs that have to be addressed immediately. Often clients present in crisis at the time of their first contact. For example, if a client presents to treatment and is homeless and has not eaten in days, a critical first step will be to help the client secure food and shelter. Problems requiring immediate crisis management also include suicidal behaviour or serious psychological distress and medical emergencies. Written protocols help to ensure that crises are managed effectively (e.g., written procedures for assessing and managing suicidal behaviour). Medical and psychiatric emergencies should be brought to the attention of the attending physician, and the client should be referred or, if necessary, accompanied to the closest hospital emergency department. MMT counsellors should keep some specific items and information materials available on-site to assist clients in crisis. These include money, tickets or tokens for transportation, clothing (in particular, winter clothes), and brochures listing food banks, free meal programs, emergency health services and drop-in centres. Counsellors should also have a list of shelters to which they can readily refer. Because long-standing prejudicial attitudes toward methadone clients still prevail, methadone clients may face obstacles when trying to access shelters or other treatment services. It may be necessary to engage in educational and advocacy initiatives to help reduce the obstacles faced by these clients. Determining the Appropriateness of MMT There are two principal issues in the determination of whether MMT is the appropriate treatment for the client. The first is whether the client meets the eligibility criteria and the second is whether there are other treatment alternatives that are equally well, or better, suited to the client s needs and preferences. There are some major differences in the determination of eligibility for MMT when compared with other substance use treatments. The assessment worker can and should review the client s presenting concerns and potential treatment options, but if MMT appears to be the treatment of choice, there are two additional steps to be taken before the treatment decision is finalized. First, 87 Methadone Maintenance: A Counsellor s Guide to Treatment opioid use must be verified by urine drug screening. Second, there must be a diagnosis of Opioid Dependence made by the physician who makes the final decision about whether to prescribe methadone. Patients who have used opioids for less than a year, or who have never received other forms of treatment, are often advised to consider alternative treatments first. These include clonidine-assisted withdrawal management, outpatient therapy, intensive inpatient treatment and several available self-help or group counselling settings. Other Preliminary Considerations There are other important preliminary considerations to be addressed by the counsellor early in the assessment phase. For example, clients may have misconceptions about the nature of MMT and its suitability to their needs. Alternatively, the person may not understand that the service is limited to the treatment of opioid dependence. The use of motivational interviewing strategies to explore the client s concerns and reasons for interest in MMT will generally serve to clarify whether MMT is a viable option and provide a basis for continuing the assessment process. When MMT is clearly not an option, it is very important to help the client make a more suitable link to treatment. When the MMT service is part of a larger multifunctional service, there will normally be mechanisms available to effectively link the client with a more suitable alternative. The challenge is greater in standalone MMT services. Ideally, staff involved in screening clients for the MMT service should be familiar with other substance use treatment services in the community and be able to make an appropriate referral. When MMT is a viable option, the client will need to be oriented to the nature of MMT as part of the process of giving informed consent to participate in the treatment. Often it will be part of the counsellor s role to provide this orientation. Clients should receive information about methadone and how it works, the relevant treatment requirements (e.g., frequency of urine screening and procedures for methadone pick-up) and aspects of the take-home carry system. Clients may regard supervised urine collection procedures and methadone carry procedures as punitive and controlling. Consequently, counsellors should emphasize the therapeutic benefits as well as the rationale for any contingency management interventions used in the process. As well, the federal and provincial or state guidelines that apply to the administration of methadone can be discussed. 