Developing Effective Intervention Plans

1. Developing Effective Intervention Plans Developed by DATA of Rhode Island Through a special grant from the Rhode Island Department of Human Services September 2006

2. Training Overview • This course focuses on trainees developing skills to select reasonable goals, negotiating contracts, and develop intervention/action plans. • These activities are presented as they may apply to both voluntary and involuntary clients. • The rationale for goals and guidelines for selecting, defining, and negotiating goals is delineated in the first part of the training. • The final portion of the training is devoted to the elements and skills involved in formulating an intervention plan. • The intervention plan is illustrated with the use of case examples.

3. Purpose • The purpose of this training is to provide participants with the opportunity to acquire the beginning knowledge and skills to design and implement -- as partners with clients -- individualized intervention plans which address the needs of individuals experiencing a variety of problems.

4. Importance of Intervention Planning • 3 Components of Intervention Planning • Multi-dimensional Assessment • Developing a Problem List • Assessing Interpersonal & Environmental System Factors • Negotiating Goals & Formulating Intervention Plan

5. Multi-dimensional Assessment: Knowledge & Skills of Assessment

6. Multidimensionality of Assessment • Reciprocal interaction between person and external world • Humans are social creatures • An understanding of interactions between numerous systems • Biophysical • Cognitive • Emotional • Cultural • Behavioral • Motivational • Priorities based on: • Client’s needs • Agency’s purpose and resources

7. Assessment • Both a product and a process • Can be based on legal/programmatic mandates as well as the needs of the immediate situation • Seeks to understand problems and needs • Not deficits based • Strengths based

8. Defining Assessment: Process and Product • What does the client see as his or her primary problems or concerns? • What (if any) current or impending mandates the client and helper must consider? • What (if any) potentially serious health or safety concerns might require the helper worker’s and client’s immediate attention?

9. Overview: Areas for Attention in Assessing Strengths and Problems • Problems as seen by potential clients • Health and safety concerns • Legal or program mandates • Culture, race, gender, sexual orientation and other areas of difference • Strengths and resources • Personal and family coping capacities • Skills • Values • Motivations • Community resources and support networks including cultural supports • Problems and challenges • Severity • Sites of problem • Duration • Frequency • Emotional reaction • Consequences • Resource deficits Developmental needs and life transitions

10. Culturally Competent Assessment • Possibilities for distinguishing individual members of an ethnic minority • Degree of commonality between the two cultures (norms, values, beliefs, and perceptions) • Availability of cultural translators, mediators, and models • Amount and type of feedback provided by each culture regarding attempts to produce normative behaviors • Conceptual style and problem-solving approach of the individual and the mesh with the prevalent or valued styles of the majority culture • Individual’s degree of bilingualism • Degree of dissimilarity in physical appearance from the majority culture

11. Emphasizing Strengths in Assessments • To emphasize strengths and client empowerment • Give preeminence to client’s understanding of the facts • Discover the client’s wants • Assess personal and environmental strengths on multiple levels • Commonly overlooked strengths • Facing problems and seeking help • Risking by sharing problems • Persevering under difficult circumstances • Being resourceful and creative • Seeking to further knowledge, education, and skills • Expressing caring feelings to family and friends

12. Emphasizing Strengths (continued) • Commonly overlooked strengths (continued) • Asserting one’s rights rather than submitting to injustice • Being responsible in work or financial obligations • Seeking to understand the needs and feelings of others • Having the capacity for introspection • Demonstrating the capacity for self-control • Being able to function effectively in stressful situations • Demonstrating the ability to consider alternative courses of action and the needs of others when solving problems

13. Strengths Perspective • gives preeminence to client understanding of the facts • discovers what the client wants • assesses personal and environmental strengths on multiple levels

14. Principles of the Strengths Perspective • Every individual, family, group and community has strengths • Trauma, illness, abuse and struggle may be injurious but may be sources of challenge and opportunity • We do not know the upper limits of the capacity to grow and change, take aspirations seriously • Best serve clients by collaboration • Every environment is full of resources

15. Strengths Perspective • Quadrant 1 Environmental strengths • Quadrant II Client’s personal strengths • Cognition • Emotion • Motivation • Coping • Quadrant III Environmental challenges • Quadrant IV Personal challenges

