Treatment Planning Using the CASSP| Addiction Counselor Exam Review

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome everybody to today's presentation on writing effective treatment plans. The Pennsylvania CASSP model. Now, this model is designed for working with children and adolescents, but there's a lot of it that we can take from it. For working with individuals of all ages. We're going to learn the principles of the model. Review the difference between goals, objectives and interventions. Now I know you might be thinking, well that's kind basic and it is, but it's one of those things that I find when I'm trying to help staff learn how to treatment plan. They get really confused and hung up and overthink it. It's really, really very simple and they try to make it harder than it is. And sometimes when you're working in electronic health records and stuff, it feels weird to plug different things in and different models call them different things. So we're going to try to clear up some of the confusion today. And for this model we're going to talk about what goals, objectives and interventions are and then we'll identify qualities of good goals, objectives and interventions. Because you can write them, but if they're not good, they ain't going to work. Okay, so principle one. Services are planned to meet the individual needs of the child or the person rather than to fit the person into an existing service. And this is really important because when each person is a little bit different and each person has different needs. So I want you to consider three different cases, if you will, as we go through this one is a six year old girl from a rural area, low socioeconomic status, parents are loving, Christian, low educational attainment, and the child has a diagnosis of anxiety. Okay, so what kinds of services is she going to need? What resources are available and what are the capabilities of the community, the resources and the family. So with this little girl, she's in a rural area so they may not have access to counseling really easily. The place that I came from in Florida, you know, there was the University of Florida and then you could go out for, you know, 10, 20, 40 miles and it was just, it was very, very rural. So those are the things that, that you want to consider when, when you're talking about what resources are available for a person to use and you want to talk about what their capabilities and needs are. What capabilities does this little girl have? What can she do for Herself as a six year old, she's got some skills, so let's build on those. What capabilities does her family have? They have low educational attainment, so they may not be working as CEOs or lawyers or doctors or something, but they are very loving. So that is a strength that we can build on. What are their capabilities? And we also want to consider cultural issues when we're thinking about those. So this next one is a six year old boy from a metro area, high socioeconomic status, mother's emotionally detached, father's an alcoholic and he's diagnosed with anxiety. So how would their service availability differ? And you know, I live a little bit outside of Nashville right now, and even when I was in Florida, if you were in Gainesville, around the University of Florida, you had services just coming out your nose. There are all kinds of services. But if you got 10 miles outside of the city, there wasn't much. And if you didn't have, you couldn't afford to drive into the city every day, or you didn't have transportation, you were pretty hamstrung. The same thing around here. I mean, metro Nashville is pretty big. But then when you get out towards where my farm is, you can't get in anywhere easily and there's not public transportation. So this little boy lives in a metro area. So ostensibly there are services everywhere. There are high ses, so they can afford services. They can afford services, we'll say anywhere. The mother is emotionally detached, so she may not be as involved in being a support in this particular scenario, at least at the beginning. And father is an alcoholic, so. So we don't really know what kind of impact that has on junior at this point, that contributes to the anxiety. But when we're talking about resources that are available, these two children, same age, same diagnosis, very different treatment plans, and then the third one is a 16 year old gifted youth. And I didn't identify gender here. 16 year old gifted youth with anxiety, supportive single father, and they live in a suburban area. So obviously I was trying to make these as different as possible to help you see that you can be working with kids with anxiety and still, you know, have a whole bunch of differences in what resources they have. So we can't just say, all right, you're a kid with anxiety, you need to come to group three nights a week. Well, that might not be possible for the 16 year old who may not drive yet. Single father may have to work nights, may have the only car. So that might not work for them. The six year old little boy, you know, if we're going to put him in some sort of group activity or even individual therapy in the metro area, they may be able to access a lot of stuff. The six year old girl in a rural area may not be able to get into town for these. So how can we provide services? Maybe we need to look toward telehealth, maybe we need to look toward, you know, residential. Depending on how bad her, her anxiety is. We want to make sure that services are developmentally appropriate and child specific. Children are not little adults. They don't think the same way, they're not cognitively developed the same way. Heck, up until 25 the prefrontal cortex isn't completely develop. So we want to remember that children think back to Piaget, think and reason and rationalize much differently at different ages and definitely differently than adults. Part of this is because of cognitive development, part of this is because what they've been exposed to in their life, I mean when you're six, you don't have as many experiences as somebody who's 16 or 26 and you know, they may just have different skills and tools. And we want to build on the strengths of the child and their family to meet the mental health, social and physical needs of the child. So why do I have and family and italics? Well, at this age, you know what, most of these kids are probably going to be living in that household. It's not like they can say, oh, this is a bad fit, not a good recovery environment, bye mom, I think I'm gonna move out. They can't do that. So we need to find the strengths of the family and we need to work within this ecosystem that they're in. So Principle 2 services recognize that the family is the child's primary support system. The family is a full partner in all stages of the decision making and treatment planning process, including implementation, monitoring and evaluation. So what does that look like? Well, it depends on the family. You know, for the 16 year old gifted student who has a single father, you know that father is not going to be able to stay home and do check sheets all day long. It's just not going to happen. And you're not going to monitor a 16 year old probably the same way that you're going to monitor a six year old. So you know, we want to figure out how is what resources do we have to monitor and what does the family see needs to happen. You know, their ideal outcome is obviously to fix the identified patient, but what