88 Assessment and Treatment Planning Chapter 7 Finally, there should be a discussion of expectations. The counsellor should explain to clients what they can expect from the treatment team (e.g., to be treated respectfully). Similarly, the counsellor should outline the team s expectations of the client (e.g., drug dealing on the premises or engaging in threatening behaviour will not be tolerated). Initial Orientation to MMT Orientation to MMT involves giving the client the information needed to understand and consent to treatment. Clients often feel physically uncomfortable during the first week of treatment, and it may be difficult for them to retain a lot of the information. Orientation is also an opportune time to educate clients about health, safety and confidentiality. Many clients will continue to use other opioids until they become stable on methadone, and they need information about needle exchange programs, techniques for safe injecting, methods of needle cleaning and safe sex practices. It is helpful to give the client a handbook about MMT treatment to help her or him understand the nature of MMT and to be used as a reference throughout the treatment process. (See, for example, Methadone Maintenance Treatment: Client Handbook, Centre for Addiction and Mental Health, 2001.) It may be best to give the client some time to read over the handbook after the preliminary discussion and then meet again to discuss any questions or concerns the client may have. Counsellors should be sensitive to the fact that some of their clients may have difficulty reading or understanding written materials and will require assistance. Because of the stigma that is attached to illiteracy, this issue must be handled very carefully. Once the client has agreed to participate in the MMT program, expectations of the client and treatment team should be documented in the form of a written treatment agreement, signed by both parties and a copy provided to the client. Treatment Agreements Treatment agreements are a useful way to ensure that the rights and obligations of both parties are clearly understood. They are also useful in addressing any misunderstandings that may arise in the course of treatment. The treatment agreement specifies the rights of the client (e.g., to be treated with respect, to receive methadone daily, to have access to counselling, medical and other 89 Methadone Maintenance: A Counsellor s Guide to Treatment services, and to have the opportunity to earn carries). The treatment agreement should outline the expectations of the client with regard to such things as urine screens, pharmacy hours, methadone pick-up and aggressive behaviour. The agreement should also describe the steps the client should take in the event that he or she believes that the agreement has been violated. (See Appendix A for a sample treatment agreement.) Introduce All Aspects of the MMT Program The orientation process should address all aspects of the program that the client is likely to use (e.g., physician, pharmacy and counselling services). Also, counsellors should introduce clients to the staff, orient them to the physical environment and make them feel welcome, to help alleviate their anxiety. Limits of Confidentiality The limits of confidentiality should be discussed in a straightforward manner at the outset of discussions with the client. These limits include the legal duty to report (e.g., child welfare and driving), the legal duty to warn and/or protect (e.g., threats to harm self or others) and court subpoena. Ideally, the nature of and limits to confidentiality should be included in written materials (e.g., client handbook or the treatment agreement) provided to the client; see, for example, the publication produced in 2001 by the Centre for Addiction and Mental Health, entitled Methadone Maintenance Treatment: Client Handbook (Toronto). Although issues of confidentiality are a common concern of all clients, they are of even greater concern to clients who have been mandated to treatment or who have children and have experienced encounters with child welfare agencies. Developing a Comprehensive Treatment Plan Developing a comprehensive treatment plan follows a thorough assessment. The assessment will normally consist of a psychosocial assessment completed by the MMT counsellor, supplemented by a medical examination by the attending physician. In some instances, additional specialized assessment will be required, such as psychiatric assessment to investigate concurrent disorders or psychological assessment of cognitive functioning. Vocational assessment may also be indicated to explore vocational aptitudes and readiness for employment. 90 Assessment and Treatment Planning Chapter 7 Psychosocial Assessment It is advisable for clients to complete a psychosocial assessment as soon as possible upon entry to methadone treatment and not later than four weeks after admission. In preparation, clients should be fully informed about the nature and purpose of the assessment process and should be clear about how the information gleaned from the assessment will be used and who will have access to it. A psychosocial assessment should involve a standardized set of procedures. In Ontario this would usually involve the use of tools recommended in The Standardized Tools and Criteria Manual (Cross & Sibley-Bowers, 2002). The psychosocial assessment has two primary goals. First, it is an opportunity to clarify information related to the client's decision to seek treatment. This information can help clarify goals and motivation for change. Second, the assessment also helps to identify specific problems information that can be used to design an individually tailored treatment plan. Consideration should be given to