16. Framework for Strengths Assessment Strength or Resource 1 2 Environmental Factors (family, community) Individual or Personal Factors 3 4 Deficit, Obstacle, or Challenge

17. Strengths / Assets You’ve identified Strengths / Assets Identified by Others Needs / Vulnerabilities You’ve Identified Needs / Vulnerabilities Identified by Others Strengths Assessment

18. Sources of Information • Background sheets or other forms that clients complete • Interview with clients • Direct observation of nonverbal behavior • Direct observation of interaction between marital partners, family members, and other persons • Collateral information from relatives, friends, physicians, teachers, employers, neighbors and other professionals • Personal experiences of the worker based on direct interactions with clients • Client self-monitoring and self report

19. Questions to Answer in Problem Assessment • Example list of general questions as a checklist • Identifying the problem, its expressions, and other critical concerns • The interaction of other people or systems • Assessing developmental needs and wants • Typical wants involved in presenting problems • Stresses associated with life transitions • Severity of the problem

20. Questions to Answer (continued) • Frequency of problematic behaviors • Duration of the problem • Other issues affecting client functioning • Physical health • Mental health • Substance abuse • Life cycle stage (young adult versus older adult) • Clients’ emotional reactions to problems • Coping efforts and needed skills • Cultural, societal, and social class factors • External resources needed

21. Solution-Focused Assessment Questions • Seeking exceptions • when is the problem not a problem • Scaling the problem • On a scale of 1 to 10 how severe is the problem today? • On a scale of 1 to 10 how severe is the problem today compared to a month ago • Scaling motivation • On a scale of 1 to 10 how motivated are you to deal with the problem today? • On a scale of 1 to 10 how motivated are you to deal with the problem today compared to a month ago? • The miracle question • Suppose you go to bed tonight and discover tomorrow the problem that brought you here is resolved. What would be different? Who would be the 1st person to notice the change?

22. Assessment:Exploration of the problem, concern, needCommon sources of information • Give examples of the problem • verbal report client and others • direct observation of nonverbal behavior • observation of interaction – naturalistic assessment • client self-monitoring • collateral sources of information • personal experience based on direct interaction

23. Multidimensionality of assessment • The person – the whole person • The meaning the person derives from the problem or need • The person in time • Developmental aspects • The problem duration, onset, future • The person in social context • The relationship of the problem or need in relation to family, friends, neighbors, social supports • The person in environment • Resources, opportunities • The physical environment

24. Manifestations of the problem Strengths & obstacles Ecological perspectives Developmental & unmet needs/wants Severity of the problem Meanings ascribed to the problem Sites of problematic behavior Time Frequency Duration Antecedent events Acute and chronic problems Reasons for help-seeking Reason for programmatic actions Relationships of substance use Client’s emotional reactions Coping efforts and needed skills Cultural, societal and ethnic factors External resources needed Comprehensive Assessment Factors

25. Identifying the Problem • Involve the client in uncovering the problem • Why is the client seeking help? • A deficiency, a need, an excess? • Why now? • Importance • Relation to motivation • Voluntary • Involuntary

26. An Ecological Perspective • Who are involved? • Family • Social network • Social institutions • Organizations • In what way? • Interaction • Benefits and challenges • Does the problem have meaning and history in relationship to these networks?

27. Developmental Needs and Wants • Needs • essential elements of human well-being that must at least be partially met • Physical needs • Positive self-concept • Emotional / relational/ belonging • Personal fulfillment

28. WANTS • Wants: • strong desires that motivate behavior and when satisfied, enhance satisfaction and well-being • translate complaints and problems into wants and needs

29. Developmental Aspects of Needs and Wants • Consider developmental period • infants • early childhood • childhood • adolescence • young adulthood • adulthood • older adulthood

