Treatment Planning MATRS
Jennifer Wyatt, LMHC, MT-BC, CDP: [email protected]
Northwest Addiction Technology Transfer Center (ATTC)
Rev Apr 2015
The ATTC Network
Ten Regional Centers
Four National Focus
Area Centers
• SBIRT
• Hispanic and Latino
• Native AmericanAlaska Native
• Rural and Frontier
•
•
•
Handouts
Mobile phones
ATTC Consent
forms &
evaluations
Training split into 4 sections
Mon,
May 4 in The Summit
– 10:15-11:45am
– 1:15-2:45pm
– 3:15-4:45pm
Tues, May
5 in The Summit
– 10-11:30am
Please bring handouts to
and attend all parts.
each section
Participant Introductions
•Name
•Agency
•Job
•Experience with assessment and
treatment planning
•What is your favorite thing to do
outside of work?
Training Expectations




Identify characteristics of a program-driven (“old
method”) and an individualized treatment plan (“new
method”)
Understand how individualized treatment plans improve
client retention and ultimately lead to better outcomes
Discuss the importance of language and words we use
Practice formulating treatment plans and develop:
Problem Statements
Goals based on Problem Statements
Objectives based on Goals
Interventions based on Objectives
Treatment Plans are . . .
“Meaningless & time consuming”
“Ignored”
“Same plan, different names”
We’re going on a road trip . . .
Let’s play the “Car Game.”
Positive aspects of
Treatment Planning
Negative aspects of
Treatment Planning
Treatment Planning Process
Conduct assessment.
Collect client data and collateral
information.
Identify problems and strengths.
Prioritize problems; write
problem statements.
Write goal statements to address
problems.
Treatment Planning MATRS
Measurable
T
Attainable
Time-limited
Realistic
Specific
Overview of your work for today:
1.
2.
3.
4.
5.
6.
7.
Read the case scenario.
List the problems and strengths.
Write problem statements.
Prioritize concerns to be addressed in your treatment
plan; no more than 3.
Develop goal statements for the 3 primary concerns.
Create objectives (what the client will do) and
interventions (what the counselor/agency will do) to
resolve the problems.
Note completion dates and methods to evaluate
progress.
Take a look at ASAM.
 How
can this placement information be
used in conjunction with your assessment
data to create successful treatment
planning?
 Could
it guide the treatment priorities and
assist in decreasing the level of care
needed?
ASAM Dimensions
1
• Acute Intoxication and/or Withdrawal Potential
2
• Biomedical Conditions & Complications
3
• Emotional, Behavioral, or Cognitive Conditions
& Complications
4
• Readiness to Change
5
• Relapse, Continued Use, or Continued Problem
Potential
6
• Recovery/Living Environment
The What, Who, When, & How
of Treatment Planning
• What is a Treatment Plan?
• What should it do?
• Why do we have one?
What is a Treatment Plan?
A written document that:
–Identifies the client’s most important goals
for treatment
–Describes measurable, time-sensitive steps
toward achieving those goals
–Reflects a verbal agreement between the
counselor and client
Center for Substance Abuse Treatment, 2002
At its best, the treatment plan is an
incremental road map for client success
detailing where the client is going and
how we will support them in getting there.
Who Develops the Treatment Plan?
–Client partners with treatment providers
(ideally a multi-disciplinary team) to identify
and agree on treatment goals and identify
the strategies for achieving them.
Should others, such as
family members,
prescribers, or POs
contribute to a
treatment plan?
When is the Treatment Plan developed?
–At the time of admission
–Continually updated and revised throughout
treatment
–Reviews are required every 30 days for the
first 90 days of treatment, and then every 90
days thereafter.
When might you conduct
an additional treatment
plan review?
How does the Assessment guide
treatment plan development?
–The assessment provides initial information to
begin the process of treatment.
–It should be comprehensive and indicate
multiple areas of concern from the client’s
perspective.
Update Assessment Information
 The
Assessment should represent the
presenting issues and identified problems
at the time of admission to treatment.
 Note that
the information may need to be
updated to reflect the willingness of the
client to share more information after they
have developed a relationship with the
primary counselor.