does that look like? So if Johnny is less anxious, you know, what is that going to look like in the household. And when Johnny's been less anxious in the past, what's been different? And then we can work with the family to help them create an environment that can support Joni in being less anxious. Families we need to remember not to be too close minded. When we define families, they can include biological, adoptive and foster parents, siblings, grandparents, other relatives, and even other adults that are just committed to the child. You know, there are a lot of families who have, you know, an Uncle Bob or an Auntie June or whoever they are that are not blood relatives, but they are very close friends of the family. And if they are part of that child's life, then they can potentially be integrated into the treatment plan. We want to examine to determine who's in the family. Who does the youth spend the most time with? And, you know, again, be very open minded. If you're working with runaways and homeless youth, they may not have what you consider a family. They may not have those parental units or those legal caregivers. So who's their family? Generally the people in the group that they travel with. We also can look at youth in boarding school. Who's their family? And yes, they may have some biological relatives back at home that they're kind of close to, but they've also got the people that they spend 247 with when they're at the boarding school. So those people are part of their family. And we want to think about what the family's perception is of the youth's functioning and the family's functioning, the youth's strengths and the family strengths. And then what are the priorities for treatment and what are the cultural values supporting this ideal outcome? So we want to talk to them and really help them define what they want. Because if they're not getting. If they're not moving toward what they want, they're going to be less invested and engaged in the process. Whenever possible, services are delivered in the child's home community, drawing on formal and informal resources to promote the child's successful participation in the community. So what does that mean? That means in this model, we really want to look for. For. If you remember if you were in the recovery oriented Systems of Care class that we just did, we really want to look to community resources. You have your formal things like Department of Children and Families, doctors, counselors, churches, those sorts of things. But then you also have informal resources such as the Boys and Girls Club and any volunteer activities. So we want to look at where can we find support for the family, for the child, in order to address his or her needs. Community resources include not only mental health professionals and provider agencies, but also social, religious, cultural organizations and other natural community support networks. So thinking about some of these organizations, how could they be used in the example cases? And let's just start with the six year old girl living in a rural area. And you know, I'm thinking if I'm doing an assessment in a rural area and I used to go out to our outlying counties twice a week and I would do assessments and see clients, but you know, that was it. And if they needed something in the interim, they had to come into our main office, which was quite a haul for a lot of them. So what kinds of supports are available in that community? In a lot of those communities? There are strong faith based networks in there. So you can work with that, you can consult with the clergy, with the staff at some of the faith based organizations and help them provide education and support systems for youth. We can work on anxiety prevention. We can identify maybe this little girl has social anxiety and she has trouble with self esteem. So we might want to talk about, okay, you know, what can we do? What kinds of programming can the daycares put on? What kinds of programming can the after school programs put on to help youth in general? Not necessarily just specifying this little girl, help youth in general develop self esteem and develop appropriate communication skills and address their anxiety. And those sorts of things we can rely on, we can reach out to libraries. Libraries are often very attentive, especially in rural communities, very attentive to the people in their community. And they're happy to put on programming, they're happy to have somebody come in especially. And you may have to have one of your clinicians go and put on that prevention program, but that's one hour for a group of people as opposed to, you know, seeing people individually. So there are a lot of ways we can use group community education. We can use things on the Internet, we can use multimedia resources to help youth thrive. For the six year old boy from the metro area, you know, what types of community services might be out there, what kinds of things might he be able to tap into or his family be able to tap into that might help him with his anxiety? In the metro areas we generally have a fair amount of access to resources, but a six year old is not going to get on a bus by himself and, and get to an appointment. So he or she or he still has to rely on mom or dad to transport. So we want to look at, okay, maybe counseling exists, but parents are just not Involved, we can't count on them to get Junior to appointments even though it's pretty accessible. What's the gap? The gap is transportation. So what kinds of transportation services might we be able to find to help fill this gap to help Junior get here? What types of things might we do to increase the likelihood if we can't find transportation? Increase the likelihood that a caregiver will transport Johnny to treatment to his counseling appointments? Some of it could be, you know, we can provide youth support groups and that's a good suggestion. Anytime you can put people together in a group, it's going to be more cost effective for the agency as well as it's a really time efficient approach for a lot of different diagnoses. Other things that we might want to look at with the six year old boy is providing information to mom about, you know, helping. We're going to call him Johnny. Helping Johnny start to feel a little bit less anxious. This may help her be a little less detached and them to start having a more secure relationship. And we also want to provide resources to make sure that dad can access treatment when and if he's ready. For the 16 year old gifted youth. You know, she's really smart, she's got a lot of stuff going on, she's great in school, she feels comfortable in school, but you know, she's got this anxiety. So school is a safe place for her. She likes this place. So maybe we can look toward providing school based interventions. Another suggestion that y' all offer are Boy Scouts and Girl Scouts groups. Those are places where youth can connect with other youth of their own age, which can be helpful. And sometimes it's a matter of developing healthy social supports, not just therapy, not just treatment. Principle four says services are planned in collaboration with all of the child serving systems involved in the child's life. So what systems are these? I don't know, the school, any faith based networks, any sort of after school care system. If they're, if they stay after school or if they go to daycare afterwards, if they have whoever takes care of them right after school. We want to