APS Service Planning

A Realistic Look at Substance Abuse, Mental Illness, and Financial Dependence

• 50% of the homeless are either mentally ill or substance abusers
• Lack readily-available treatment programs
• No therapy is 100% effective
• High recidivism rates
• Assistance programs have been cut back
• Conclusion:
  • Difficult and complex problems
  • Society does not have all of the answers
  • Work to minimize the risk to our victims within this context
  • Caseworkers need to be realistic

Working With the Victim When the Alleged Perpetrator Is a Substance Abuser

1. Clearly identify the problem
2. Educate elder/vulnerable adult about enabling behavior
3. Consider the “stage” when offering alternatives
4. Discourage confrontation (An “intervention” should be made only with professional staff of substance abuse treatment agency)
5. Reduce isolation
6. Remain non-judgmental. Don’t show frustration if victim doesn’t act. Tough love isn’t easy.
7. Remember, we can’t “fix” the victim. We don’t “own” the problem.
8. Work with the supervisor and a multi-disciplinary team to determine when it is time to walk away.

Service Planning

Service planning needs to meet the same criteria as goal setting in that the services we offer will be:

• time limited
• specific
• feasible
• desirable
• measurable

It is vital to recognize the importance of establishing rapport with APS clients before making the offer of services. A worker can often tell how a client will react to the offer by the client’s demeanor, and it is in the client’s best interest for the worker to schedule another home visit and postpone the offer of services until the client is more receptive.

REMEMBER: monitoring is not a service plan in and of itself. It is not justification to leave a case open when nothing productive is happening, unless other documentation supports the need to monitor.

When a specific set of services are offered to the client – and this should happen on all substantiated cases – the client’s response to the service offer on each service will also be documented in the case. Additionally, any change in the plan will be documented in the case, along with the reason for the change.

APS service cases are usually open for a short period of time: 30, 60, or 90 days. Our goal in the service planning is:

1. to assess the need for services;
2. make a service offer;
3. provide the accepted services; then,
4. ensure that the service plan is in place and stable prior to case closure.

There are cases which require long-term service provision and these are going to remain open for much longer periods of time.

Service Planning Guide

Consider all identified needs, and for each identify:

• services available in the client’s community
• services available within a reasonable distance outside the immediate community
• services which are not available but could be used if they were available

Consider the client’s resources: What services is the client likely to be able to afford? Willing to pay for?

CREATIVITY and INNOVATION are often needed.

Involve as many people as appropriate. Who is “appropriate” will vary on a case-by-case basis. Everyone involved must be given the opportunity to understand:

• service needs must be considered from the client’s perspective
• even if the client lacks the capacity to consent, no one but a legal guardian can force the client to accept services
• OKDHS can petition for an order to provide involuntary protective services for a client who lacks decision-making capacity ONLY if an EMERGENCY exists

The client retains the right to accept or refuse any service EXCEPT in an emergency when the client lacks decision-making capacity.

Keys to Working with the Self-Neglecting Client

• Establish rapport.
• View the situation as much as possible from the client’s perspective.
• ALWAYS contact collaterals to determine how credible the client’s story is.
• Don’t try to fix everything at once. Determine the client’s major needs from the client’s point of view and go from there. Small improvements that meet a need perceived by the client can encourage the client to accept more later.

Communicating with Persons with Alzheimer’s Disease

1. Be matter-of-fact; avoid ambiguity. Ask closed-ended questions.
2. Do not present unnecessary choices or decisions, but give positive direction.
3. Be concrete.
4. Speak slowly, use single words, and keep sentences simple. Keep voice low and maintain resonance with a calm, reassuring tone that projects a sense of control.
5. Eliminate competing and distracting background stimuli.
6. Identify yourself at the beginning of each interaction.
7. Look directly at the person and get his/her undivided listening attention before you speak.
8. Give the person ample time to respond. Repeat your previous verbalizations and gestures exactly if you don’t get a verbal or non-verbal response in one or two minutes.
9. Consistently use the same word for the same thing, choosing the word most familiar to the person. However, if there’s resistance to a topic (e.g., bathing), vary your introduction.
10. Provide affectionate encouragement. Use diversion and humor to overcome resistance.
11. Match – If the person is only able to produce single words, then you do the same.
12. If the person’s verbalizations don’t make sense, listen for important key words and repeat them in order to evoke a feeling of being connected with that person.
13. Break down tasks into individual steps and ask the person to do them one at a time.
14. Make sure your non-verbal signals are congruent with what you’re saying.
15. Don’t pretend to understand when you don’t. Don’t agree if you don’t understand.
16. Don’t attempt to force the person to do anything. If he/she is not cooperative, leave and come back when he/she is more approachable.
17. Don’t assume that one set of behaviors (positive or negative) will continue unchanged.
18. Elicit listening behavior and maintain by touching.