30. Assessing Interpersonal & Environmental System Factors

31. Overview: Areas for Attention in Assessing Intrapersonal Function Biophysical Functioning Physical characteristics and presentation Physical health Assessing Emotional Functioning Emotional control Range of emotions Appropriateness of affect Assessing affective disorders Bipolar disorder Major depressive disorder Suicidal risk Depression and suicidal risk Assessing Use and Abuse of Medications, Alcohol and Drugs Alcohol use and abuse Use and abuse of other substances Dual diagnosis: co-morbid addictive and mental disorders Assessing Behavioral Functioning Assessing Motivation Assessing Environmental Systems Physical environment Social support systems Spirituality and affiliation with a faith community Assessing Cognitive/Perceptual Functioning Intellectual functioning Judgment Reality testing Coherence Cognitive flexibility Values Misconceptions Self-concept Assessing thought disorders

32. Biophysical Functioning • Physical characteristics and presentation • Physical health

33. Assessing Use and Abuse of Medications, Alcohol, and Drugs • Alcohol use and abuse • Use and abuse of other drugs • Prescribed medication • Other the Counter drugs • Dual diagnosis: Addictive and mental disorders

34. Interviewing for Potential Substance Abuse • Do you, or did you ever, smoke cigarettes? For how long? How many per day? • Do you drink? • What do you drink? (beer, wine, liquor?) • Do you take any prescription medications regularly? How do they make you feel? • Do you use any over-the-counter medications regularly? How do they make you feel? • Have you ever used any illegal drug? • When was the last time you had a drink/used? • How much did you drink/use? • When was the last time before that? • How much did you have? • Do you always drink/use approximately the same amount? If not, is the amount increasing or decreasing? • (If it is increasing) Does that concern you? • Do most of your friends drink/use? • Do (or did) your parents drink/use?

35. Interviewing for Potential Substance Abuse (continued) • Have you ever been concerned that you might have a drinking/drug problem? • Has anyone else ever suggested to you that you have (or had) a drinking/drug problem? • How does drinking/using help you? • Do other people report that you become more careless, or angry, or out of control when you have been drinking/using? • Do you drink/use to “get away from your troubles?” • What troubles are you trying to get away from? • Are you aware of any way in which drinking/using is interfering with your work? • Are you having difficulties or conflict with your spouse or partner because of drinking/using? • Are you having financial difficulties? Are they related in any way to your drinking/using? • Have you ever tried to stop drinking/using? How?

36. Assessing Cognitive/Perceptual Functioning • Intellectual functioning e.g.. Memory, concentration, attention, problem solving • Judgment • Reality testing • Coherence • Values • Self-concept • Cognitive Disturbance or thought disorders

37. Mental Status Exam • Appearance • How does the client look and act? • Stated age, dress and clothing • Psychomotor movements, tics, facial expressions • Reality testing • Judgment • Dangerous, impulsive behaviors • Insight • Speech • Volume • Rate of speech

38. Mental Status Exam (continued) • Emotions • Mood: How the client feels most of the time • Affect: How the client appears to be feeling at this time, variability, and intensity • Thought • Content: What the client thinks about • Delusions: Unreal belief, distortion • Other thought issues: Obsessions, compulsions, phobias, thought broadcasting, ideas of reference • Homicidal ideation • Suicidal ideation • Process: How the client thinks

39. Mental Status Exam (continued) • Sensory Perceptions • Illusions • Hallucinations • Mental Capacities • Orientation: Time, person, place, situation • General intellect • Memory • Concentration • Attitude toward interviewer

40. Assessing Emotional Functioning • Emotional control • Range of emotions • Appropriateness of affect • Affective disorders • Bipolar disorder • Major depressive disorder • Suicidal risk • Depression and suicidal risk

41. More Areas of Assessment • Assessing behavioral functioning • Assessing motivation

42. Behavioral Patterns Dimensions of Dysfunctional Functional Behavior Patterns Patterns (Strengths) Power/control Autocratic, overbearing, aggressive, ruthless, Democratic, cooperative, assertive, demanding, domineering, controlling, passive, includes others in decision making, submissive; excludes others from decision making. stands up for own rights. Nurturance/support Self-centered, critical, rejecting, withholding, Caring, approving, giving, empathic, demeaning, distant, punitive, fault-finding, encouraging, patient, generous, self-serving; insensitive or unconcerned altruistic, warm, accepting, supportive; about others. interested in others. Responsibility Undependable, erratic; avoids responsibility, Dependable, steady, consistent, reliable; places pleasure before responsibility, externalizes follows through, accepts responsibility, responsibility for problems, neglects maintenance owns part in problems, maintains of personal property. personal property.