involve the family system, the parents and anybody who lives in that household. We want to involve medical personnel. Let's get the pediatrician on board so he or she is weighing in as needed. A lot of times it's not a physical issue with the kid. A lot of times the child doesn't need to be on medication, but it's always good to have, you know, a multidisciplinary team. What other systems might we want to get Involved. While I didn't mention in these case studies, you also may have the Department of Juvenile justice that's involved with the youth school counselor. Great suggestion. Bring the school counselor in. Because just like we are at work, a whole bunch of our waking hours, each week, kids are at school or working on schoolwork, a whole bunch of their waking hours. So if we can bring the school counselor in and get that person looped in, even if the child's behavior is not disruptive in the classroom, if it is impeding their quality of life, a lot of times school counselors will help to try to get involved and facilitate the treatment plan as much as possible. Now, when you're working with all these people, how do you make sure that everybody knows what everybody else is doing? Because you're probably not going to get everybody together in a meeting once a week. That's just. That's a pipe dream. So how do you make that happen? And one of the things that we used to do is for our multidisciplinary teams, we had one person who was the central case coordinator. And I avoid the word case manager because it was usually a therapist because we didn't often have case managers involved. But the case coordinator was the single point of contact. So if it was me, I would collect all of the progress notes that came in for that child for the week, and I would compile them and create a master document that everybody could log into and look at. Once they finished looking at it, they would initial it and be done. If you're trying to get feedback on a child that went to see the pediatrician, for example, sometimes it can be difficult to get feedback from other providers. So if you send over when the child goes, if you send a form with them that's as much of a check sheet as possible, that's helpful, and then have the youth bring it back, that can be helpful at least in getting some sort of input from that provider. So there are a few ways that you can do it instead of just calling and going, please call me back, and then calling the next day saying the same thing and just never getting a call back, which I hate to say happens a fair amount of time. So we do want to make sure if we've got these systems involved, that they feel integrated and that we're all communicating representatives from all of these systems and the family. So because the families are going to be the ones that are actually implementing the treatment plan a lot of the time, the other however many hours minus one in a week, they're going to define the goals with the child. Notice they say with the child. What is it that you want? We're going to develop a service plan, develop the necessary resources to implement the plan, provide appropriate support to the child and family and evaluate progress. Okay, well that seems like a no brainer. That's what we want to do, but we have to make sure that we do it step by step that we figure out what is it that this family needs at this point in time, not what does the average 6 year old with anxiety need. Culture determines our worldview and provides a general design for living and patterns for interpreting reality that are reflected in our behavior. Services that are culturally competent are provided by individuals who have the skills to recognize and respect behavior, ideas, attitudes, values, beliefs, customs, language, rituals, ceremonies and practices characteristic of a particular group. Now remember, culture and ethnicity are not the same thing. Your ethnicity can be a culture, but we have a lot of different cultures that combine to make us up, make us who we are. So we want to make sure that we are paying attention. I mean, rural communities have their own culture, urban communities have their own culture. Different socioeconomic statuses may have ideas and beliefs and values and traditions that are different than other classes. So we want to pay attention to those things. For example, people who are of a higher SES may have, may put more prominence on a 16 year old's coming out party or something. So we do want to be supportive of family and cultural values. So we want to ask, when we're trying to figure out, is this treatment plan culturally sensitive? What is the view of the child in this culture? You know, is the child seen as a full participating member of the family? Is the child seen as an individual that needs to be controlled? Are they seen as helpless? How does the culture view a child of this age? What are the cultural expectations for functioning in this area? This is huge. Not all cultures operate at the same pace on different things. In some cultures, children are expected to read before they go to kindergarten. In other cultures, you know, six, seven years old, if they're starting to read, that's kind of cool. It's a little bit more lackadaisical with their approach to reading. For example, for sports, you know, what is the cultural expectation for functioning in this area? I remember when my son was born or when he was, he was little, he's never had an interest in sports at all. And what are the cultural expectations for a 5, 6 year old boy for functioning in this area and in our community? T ball was huge. I mean like literally or not literally, but you know, figuratively everybody had their kids in T ball, so he was one of those kids who, he had no interest in it. And, but that wasn't, that was just him, you know, that it wasn't anything wrong with him. But we do want to look at what the cultural expectations are. Some cultures, children don't start to talk until later on. So paying attention to that, what is the cultural perception for need for help? You know, does the family think this is a problem that needs intervention or not? And who should the help come from? Sometimes families are not comfortable getting help from counselors. They want to get help from their religious leaders. They want to get help from someone in their culture or their cultural elders. And that's okay. But we need to understand that from the get go so we can, you know, direct them and get the right people on the team. What are cultural strengths that can be capitalized on if family nurturance is a cultural strength? Well, let's, let's build on that. If high expectations and a drive for academic achievement is a cultural expectation, you know, we can work with that as a strength. So we want to figure out what does the culture bring that can be used as a strength to help this person, and what does the culture perceive as the child and family's existing strengths? So let's just step back and say, okay, you know, when we take a snapshot of this family from this cultural point of view, what do they got going for them? You know, they are, you know, do they have a house, do they have a stable living condition? Do they have employment? You know, what things are important in their culture? You know, I'm talking about one culture, you know, which. And some of these things may not be as important in other cultures. Some, some cultures the mother is expected to stay home with the children until they get out of