Interventions in Self-Neglect Cases

Wendy Lustbader

What do people resist giving up?

• Control
• Anything on which their self-esteem rests
• Martyrdom
• Destructive behaviors such as substance abuse
• Denial
• Anger/rage

Self-neglect issues which must be resolved:

• How strenuously should we insist?
• Should we attempt to enforce our standards of health and safety by threatening to withdraw needed services?
• Should we bribe clients to accept services?
• What IS safety/cleanliness?
• What IS eccentricity?

Kinds of self-neglect:

• Caring for pets instead of self
• Protecting grandchildren and neglecting oneself
• “Characters”
• Untreated CMI
• Pack rats
• Resisting medical advice
• Depression
• Parents at the mercy of abusive children

Getting in the door when you’re not wanted

• Good opening line – “I like to keep people out of the nursing home.”

The interview

• Remember that you’re being interviewed, too
• Speak to the unspoken word
• Have respect for the person’s shame
• Let people speak between the lines
• Watch your body language
• Be aware you may be overheard

SELF-NEGLECT BECAUSE OF PETS

• Touch deprivation
• Filling in the empty spaces in their lives
• SN is often caused by untreated clinical depression
• Argue for the welfare of the animals
• A lot of people will go to the hospital if they have someone to care for the pets

PACK RATS

• Control is one piece. Never try to take control away.
• Obsessive/Compulsive Disorder – this is BIOLOGICAL – treatable by a new drug, Anaphronil. The incidence of OCD in pack rats is very high. Prozac is also a drug used successfully with this disorder. Client may suffer a complete absence of human contact, so they fill the absence up with things.
• Look for basic needs and offer what we can do to keep them safe.
• We need to adjust our goals to what is realistic – we have to protect ourselves. Your kindness is never wasted… listening is much better than nothing.

PARENTS AT THE MERCY OF substance-abusing children so they can care for grandchildren/Parents at the mercy of substance-abusing children:

• Children dependent upon them for food, clothing, shelter
• What do children/adults feel when they are being abused?
• There’s nowhere else to go
• Fear of retaliation
• Need to protect the abuser
• Denial/hope
• Self-blame – “If I was good, if taking care of me was easier, nothing I do makes any difference…”
• Not perceiving that the treatment is in fact abuse
• HOOKS to get parent involved in changing his/her response to the abuser:
  • “You’re not immortal.”
  • “Have you thought about what he/she is going to do when you’re gone?”
  • “Legacy of hatred.”
  • “Isn’t it time we helped Johnnie grow up?”

UNTREATED CMI

• CLINICALLY PARANOID people are the loneliest people on earth. Very rarely successful interventions. With the true paranoid, you have to hang around long enough for the person to trust you enough to accept services.
• PARAPHRENIA – Not in the DSM3, it’s different from paranoia. It is a delusion of someone coming in, someone “out to get them”. It is very narrow in scope, not like a life-impairing paranoia. Just a facet of life is affected. Explains loss of memory in a way that doesn’t hurt the client’s pride. TREATABLE with a sub-clinical dose of Haldol. HALDOL use with the elderly can be tricky if the dose is too large. The manual will NOT give the correct dosages, it will be too much.
• ECCENTRIC PEOPLE – Differ from the CMI in that the choice to be different IS a choice rather than a function of mental illness. They are unwilling rather than unable to live a normal life. We HAVE to inform them of the consequences of remaining in that environment.
• PICK’S DISEASE – Like Alzheimer’s Disease, except that it affects the frontal lobes which impairs judgment.
• MULTI-INFARCT DIMENTIA – small strokes like Alzheimer’s, except the progression is a stair step progression rather than a gradual progressive decline.

TREATABLE CAUSES OF DIMENTIA

• DEPRESSION – pseudo-dimentia from depression
• DIABETES
• MALNUTRITION
• BODY CHEMISTRY IMBALANCE – Potassium is depleted by heart medications
• MIXED MEDICATIONS – Mixing old medications with new ones, chemical reactions
• DIGOXIN TOXICITY – supposed to be measured regularly, and can be deadly (commonly called Lanoxin)
• THYROID DEFICIENCY – will cause irreversible dementia if not treated
• TOXIC HOUSE – carbon monoxide poisoning cause dementia and it is produced by an old furnace. The housing inspector can be called to do a measure. If a person clears up after two or three days of leaving the house and all other factors are the same, this could be an indicator of a toxic house.