Designing Effective Treatment
Client
Assessment
ASAM
DSM
GAIN
Collateral
Information
Referral
Individualized
Treatment
Plan
Indiv.
session
Group
Group
Components in a Treatment Plan
1. ASAM Dimensions & Problem Statements
2. Goal Statements
3. Objectives
4. Interventions
5. Completion Dates
Treatment Plan Components: Problem & Goal Statements
Problem
statements
• Based on information
gathered in the
assessment and
updates
Goal
statements
• Based on problem
statements
• Reasonably achievable
during active treatment
Treatment Planning Essentials
Measurable
T
Attainable
Time-limited
Realistic
Specific
Let’s get started…..

Get into groups
of 4-5.
Read the case scenario.
– List all Problems, Strengths, & Questions.
– Prioritize no more than 3 problems to address
in your treatment plan.
– Decide on levels in ASAM Dimensions (0-4);
no need for specifics, just a general level.
– Choose overall level of care (0-4).
– We will discuss as a large group before
moving on.
You
have 20 minutes.
Group reports
Each group shares:
– Strengths
– All problems, including 3 priorities
– ASAM PPC across Dimensions 1-6
– Overall recommended level of care for
your treatment plan
Do you have questions you’d like to ask
Betsy? Info that might help?
• Each group can ask Betsy 3
questions:
o Craft them carefully
o Use your best MI skills:
 Remember openended vs close-ended
questions
 Use: What, how, tell
me about…
 Avoid: Is, can, do, have
Remember Maslow’s Hierarchy of Needs?
5 Self-actualization
4 Self-esteem
3 Love & Belonging
2 Safety & Security
1 Biological/Physiological
Biological and Physiological Needs
•Substance Use
•Physical Health Management
•Medication Adherence Issues
1 Biological/Physiological
Safety & Security
•Mental health management
•Functional impairments
•Legal issues
2 Safety & Security
Love & Belonging Needs
3 Love & Belonging
•Social & interpersonal skills
•Need for affiliation
•Family relationships
Self-Esteem
4 Self-Esteem
•Achievement and mastery
•Independence/status
•Prestige
Self-Actualization
5 Self-Actualization
• Seeking personal potential
• Self-fulfillment
• Personal growth
Take a minute to reevaluate your treatment
planning priorities…
Has your group
identified the
most pressing
issues from
Betsy’s
perspective?
“One size fits all”
Program Driven Plans
Program Driven Plans
• Created to serve the largest number
of clients without individualizing
treatment.
• Assume that something we do in
our program will be beneficial to the
client without special attention to
“individual needs”.
Program-Driven Plans
 Client has to “fit” into the standard treatment
program.
 The client must “fit” or he/she is often determined
“not ready” or “inappropriate” for treatment.
 Plan often includes only
standard program
components (e.g., group,
individual).
 There is little difference
between clients’ treatment
plans. They appear to be
“cookie cutter”.
Program-Driven Plans
Goals are often written as:
1. “Attend 3 AA meetings/wk”
2. “Complete Steps 1, 2, & 3”
3. “Attend group sessions 3x/wk”
4. “Meet with counselor 1x/wk”
5. “Complete 28-day program”
Program-Driven Plans often…
 Include only
those services
immediately
available in
agency.
 Do not include
referrals to
community
services (e.g.,
parenting
classes)
 Lack creativity
Individualizing Treatment
Our goal is to identify the individual problems and
needs of each client, and make every attempt to
tailor the treatment to meet those needs.
Review of the Treatment Process
Is treatment the same for everyone?
Are there groups to meet the special
needs of individuals in the program?
Do the treatment groups address
issues in the ASAM dimensions?
Let’s Review the Treatment Plan Format.
ASAM
Dimensions
Problem
statements
Objectives
Goal
statements
Interventions
Completion
dates
Signatures
What information is needed to
individualize a Plan?
Possible sources of information:
• Client
• Probation reports
• Screening results
• Assessment information
• Collateral interviews
The “Old Method” (Program-Driven)
Problem Statement
“Alcohol Dependence”

Not individualized

Not a complete sentence

Doesn’t provide enough information
A diagnosis is not a complete
problem statement.