school. And that's the cultural expectation. So if that's what's happening, then that can be possibly perceived as a family strength if that's what the family likes. Remember that what a culture says and what the family needs are not necessarily the same. It depends on their level of acculturation, which means how much have they embraced that culture. People who immigrate here from other countries may hold on and embrace their home culture when they're here. Other times they may assimilate into American culture. So we want to look at how culturally assimilated they are and which beliefs they espouse. And we need to ask them, don't assume that just because you're of XYZ ethnicity or culture that anything necessarily Applies services take place in settings that are the most appropriate and natural for the child and family. In the daycare center, in the school, in the home, whenever possible. This gives us a much better idea of what's going on. Because how Johnny behaves and how Johnny's parents behave or when he's in my Office on the 8th floor of the hospital are very different than how they behave during a home visit when the dog's running around and the siblings are there. And, you know, you get a much different picture. Not to say that they're trying to be deceptive when they're in your office, but certain settings connote certain behaviors. When I go into a doctor's office or into the library or into a church or, you know, I know that there are certain expectations for behavior. So I'm not going to be as, you know, fancy free as I am at my own house. So if we can get into this appropriate and natural environment and figure out what are the strengths, what's working for this child and what might be triggering the anxiety, we're going to have a much better picture than if we're just guessing from our quarterback seat. We want to choose the least restrictive and intrusive available method to meet the needs of the child and family. So if we don't have to have them come to come into town every day or every week, that's ideal. If we can see the child once a month and then have the parents do telemental health visits with us the other three weeks of the month to update us on progress and share videos or something, that's possible. And these are all things that we can get creative with. And obviously you got to pay attention about HIPAA and how you share videos and stuff, but that's a different course. But there are a lot of ways that we can sort of eavesdrop on the natural environment and engage the family without making it inconvenient for them or further adding stress to the, to the family. So are there any questions so far about these principles? And I think those are all pretty general principles that apply both to children and adults. We want to be as culturally responsive and individualized as possible. Okay, so moving on to treatment plans. An effective treatment plan should be both informative and practical. It's a recipe. And I want you to just continue to think about treatment plans as recipes. When you bake bread, you know, let's, let's just start with that. You have a bunch of dry ingredients and a bunch of wet ingredients, and you have to combine them. Well, you get them together, and then you have to combine them, and then you have to let them rest and rise, and then you move them into the baking pan. There's a whole set of steps. That's what a treatment plan is. Don't overthink it. The goal, we want bread. The objectives are the steps that we take along the way, the smaller steps. So the first objective would be to get all of the ingredients together. The second objective would be to combine the ingredients in the right order in order to make the dough. The third objective would be to let it rise. But in the meantime, there are steps in there. There are interventions, things that we've got to do to make those things happen. Like, it won't rise, the bread won't rise unless it's in a warm environment and covered. Okay, so those are things we need to do. So that's what I really want you to think from the perspective of a recipe, or if you are more comfortable with the metaphor of, you know, repairing a car engine or fixing something. I'm not mechanically inclined, so I stay away from those metaphors. But it's the same sort of thing. You got to get your tools together. You've got to, you know, first disassemble whatever it is and then start putting it back together. A person reading a treatment plan should be able to grasp the major concerns and how they're being addressed. And this is one part, and you'll see as we get into it, that's a little bit different than the way that I've ever had to write treatment plans. Really useful because it almost combines the integrated summary and the treatment plan in one document. The initial treatment plan identifies the work to be done and subsequent treatment plans. You know, we're supposed to update them at least weekly, and then, you know, do a reassessment every 30 or 90 days, depending on your agency. Subsequent treatment plans identify what's currently being done, what has recently been achieved, and work and services plan for the future. So subsequent treatment plans really combine the reassessment with the treatment plan. By defining goals and objectives, which can be monitored, the treatment plan becomes an instrument of accountability. So if you're going through the recipe, you know, you have steps that you check off, and there are yes or no steps. Did it or did it not get done? And it provides accountability. If you're repairing something, you know, again, you have the checklist or, you know, when you're putting together a piece of furniture, oh, my gosh, I hate putting together furniture. But you have accountability. And if you get through, if you follow all the steps, you shouldn't have pieces left over at the end. At least that's what they tell me anyhow. And identified goals and objectives and outcomes can be actively tracked by the team and modifications and treatment are made as needed. So if we see somebody getting stuck somewhere and they're just not progressing or they're not able to accomplish this one objective, then we can say, all right, what is it that this person or family needs in order to accomplish this objective? Maybe they just don't have the knowledge about, you know, what to do next. So the first part of the CASSP treatment plan is a brief description of the child. So we're going to talk about Tony here. Tony's a 13 year old Caucasian male living with his mother and four sisters in a three bedroom mobile home. Tony is currently in the seventh grade and attends special classes for reading. He's been referred to counseling on multiple occasions for behavioral issues at school, but has yet to keep an appointment. He says counseling is dumb and school is useless. So what questions come up with you in your mind? Just reading this brief description of the child. What else do you want to know? Because there was a lot more stuff I wanted to know. And if you're cheating and reading my notes over here, I'll start with those. And if there's anything else you want to know, you can add in the chat window. First thing I wanted to know, he's living with his mom, where's dad? And if Tony's having behavioral issues, you know, it could be from exposure to adverse childhood experiences and trauma. So from a trauma informed perspective, I really want to assess that. So what happened to dad? Is he not in the picture? Why is he in special classes