using a standardized tool (such as the Addiction Severity Index) that can be re-administered periodically both to track client changes and facilitate ongoing treatment planning. Some clients may regard methadone as the answer to their problems. They may see little value in engaging in a psychosocial assessment or counselling for that matter. All members of the treatment team should emphasize to clients that their treatment success could be enhanced significantly if they participate in counselling. Opportunities to engage clients in a psychosocial assessment and later in counselling can be improved if the psychosocial assessment is scheduled to immediately follow the medical assessment and to precede the client s first dose of methadone. However, it is not advisable to delay the administration of the first methadone dose once the suitability of MMT has been established. There are two fundamental stages to a comprehensive assessment. These are: identification of problems or changes the client would like to make development of a treatment plan. Problem Identification The problem areas listed below in the assessment checklist should be covered in the comprehensive psychosocial assessment, as well as any other areas that appear relevant. 91 Methadone Maintenance: A Counsellor s Guide to Treatment ASSESSMENT CHECKLIST Drug Use Past history of use (e.g., age of onset, type of substance, route of administration, duration of use, amount, frequency) Current substance use behaviour, including risks associated with use Primary and secondary substance problem Prescribed medications (including how the client s prescriptions are paid for, e.g., insurance, Trillium, etc.) Alcohol Use Past history of use (e.g., age of onset, duration, amount, frequency, current use, complications from use) Medical Status Hospitalizations Current serious health problems Prescribed medications for any conditions Psychological Psychological problems in the past 30 days Status History of psychiatric problems (treatment for psychiatric problems, hospitalization, medication) Suicide attempts and any current thoughts Social and/or Housing Family Supports Close friends or family Violence in any current relationship Legal Status Legal mandate for treatment Potential limits of confidentiality Education and/or Employed/unemployed Occupational Status Knowledge/skills level and capacity for employment Readiness for Level of client s motivation to commit to change Change process (e.g., client s stage of change) 92 Assessment and Treatment Planning Chapter 7 Information concerning the above areas can be gathered through an unstructured interview. When inquiring into these areas, the counsellor should prioritize the exploration of problems and concerns so that certain areas are covered first (e.g., medical problems should precede questioning about vocational skills; McCann et al., 1994). It is usually unwise to inquire about highly personal or emotional areas, such as abuse history, until a rapport between client and counsellor has been established. Assessment Instruments A comprehensive psychosocial assessment can include the application of structured assessment tools. The assessment instruments identified for use in Ontario substance abuse treatment services are suitable for use in MMT programs. These include tools to assess drug use history, adverse consequences of drug use, problem behaviours and symptoms, perceived social support, self-efficacy, readiness for change, and general health. For a detailed description of these instruments and their application, see Cross and Sibley-Bowers (2002). Addiction Severity Index The Addiction Severity Index, or ASI (McClellan et al., l992) is a structured assessment tool that has been widely used in U.S. MMT programs. The ASI is a structured clinical and research interview. This interview is designed to assess the severity of problems that clients experience across a wide range of areas of functioning. The problem areas assessed include legal, psychiatric, social and family, drug use, medical and employment and/or other support. When using the ASI, the interviewer asks various questions in each of these areas concerning the number, extent and duration of problems. In addition, clients are asked to rate the degree to which these problems bother them and whether they want counselling for these problems. Selected items from each problem area are summed to produce an estimate of the problem severity. One advantage of the ASI is that it is brief (approximately one hour to administer). Another advantage is that it can be re-administered at various points during treatment and can therefore be used to monitor treatment progress. Outcome measures have also been incorporated within the ASI and these are useful for evaluation purposes. 93 Methadone Maintenance: A Counsellor s Guide to Treatment Some familiarity with the interview is necessary. Training tapes are made available through the ASI author (A.T. McClellan, Department of Psychiatry, University of Pennsylvania). Beck Depression Inventory An instrument that is useful when assessing for the presence of depressive symptoms is the Beck Depression Inventory or BDI (Beck et al., l961). Upon entry to metha
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