Improved Problem Statement Examples
Van: “I am drinking every day and it
takes more liquor now to get me
drunk.”
Meghan: “I am pregnant and need
help with prenatal care.”
Tom: “I have mental problems that
get in the way of my recovery.”
Tips on writing Problem Statements
 Include all identified problems, regardless
of available agency services.

A referral to outside resources is a valid
approach to addressing a problem.
 List all problems, whether deferred or
addressed immediately.
 Review and assess each ASAM domain.
 Avoid jargon.
 Use non-judgmental language.
 Use complete sentence structure.
Changing Language
What do you think about these Problem
Statements?
• “Client has low self-esteem.”
• “Client is in denial.”
• “Alcohol dependent”
• “Client is promiscuous.”
• “Client is resistant to treatment.”
• “Client is on Probation because he is a bad
alcoholic.”
Changing Language - Examples
Old language
New language
1. Client has low self-esteem.
1. “I don’t feel good about
myself. “
2. Client is in denial.
2. “I have two DUIs in the
past year, but alcohol use
is not a problem.”
3. Alcohol Dependent
3. “If I don’t drink when I
wake up in the morning, I
get the shakes.”
Changing Language - Examples
Old language
New language
1. Client is promiscuous.
1. “I have sex with multiple
partners.”
2. Client is resistant to
treatment.
2. “In the past year, I started
three different treatment
programs but didn’t finish
any of them.”
3. Client is on Probation
because he is a bad
alcoholic.
3. “I have legal issues because
of my drinking.”
Vague terms to watch out for
SAFE
HEALTHY
GOOD
POSITIVE OR
NEGATIVE
APPROPRIATE
What else?
Rate these Problem Statements:
1.
“I don’t have a safe place for my
children.”
2.
“I have medical and substance
abuse issues.”
3.
“I don’t have job skills.”
4.
“I drink alcohol every day.”
Rate these Problem Statements:
5.
“I have diabetes and a leg wound that
won’t heal.”
6.
“The adults I live with drink alcohol.”
7.
“I can’t leave my kids to go to
treatment.”
8.
“I don’t have a safe and drug-free place
for me and my children to live.”
Write Problem Statements for Betsy
You have 20 minutes to develop
problem statements for the three
problems you have prioritized.
THEN, I’ll ask you to have a group
spokesperson report on your work before we
move on to the rest of the treatment plan.
The “Old Method” (Program-Driven)
Goal Statement
“Will refrain from all substance use
now and in the future”
•Not helpful for treatment planning
•Cannot be accomplished by program
discharge date
The “Old Method” (Program-Driven)
Objective Statement
“Will participate in an outpatient
program”
•Not specific
•A level of care is not an objective.
The “Old Method” (Program-Driven)
Intervention Statement
“Will see a counselor once a week and
attend group on Monday nights for 12
weeks”
•This sounds specific, but it really
describes a program component.
Problem and Goal Statements
Problem
Betty: “I have sex with multiple partners
weekly.”
Goal
“I will learn sexual practices to protect
me from HIV/STI.”
Problem
Thomas: “I hear voices in my head and
talk back to them.”
Goal
“I will meet with a mental health
provider for an evaluation.”
Problem and Goal Statements
Problem
Edward: “If I don’t drink alcohol when I
wake up in the morning, I get the shakes.”
Goal
“I will manage withdrawal from alcohol by
going into a medical detox program.”
Problem
Marta: “I have two DUIs in the past year,
but alcohol use is not a problem for me.”
Goal
“I will learn about alcohol use disorder.”
Problem and Goal Statements
Problem
Effie: “I don’t feel good about myself.”
Goal
“I will learn about my personal strengths
and skills.”
Problem
Damian: “In the past year, I started three
different treatment programs but didn’t
finish any of them.”
Goal
“I will commit to completing a 4-week
treatment group.”
Why make the effort to individualize
Treatment Plans?