for reading? You know, do we know? Was he just behind? So they put him in remedial classes? Has he been tested for a learning disability? What specifically are the behavioral issues? I mean, behavioral issues can be falling asleep in class, being truant, throwing chairs across the room. Very different behaviors. Why has he not kept the appointments? He's 13, he can't drive, which means for some reason he hasn't gotten there. Is it because mom is working and can't transport him? Does he live in a community where he can't get transportation? What's going on? And why does he feel that school is useless? And you know, this sounds like a youth who feels very dejected, feels like nobody really notices, feels like he's not able to succeed. So I want to empower him. That's the first thing I want to do. Now, I don't know what he wants yet, but you know, that's where my heart goes. Another couple of questions that come up from y' all are, why can't he keep the appointments? Has he had a full assessment? Is substance abuse an issue? And what are his social supports and friends like? And what are his strengths? So in this particular scenario, we're assuming he has had a full assessment. We don't know about substance abuse or the other things yet. So the next section addresses needs, concerns, and problems. So we want to identify the way the child was referred to the service and include the reasons. Intervention so like Tony is at high likelihood of failure, as evidenced by. And I love this phrase in treatment plans because. And in comprehensive integrated summaries because it really forces people to identify objective evidence. How do we know he's in jeopardy of failure? Because his grades in four out of six classes are below 60% and he's failed his last three tests or has been truant or absent 14 out of the last 35 school days. Major depression as evidenced by. So again, we want to look at what's giving us pause to think that Tony has major depression. As an aside, if you have in the integrated summary and the treatment plan that Tony has major depression, for example, okay, that better be in the assessment. We better see indication that that was identified in the assessment. If you have. If Tony's on medication. And this is another thing that I would see in assessments that just drove me bonkers. And I know I'm a little off target here, but if you have in the assessment that Tony's on antidepressants, but then don't have him diagnosed as depression, you know, that's. That's going to be a red flag there. So we want to make sure that the assessment, the integrated summary, and the treatment plan all kind of build on one another. The treatment plan incorporates the child and family's perception of the needs and concerns. So we talked about that earlier. How big of a problem do they think this is in their culture? How big of a problem is this? And who do they think is appropriate for responding to this kind of issue? Specific targets for intervention are clearly stated and prioritized. Tony will attend class, attend school 19 out of every 20 school days or something. You're going to have something that's very objective and observable. Forms the basis for the specific intervention. Problems not related to the reason for the referral are omitted. So Tony's referral was because he was in jeopardy of failure, and behavioral problems at school might he have anxiety? Yes. Might there be substance abuse in the family? Yes. But right now, in this model, we're going to focus on the reason for the referral. Some of that may come in ancillarily, if that's even a word. But we really want to focus on addressing this problem here. It's more of a brief intervention approach. So we would go on in the treatment plan for Tony. Tony was referred to treatment to help increase his chances of school success. He is frequently truant and in danger of failing. Tony's mother is also concerned that Tony doesn't come home in the evenings until after midnight, expresses no interest in school, and feels school activities aren't relevant. Okay, you know, if you've got kids, you've probably been down this road before. Where the kids are going, when am I ever going to use algebra? Or when am I ever going to use whatever the skill is? And so we want to help them figure out how it's relevant to them. So he's truant and in danger of failing. We want to look at how many days he's had absent and improve his attendance. Look at what his grades are right now. Get those up. He doesn't come home in the evenings until after midnight. So we want to try to start getting him home before midnight because that's one of the things that mom thinks is probably contributing to his problems at school and help him get invested in school. Because youth with a connection to their school and to their community, that's a preventative factor for a lot of mental health and substance abuse issues. We want to figure out these problems, these issues here. How does resolution of these relate to school success? So if he's not truant, how does that help him succeed? If he starts coming home at a reasonable hour, how does that help him be more successful? If he develops interest in school, how does that help him succeed at school? What does the school want specifically? You know, what do they want to see happen? What does the mom want to see happen? We know that she wants him to start doing better, not flunk out of school and come home in the evenings on time. And then what does Tony want? And Tony doesn't want to be in school and probably not in our office. So, okay, let's work with that in order to help him achieve that goal of getting out of school and not having to deal with us. What needs to happen, let's make a mutually agreeable goal. And yes, you're jumping ahead. I think you read ahead on the presentation. School may not be relevant Right now. So we need to figure out how to make it relevant. His areas of strength, we want to assess these. His interests, his abilities, his activities, and his capacities. So what are his. He's interested in rap music, Snoop doggy dog and motorcycles, Harleys in particular, and the concept of social injustice. Okay, cool. He relates to older adult males and participates in activities with his sisters. He writes rap lyrics, makes friends easily, both male and female, so that's a strength. And knows how to relate to the opposite gender. So he doesn't have any social anxiety going on here. Tony's family members look out for each other and defend each other in public. And his mother is interested in her children graduating from high school. So all these can be seen as strengths. These are things that we can work with. We just have to figure out how. It's kind of like when somebody opens a toolbox in front of me and I'm like, wow, that's interesting. I can do something with it. I'm just not sure what yet. So we want to look in the assessment for interests, abilities, activities and capacities. Do avoid including disguised weaknesses such as, you know, Tony performs well if highly supervised, or Tony could succeed in math if he just applied himself. No. What is a strength? A strength is something that's there. It's not conditional. So the statement of goals and objectives. A goal is a global statement that is smart, specific, measurable, achievable, related, or relevant, and time limited. It reflects a positive resolution to the identified need or the problem. So we're not eliminating truant behavior. We're improving school success. It