Self-Neglect: A Practitioner’s Perspective

Paula Mixson

Reasons for self-neglect to occur:

• Mental impairment
• Interpersonal conditions
• Environmental conditions

Capacity to consent

• express understanding of his/her situation options
• consequences
• Do they have a choice?
• Is it rational?
• Do they have the ability to understand what we’re saying to them?
• restate issues a different way – Do they respond consistently?

Hogg Study

• dying elders
• despairing elders
  • slow suicide
  • little worked
• wrongly despairing
  • too depressed; can successfully intervene
  • too angry
• denying elders
  • vision/hearing/acknowledging the loss of ability
  • CMI – success was based on gradual acceptance of worker
  • Mistrusting/independent elders – resisted control from outsiders
  • Prideful elders – status in the community, didn’t want loss of status – success was based on worker’s ability to build trust
  • Switching the “helping role”

Successful interventions based on the worker’s ability to build trust: work on rapport, not problem

• Adjust to losses – major factors:
  • Self-esteem – casework needs to foster this
  • Sense of will
  • Awareness of potential – can they adapt
  • Options in the environment
    • Formal
    • Informal
  • Acceptance
• Motivation = Clear** Positive** Consistent Wants** Beliefs** Rewards

_____________________________________________

Costs

If the costs are larger, the motivation to change won’t occur.

If the client is not motivated, check the formula and see which piece is out of balance.

To improve motivation:

• Reduce the perceived costs
• Clarify wants
• Correct beliefs if they’re unrealistic
• Provide sufficient rewards to support the desired behavior

Motivators:

1. Match/mismatch
2. How many times do they have to hear it for it to be true?
3. Possibility/necessity
4. Expert… build rapport by acknowledging his/her expertise
5. Novice… you can play the expert here, but it works best if you empower the client
6. Sort by self/others

Social work study:

We trust people who

• Go slow
• Explain simply
• Don’t surprise us
• Trust US
• Care about what WE care about
• We know
• Have flaws, and tolerate them in others
• Like themselves
• Do what they don’t HAVE to do

These techniques help build rapport:

• Matching – patterns of perception – what people gain from what you say is broken down as follows:
  • 55% body language
  • 33% tone of voice
  • 7% words
• Pacing – uses matching to control interview; matching with
• Verbalizations from representational systems
  • Visual
  • Auditory
  • Kinesthetic
• Exchange strategy – what we do when persuasion doesn’t work is use logical persuasion, which seldom works, just causes the other party to become entrenched.
• Concept – the idea that does not have to be defended is more easily exchanged **don’t push if you know he/she isn’t going to agree **ask him/her for the reasons, then ACCEPT the reasons as important to the client **see what you can offer to get what you want Special communication techniques for special clients: Validation therapy Validation Training Developed by Naomi Files Resolution Stage: 75-100 years of age
  • No major problems in lives
  • Impairments in various areas
  • Retreating from reality
    • Escaping the painful present
    • Resolving past conflict
    • Reestablishing identity
    • Coping
    • Counter to depressionUsing validation training you cannot restore cognitive function, but you can slow the deterioration Stage 1: Mal-orientation Can result in
  • Sexual fixation
  • Spraying house with poisonPresents as:
  • Ambulatory
  • Very tense
  • Eyes clear, focused, and direct
  • Denies memory loss
  • Blames others
  • Wants to be understood
  • Wants to control personal belongings
  • Holds on to rulesStrategies for communication
  • Do not touch or try to establish intimacy
  • Do not argue facts, explore them (who, what, why, when, where)
  • Use polarity (when is it bad, when is it better)
  • Lead into life review – The more easily the client slips into the life review, the better the client is functioning. Positive feedback is important. The goal is to keep the client talking to prevent the client from slipping into the next stage.Stage 2: Time confused Present reality is too unpleasant Presents as:
  • Other confused: thinks you’re their mother, son, daughter
  • Needs help with dressing
  • Can toilet self
  • Can feed self
  • Doesn’t use clock time
  • Cannot respond logically
  • Limited present memory, good past memory
  • Creates unique language
  • Responds emotionallyStrategies for communication
  • Likes to be touched
  • Reflect back to them their gut emotions
  • Keep eyes at level with theirs
  • Approach from the front
  • Verbalize what you observe
  • Offer reassurance
  • Use mirroring and matchingStage 3: Repetitive sounds and motion Presents as:
  • Needing help in all ADLs
  • Can’t conform to social rules
  • Responding to motionStrategies for communication
  • Use song, dance, pacing, mirroring, touch movementStage 4: Vegetation Presents as:
  • Completely withdrawn