• Leads to increased retention rates which are
shown to improve outcomes
• Empowers the counselor and the client, and
focuses counseling sessions
• Honors the uniqueness
of each individual
• Recognizes multiple
pathways to recovery
University of Washington Alcohol and Drug
Abuse Institute: Retention Toolkit
 Research
shows a direct correlation between
remaining in substance use disorder treatment for
at least 90 days and positive outcomes, including a
reduction in substance use and criminal justice
involvement.
 Website includes information on:
–
–
–
–
–
Online training videos
Cultural competence
MI
Motivational Incentives
Family involvement
 http://adai.uw.edu/retentiontoolkit/
Goal Statement Examples
1.
“I will safely withdraw from alcohol,
stabilize physically, and begin to
establish a recovery program.”
2.
“I will obtain safe care for my children
when I go to residential treatment.”
3.
“I will obtain medical treatment for
my leg wounds.”
4.
“I will eat better.”
Objective Statement Examples
1.
“I will report any withdrawal symptoms.”
2.
“I will begin activities on Monday that
involve a substance-free lifestyle to
support my recovery goals.”
3.
“I will call Group Health to find a doctor
to treat my leg wounds by 03 31 2015.“
4.
“I will consult three agencies to seek
assistance for my child care needs by
Thursday.”
Intervention Statement Examples
1.
Staff will assist Betsy in making an
appointment with a primary care provider.
2.
Staff will assist Betsy in finding child care
services and help her to develop a dialogue
for the phone conversations by role playing.
3.
Staff will teach Betsy skills to cope with
cravings for alcohol including using self-talk
and urgesurfing.
4.
Staff will assist Betsy in finding a sober
support group for women.
Let’s Create Goals, Objectives, and
Interventions for Betsy
Goal
statements
• Resolution of the Problem
statements
Objectives
• Small incremental activities for
the client to achieve the goals
• Activities the Counselor will
Interventions complete to assist the client in
achieving the goals
Check-in Discussion
Are your treatment plan components…
 Likely to be understood by the
client?
 Free of clinical jargon?
 Clearly stated?
 Written in complete sentences?
 Attainable in active treatment
phase?
 Agreeable to both client and staff?
Prep for the next exercise
 Each
group will hand off their treatment
plan to another group.
 Each
group will point out strengths and
share feedback.
 Please be
sensitive. The treatment plan in
front of you represents a group’s best work
today.
First, let’s go over a framework that
will help you provide feedback.
Treatment Planning Essentials
Measurable
T
Attainable
Time-limited
Realistic
Specific
Objectives & Interventions (It MATRS!)
Measurable
•Achievement of objectives and
interventions is measureable.
•Measurable indicators of client progress
•Assessment scales/scores
•Client report
•Behavioral and mental status changes
Objectives & Interventions (It MATRS!)
Attainable
•Objectives and interventions can be achieved
during the active treatment phase.
•The focus is on “improved functioning”.
•Identify goals that are attainable in Level of Care
provided.
•Remember to revise goals when client moves from
one Level of Care to another.
Objectives & Interventions (It MATRS!)
T
Time-limited
• Focus on goals and objectives that are
short term.
• Objectives and interventions should be
reviewed within a specific time period.
Objectives & Interventions (It MATRS!)
R
Realistic
• The client can complete the objectives within a
specific time period.
• Goals and objectives are reasonable given the
client’s environment, supports, diagnosis, and level
of functioning.
• Progress requires client effort and buy in. This is
essential.
Objectives & Interventions (It MATRS!)
Specific
•Objectives and interventions are
specific and goal-focused.
•Address in specific behavioral terms
how level of functioning or functional
impairments will improve with the
interventions.
Clinical Example
Problem Statement:
“I have been in the emergency
department three times for treatment
in the last six months due to fights with
my boyfriend when we were drunk.”
M
A
T
R
S
Clinical Example
M
A
T
R
Goal Statement:
“I will develop a personalized Safety Plan.”
S
Objective Statement:
“I will create a personalized Safety Plan by
attending 6 Domestic Violence Awareness classes
between 03 20 2015 and 06 01 2015.”
Intervention Statement:
Staff will assist Betsy in contacting the Domestic
Abuse Women’s Network (DAWN) by 03 13 2015.