indicates the specific area of functioning to be addressed and includes an outcome, measure, or expectation. So instead of saying tony will do better in school or Tony will be less truant, well, what does that look like? We want to say Tony will be present 19 out of 20 days in school. Tony's grades will go from an average of 65 to 72 by the end of the semester. Make it achievable. We don't want to set something. We don't want to put him up on the honor roll in the next six months because that may not happen. Make it something that is definitely achievable. It's specific, related to this outcome that we're striving for, which is school success. We don't want him to flunk out. And in Tony's mind, he doesn't want to have to deal with us, and he wants to graduate and just move on. Goals are what the person wants to achieve, stated in positive observable. Measurable and achievable terms. So, you know, this is not necessarily Tony, but let's look at some other examples. The person will be nicotine free and have identified three other strategies for dealing with stress and boredom within the, within three months. So they will be something. And what else are they going to have? Remember, behaviors serve a purpose. You know, they serve some kind of a function. It may not be the best way to achieve something, but they're serving a function. So we need to find another way to meet that need. You can't just take it away. You know, if my dog, for example, is chewing on a shoe, if I take away the shoe he was chewing for some reason, so he's probably going to go find something else to chew on, which maybe equally is inappropriate. So I need to give him something appropriate to chew on. Especially when they're puppies and they're learning. So we want to make sure that any behavior that happens, when we eliminate it, we replace it with something more productive. The person will be happier as evidenced by a rating of three or better on a five point scale of happiness at least 80% of the time within two months. Okay, so that's a lot of stuff. A three or better. That's measurable now. Yes, it's a Likert scale. The person, there's some variability. The person ranks their happiness each day or. But the same person is ranking themselves. So you should have some reliability. And it says within two months. That gives us a period of time, an actionable window. Another example is the person will be calmer and more self confident as evidenced by Getting at least 7 hours of quality sleep at least 6 nights a week. A rating of 3 or better on a 5 point scale of contentment at least 70% of the time from both the client and the significant other within a month. So sometimes if you've got somebody with anxiety, you know, you have them rate their level of anxiety or their level of contentment for that week. But sometimes significant others in the household pick up on things and so have that significant other rate where they think that person was and then compare the two numbers and if there are discrepancies, try to figure out why. Why does one person feel? And a lot of times the person with anxiety may feel that they're doing better and the significant other is like, nah, you are still pretty edgy. So that gives you something that we can talk about. What would be a goal for a client with low self esteem? And we're going to get back to Tony, but I really want to Focus on writing good goals. At this point, they're positive. They replace something a client with low self esteem. Obviously, we want them to have good self esteem, but what is that evidenced by? How do we know when somebody's self esteem is good or if a client is grieving? You know, what would a goal look like for them? We don't want to say you want to be through the grief process or we want the client to have achieved acceptance of the loss. Well, that's great, but that's also very esoteric. It's difficult to identify what does that mean? And one of the ways you can figure out what that means is by asking the client, what will life look like when you are not grieving anymore? So maybe with grief they may say, I won't be crying every, I won't cry every day over this loss. Okay, That's a step in the right direction. I will be able to remember whatever it was with fondness without getting upset. Okay? That's another relatively objective thing. So the client can start identifying the objectives. Low self esteem. We can talk about the client's perception of themselves. You know, what does good self esteem look like? And how are you going to know when you feel better about yourself? Self esteem is a tricky one, so that was kind of a trick question there. But you want to have the client identify what they're looking toward. If they want to say they feel better about themselves, how are you going to be different when you feel better about yourself? Ask the client, how will you know when your problem is resolved? And that's the goal. If the client comes in and says, doc, I'm depressed, okay, how are you going to know when you're not depressed anymore? Because depression looks different for every single client. So what are the main symptoms that are going to be gone and what's going to be there in its place? You can also ask clients to think about the areas of their life that are being impacted. So when you're not depressed anymore, which means when you're happy, and that's the positive, instead of saying you're not depressed, we're saying when you're happy or when you're recovered, what's going to be different socially? How are you going to feel different physically? Your energy levels, your ability to sleep, your pain levels, any of that at work, what's going to be different when you're happy? How do you think that'll change? And cognitively, the way you think and emotionally, the way you feel, how will that be different when you are happy or recovered or whatever? The client wants to use as their term. So we've got the goal. That's this big, broad, sweeping thing that's still measurable and achievable and related to the reason for the referral. The objectives are the short term goals. These are the things that can be accomplished in a day or a week at most. It's directly related to a specified goal, but highly specific, reflecting small attainable steps toward a goal. Like I said, first objective, in baking bread, get your ingredients together. Second objective, combine the dry ingredients, yada, yada, yada throughout. And that's the way recipes are written. Nobody has a problem writing a recipe. Why do we have a problem writing treatment plans? Critical components of goals and objectives are that both the child and family want the goal or objective to be obtained. So if one or the other doesn't have buy in, then we're going to have to do some motivational interventions. Goals and objectives must clearly relate to the needs and priorities agreed upon by the team and identified in the treatment plan. So if you have, you know, this whole thing on school success and then you have these goals and objectives about eating more healthfully and getting nine hours of sleep at night and whatever else, Tony's looking at you, scratching his head, going, what does that have to do with me failing school? You either connect it or you get rid of it. We want to make sure that there's a direct correlation so the people involved can see that investing their energy in this activity is going to help them achieve the goal objectives. Identify steps toward achieving the goals in positive, observable, measurable, achievable