43. Behavioral Patterns (continued) Dimensions of Dysfunctional Functional Behavior Patterns Patterns (Strengths) Social skills Abrasive, caustic, irritable, insensitive, aloof , Outgoing, poised, personable, verbally reclusive, sarcastic, querulous, withdrawn, fluent, sociable, witty, courteous, engaging, self-conscious, ingratiating; lacks social delicacy. cooperative, assertive, spontaneous, respectful of others, sensitive to feelings of others; has sense of propriety. Coping patterns Rigid, impulsive, rebellious; avoids facing problems, Flexible; faces problems, considers and weighs uses alcohol or drugs when under stress, becomes alternatives, anticipates consequences, maintains panicky, lashes out at others, sulks. equilibrium, , seeks growth, consults others for suggestions, negotiates and compromises. Personal habits Disorganized, dilatory, devious, dishonest, compulsive, Planner, organized, flexible, clean, efficient, and traits overly fastidious, impulsive; manifests poor personal patient, self-disciplined, well-groomed, hygiene, has irritating honest, open, sincere, temperate, considerate, mannerisms. even-disposition, punctual.

44. Behavioral Patterns (continued) Dimensions of Dysfunctional Functional Behavior Patterns Patterns (Strengths) Communication Mumbles, complains excessively, nags, talks Listens attentively, speaks fluently, expresses excessively, interrupts others, tunes others out, views, shares feelings, uses feedback, expresses stammers, yells when angry, withholds views, self spontaneously, considers others’ defensive, monotonic, argumentative, taciturn, viewpoints, speaks audibly and within verbally abusive. tolerable limits. Accomplishment/ Unmotivated, aimless, nonproductive, easily Ambitious, industrious, self-starting, independence discouraged, easily distracted, underachieving; independent, resourceful, persevering, lacks initiative, seldom completes endeavors, successful in endeavors, seeks to advance workaholic, slave to work. or to improve situations. Affectionate/sexual Unaffectionate, reserved, distant, sexually Warm, loving, affectionate, demonstrative, inhibited, promiscuous, lacking sexual desire, sexually responsive (appropriately). engages in deviant sexual behavior.

45. Assessing Environmental Systems • Basic needs • Physical environment • Social support systems • Spirituality and affiliation with a faith community

46. Diagram of Ecological and Social Systems Schools Governmental organizations Recreational programs Work associates Child welfare Friends Family physician Nurses, health care providers Members of church Rehabilitation programs Economic (income maintenance) Parents Landlord Barber or hairdresser Clan members Siblings Employment systems Bartender Aunts and uncles Mate Individual Children Social club members Grandparents Neighbors Correctional systems Other close relatives Student associates Judicial system Stepsiblings Pastor, priest, rabbi, bishop Intimate friends Family mechanic Parents in-law Cousins Social worker or counselor Other organizations Cultural reference group Distant relatives Family dentist Political party Municipal services Action groups Law enforcement

47. What’s an Intervention Plan? • This is usually written document that lists and describes the problems or needs, the anticipated goals and all the services a client will receive to achieve these goals. • Intervention plans are based on information about a client’s strengths, problems, history, and needs. • The intervention plan also includes information on aftercare or continued care, which are services or supports are recommended for the continued maintenance of a client.

48. Goals • Factors influencing goal development • The purpose of goals • Program objectives and goals • Types of goals • Guidelines for selecting and defining goals • The process of negotiating goals

49. Purpose of Goals • Ensure that helpers and clients are in agreement, where possible, about objectives to be achieved. • Provide direction and continuity to the helping process and prevent needless wandering. • Facilitate the development and selection of appropriate strategies and interventions. • Assist helpers and clients in monitoring their progress. • Serve as outcome criteria in evaluating the effectiveness of specific interventions and of the helping process.

50. Linkage Between Target Concern & Goals Assessment Summary Target Concern Goals Maintain maximal safe independence. Explore assisted living. Margaret, age 87, feels unable to remain in her home because of concerns for her safety. She has expressed an interest in moving into an assisted living apartment complex and she wants to maintain her independence. Margaret is concerned about safety in her home.