Do the examples pass the MATRS Test?
Measureable: Yes, the counselor can
evaluate how many classes attended.
Attainable: Yes, the client has
transportation to attend classes.
T
R
S
Time-Limited: Yes, the class runs for 6
weeks.
Realistic: Yes, the client has the ability to
attend classes.
Specific: Yes, examples include specific
activities.
The MATRS Test
Measurable? Can change be documented?
Attainable? Achievable within active treatment phase?
Time-Related? Is time frame specified?
Will staff be
able to review within a specific period of time?
Realistic? Is it reasonable to expect the client will be
able to take steps on his or her behalf? Is it agreeable to
client and staff?
Specific? Will client understand what is expected and
how program/staff will assist in reaching goals
80
Review of group Treatment Plans
Does
it pass the MATRS test?
What are the
strengths of the plan?
What suggestions
do you have that
might improve the plan?
M
A
T
R
S
What have you
learned about your
own treatment
planning process as
you’ve listened to
others’ work?
The Stages of Change –
Illustrated
Adapted from Prochaska &
DiClemente, 1982; 1986
Consider how the
“Stages of Change”
impact Treatment Planning
3.
Preparation
6. Relapse
2.
Contemplation
1. Pre-Contemplation
Adapted from Prochaska & DiClemente, 1982; 1986
5.
Maintenance
4. Action
Pre-Contemplation
“I don’t have a problem.”
Person is not considering or does not
want to change a particular behavior.
“Maybe I have a problem, but I’m not
sure what to do about it.”
Contemplation
Person is thinking
about changing a
Pre-Contemplation
behavior.
“I’ve got to do
something.”
Preparation
Contemplation
Pre-Contemplation
Person is
seriously
considering
changing a
behavior
by planning
and taking
steps
toward
change.
Action
Preparation
Person is
actively
doing
things to
change
or
modify
behavior.
Contemplation
Pre-Contemplation
“I’m ready
to start.”
“How do I
keep going?”
Action
Maintenance
Preparation
Contemplation
Pre-Contemplation
Person
continues
to maintain
behavioral
change
until it
becomes
permanent.
Action
Maintenance
Relapse
Preparation
Contemplation
“What went
wrong?”
Pre-Contemplation
Person
returns
to the
previous
pattern of
behavior
that they
had begun
to change.
Basic guidelines of documentation
•Client name/unique identifier
•Dated, Signed, Legible
•Specific problems, goals &
objectives addressed
•Start/stop time
•Credentials
•Add new problems,
goals, & objectives
•Session content & client
response
•Progress toward goals &
objectives
•Interventions used to
address problems, goals, &
objectives
Documentation: Basic Guidelines
Entries should include:
 Report on progress, or lack thereof, on
the treatment goals, objectives and
interventions, with specific references
to each
 Any new developments or concerns
 The focus and content of the session
 Accomplishments or agreements
Documentation: Basic Guidelines
Describes:
 Changes in client status
 Responses to, and outcomes of,
interventions
 Observed behaviors
 Progress toward goals and
completion of objectives
The Golden Thread…
The client’s
treatment
record is a
legal
document.
Documentation: Basic Guidelines
Legal Issues & Recommendations:
 Document non-routine calls, missed sessions,
and consultations with other professionals.
 Avoid reporting staff problems in case notes,
including staff conflict and disagreements.
 Chart client’s non-conforming behavior.
 Record unauthorized discharges and
elopements.
 Note limitations of the treatment provided to
the client.
Concurrent Documentation
 Completed
in the presence of the client with their
input.
 Think of this in terms of how your physician
documents their work with you while you are in
the exam room.
 This gives the client an opportunity to assist in
documentation that they agree to, and takes away
the mystery of what is written about in the chart.
This is not always an option with all clients.
Use your clinical judgment.
What will you take
with you back to
your work?
Evaluations
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programming with us!
• We use this information to improve our services and to
share information with SAMHSA about our work.
• Please complete the Evaluation Form and the Thirty-Day
Follow Up Consent Form.
• If you complete our Thirty-Day Follow Up survey, we will
thank you with a $5 coffee card.
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