terms. Use only one outcome per objective. And one way I like to do this is to use Excel, you know, Microsoft Word. And you can write the objectives down and then you review them. And if you've forgotten one, you can add a, add a line and put it in there. Because I find. And if you find yourself using conjunctions like combine all the dry ingredients and then add the eggs, well, that's two objectives in one. So you need to break that down. Why? Well, number one, that means the person's going to be able to achieve two things in relatively short order. So that increases their sense of self efficacy, but it increases the likelihood that they're going to finish each objective. If they're simple, they're singular. Use the client's current strengths to help achieve their goals. So you can mind map on a whiteboard. I love my whiteboards. And I start talking with clients about what are your strengths, what do you like to do? And I'LL have reviewed their assessment and identified some of their strengths and, you know, put those up there if they're at a loss, just to get them started. But encouraging them to start putting that stuff up there, not only does it give you something to work with, but it also lets them start seeing pictorially how many strengths they actually have. Objectives, for example, for somebody who is trying to become nicotine free. One, remove nicotine products from the house. Two, identify triggers for use, and I should have put in there something like 15 triggers for use or something. Three, identify three alternative behaviors for each trigger. And four, identify two ways to deal with cravings when they happen. So those are things that you would put in there, and you want to have a number in there. Ideally, not just identify triggers for use. You want to have a number so you can say, yes, they did it or no, they didn't. Statement of goals and objectives. A goal for Tony might be the completion of seventh grade. And his objectives could include attendance in class at least 90% of the time, 95% of the time, completion of homework at least 95% of the time, appropriate classroom behavior 98% of the time, and passing tests with a c or better 90% of the time. I'm looking at his GPA right now, and I'm seeing he's really struggling. So, you know, let's again try to make these goals achievable. Otherwise it's going to feel even more disempowering to him. Measurable objectives ensure that the person has an individualized treatment plan, and it conveys to everybody on the team the same expectation and approach to the behavior being changed. So anybody, whether it's the school counselor or mom or the principal or whomever, can look at Tony's attendance and grade point average and say, yes, we're achieving it or no, we're not. Measurable objectives determine what approaches are used and their effectiveness. So if Tony's not passing his tests with a c or better, 90% of the time, we're seeing he's not able to achieve this objective. We need to look at what kind of interventions might we need to help him achieve this objective. Tutoring, for example, or something. All right. Descriptive statements of treatment for methods and interventions. We really want to be specific about who's supposed to do it, what are they supposed to do, where, when, and how often will they do it. So answer all those W and H questions. That way nobody can say, I thought you were going to do it, or I thought that was supposed to happen. Over here, the staff child and family responsibilities and activities are clearly stated and the identified strengths are used to obtain the objectives. So let's take a look at what that looks like. So if he's going to complete seventh grade, the objective is passing tests with a c or better 90% of the time. So interventions we can use to help him pass with a C or better. Tony will keep a log of his homework assignments daily beginning Monday. Tony will bring home all relevant materials for study daily beginning Monday. So we have a how often he's going to do it. Beginning when Tony will begin his homework by 6pm Daily beginning Monday. His mother will prompt him to start and encourage him to stay focused. Tony will write or find rap lyrics to help him learn his material and maybe even teach the class a song. So let me see if I can open this link real quick. There's a flocab for that. Flocabulary has a thousand videos and lessons in subject K through 12 aligned with common core standards, but they're all videos and the week in wrap, for example, so it can get people who are engaged and you know, there are other styles that are available the week in the news for somebody who prefers news sort of things. So this one is the algebra wrap and you can click on these links later. But it really helps students learn if you remember, you know, way back when I'm going to date myself now back to happy days when Patsy was trying to learn how the blood circulated and he did the song pump, pump, pump, pump, pump, pump, pump, pump, pump, pump your blood. Well, you know, that helped him learn how the blood circulated through the heart. And because he was musical, that worked for him. Tony will mark with a yellow highlighter areas in his studies that he's struggling with. Tony will meet with his teachers after school to get questions answered beginning Monday. And teachers will initial, initial next the highlighted areas when Tony has developed an understanding of the concept. And parenthetically I put in there. Tony can ride the late bus home, you know, if we need to make sure that he can get home and transportation is not an issue. So I'm going to skip over nicotine free for the sake of time to feel calmer. Have the client identify 10 sources of stress or anxiety. So June will make a list of the top 10 things that cause her anxiety by March 2nd. And June will identify what parts of each of those things she can control and which part she cannot control by March 2nd. And then I would also put in there. June will process this list with a therapist on March 2, identify six ways to deal with anxiety so to feel calmer, June will process that list with her therapist on March 2. Her therapist will help her identify unhelpful thoughts that keep her stuck using the challenging Questions worksheet. On 3, 2. You see how this is very practical. Step by step, there are dates, we know who's going to do what and exactly what's going to happen. June will create an emergency card to keep in her wallet with three coping strategies by March 2nd. Clients can do multiple things between sessions. They've got, you know, six days, so, you know, don't be afraid to give them multiple little, short things to do because it keeps them focused and it can help them feel empowered, like they're making forward progress towards achieving their goal. And a lot of times, just whether you want to call it placebo effect or relief or a sense that they're actually making progress, they will start showing marked improvements at the beginning if we can keep them involved and engaged. So treatment plans are like recipes. Goals need to be stated in positive terms. Instead of saying, you know, I'm not going to be hungry anymore, I might say, I'm going to bake a casserole or I'm going to bake bread. And goals are prioritized. You know, if I have, if I'm going to make a five course dinner, I'm going to have to prioritize what to do when, you know, the salad is going to be made last because that needs to stay cold. The marinara sauce is going to be made first because that takes two days. And I'll prioritize my goals. We do the same thing a lot of us do at Thanksgiving when we start figuring out, oh my gosh, how am I going to make everything before company gets here? Objectives are like steps in the recipe. So the goal is the recipe itself. Objectives are the steps in the recipe and identify what each step is. Interventions define who, what, when, where, why, how, and how often something is to be done. So in a recipe, it might say, you know, add all of these things together and blend on medium for one minute. So it tells you how often or how long to do something. Goals, objectives, and interventions must all be specific, observable, measurable, achievable, and time limited and clearly related to the overall goal for treatment. So we don't want to just throw in stuff because it sounds like a good intervention. We want to make sure that we're connecting the dots or that the client can connect the dots about why this is important. And culture determines our worldview and provides a general design for our living and patterns for interpreting reality that are reflected in our behavior. So what's culturally appropriate for one culture may be not in another culture and, you know, maybe in yet another culture. So we want to make sure that we are not judging or diagnosing or pathologizing something for someone who is in a different culture. That isn't a pathology. It's culturally appropriate. So we do need to be sensitive to those things. Alrighty. Are there any questions? And while I'm looking and listening for your questions, I'm just going to go over these real quick. And remember, you can watch the video replay of this on our YouTube channel. Go to allce.com YouTube made it really easy for you. And you can watch the video replay of this lesson. Usually I get it out by the end of the day today, but sometimes it's tomorrow. But then it'll be on that YouTube channel henceforth and forevermore. So while I'm thinking about these. And remove all nicotine from the house. If somebody's gonna be nicotine free, that's the objective. Then the interventions for that. To remove all nicotine from the house. Who's gonna do it and how's it gonna be done? Sally will go through the house and car and discard all nicotine products within three days. So we have a time limit and we have who's going to do it, what she's going to do. Sally will clean the car and house, cleaning everything that smells like smoke within 14 days, because that's going to be a BIG project. Identify 35 triggers for use. Now, that's a really big number. I just kind of pulled that out of the air. But if they. If the person identifies five triggers each day for seven days, that's 35. So Sally will make a list of the top five sights, sounds, smells, tastes, feelings, activities, and times that trigger her to want to use within seven days and will add to it as necessary. So I want her to consider all types of triggers that are there. And this will get her again, being more cognizant of the issue and what she's doing. It's like when you start keeping track of your. What you eat in a nutrition diary. A lot of people actually eat about 20% less calories when they're putting it into a nutrition diary because they're seeing it and they're more cognizant of what they're eating. Identify three ways of coping with each trigger for smoking. So she'll do that. Make a list. Sally will make a list of three ways of coping with each trigger within seven days. Sally will keep an emergency card in her wallet with those three strategies within seven days. So we want her to create three generalized ways of coping when she starts getting that urge to use, what can she do? And to create an emergency card. Identify three ways to deal with urges and cravings. Sally will make an appointment to get smoking cessation meds from her doctor within 14 days. Now, obviously this is if she agreed to pharmacological interventions, but the research has shown that for nicotine cessation, the medication does help a lot. So that's one thing that she may do. Sally's therapist will give her a handout on distress tolerance skills. Today. Sally will make a list of distress tolerance skills that she can use to urge sirf within 14 days. So we're writing this treatment plan. It doesn't mean that I can't send Sally home with some sort of informational handouts. If you have some that you typically use for most clients, you know at some point have them handy so you can give clients something to hold and something to work on before next session. And Sally will identify at least two vulnerabilities that make her more likely to be triggered or want to smoke. So she'll keep a mindfulness journal for 30 days noting her mood, diet, sleep, exercise, and the weather to identify things that make her more vulnerable to stress beginning today. Now, why did I identify those? And this is, I might not put it in the treatment plan, but I would talk with Sally about why are we looking at all these things? Well, a lot of times people smoke for anxiety or out of boredom. Sometimes they smoke when they're hungry, sometimes they smoke when they're tired. Sometimes when people exercise, it increases their serotonin levels and decreases the desire to smoke. And the weather can put people in a funk, which can trigger their desire to use nicotine products. So I just. These are some of those things that might be a trigger that I want her to keep an eye on. And you can do it as a checklist so she doesn't have to write out a bunch of stuff. You know, what was your mood like, what was your diet, how many hours did you sleep and was it restful? So there are a lot of yes or no questions. Unlike what we do in session, where you want open ended, you can use a lot of closed ended questions on these journals and stuff just to get people to do them. If it requires a whole lot of work on their part between sessions, they have to be really motivated to do it. So the simpler you can make it the more likely you are to get treatment compliance. So those are some other examples of how to use a goal, objectives which are steps towards the goal, and interventions which are things that you are going to do in order to achieve those objectives and ultimately the goal. Interventions and methods generally answer the question how, who, how, when, and how much. They don't answer what as much the objective says what I'm going to do, the interventions say how I'm going to do it, who's going to do it, and when it's going to be done. Okay, I am seeing no questions. So if I am right on that, then everybody have a great couple of days. On Thursday we're going to do another approach to treatment planning using something called the Addiction Severity Index to really help anchor treatment plan goals to a standardized instrument. And please remember you can download the PDF from the classroom. The recorded version should be available by, let's see, 6:00pm Eastern Standard Time. And yeah, and if you have any other questions, feel free to send me a message@supportceus.com if you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. If you want to attend and participate in our live webinars with Dr. Snipes, you can subscribe atoolbox. This episode has been brought to you in part by allce.com providing 24.7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. You can use coupon code counselortoolbox to get 20% off of your current order. 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