Rambling through Treatment

Rambling through – Interventions – Treatment – Enabling – Case Management

Don’t expect any profound treatment miracles to expose themselves as I move through this ditty.  I was preparing a 5 Step marketing piece and began to reflect on things that negatively affect behavioral healthcare treatment.  The following things came to mind; but, I was unable to create a smoothly flowing framework.  So bear with me.

In an ideal world, all our treatment chores would be completed in a timely and effortless manner.  Unfortunately, this is a pipe dream or a conclusion that one would reach after using the wrong kind of drugs.  The gist of today’s message is – “we should minimize the obstacles that prevent “ideal” treatment circumstances”.

Communications, administrative stuff, rules and regulations, emergencies, fatigue, eating, sleep and more – all interfere with flawless goings on.  The 5 Step program design is intended to reduce the impact of these nuisances and provide our Team members with some efficient solutions.

This author believes most individuals want to end each day feeling good about what they accomplished.  They do their best in completing tasks that were presented.  The issues addressed in this article are not intended to be criticisms.  The points made, herein, reflect real world happenings that can affect what we are trying to accomplish.

The other issue that came to mind is: administrative tasks can be a pain in the ass.

Don’t Worry!  I got this under Control!!

For example, I have just completed a fruitful session with an individual and it is important that I document the elements of the session so that my other team members know how we are doing.  I judiciously began my administrative task and an emergency pops out of the woodwork.  Then, ongoing daily tasks prevent me from getting back to my unfinished administrative duties.  These are real world issues and result in less than optimum treatment conditions.  Case management data entries are often done – when possible.  If group activities or external partners are included as treatment elements, getting these case entries into the system may also take some time.

Also, when administrative time is available, the first thing that needs to be completed is the paperwork – to get paid.  Government and Organization processes have been most creative.  They have provided thousands of new code options to make our lives easier and more efficient.

As I compare the data entry tasks for behavioral treatment clients, with regular medical care, I find that the behavioral efforts are more complex and time consuming.  My last two visits with my cardiology team have been 5-10 minutes of silent computer review by the professional and then approximately 5 minutes of a one sided discussion and then a closing silent computer spectacle – that results in a visit summary.

Automating verbal and text input data, using efficient forms, shifting priorities to our clients or patients and simplifying electronic data transfer and integration processes is a start.

Experience with Treatment Processes – (Sensitivity – Empathy)     

Our experience with treatment endeavors has lead us to a bias for AA/NA 12 Step programs.  The principal reason for this focus is that these organizations’ team members believe in individual responsibility and accountability.  Enabling continuing destructive behaviors is not part of their program objectives.

Our experience with counselors and other professional clinicians provides a different set of insights.  To continuously work with a client a degree of sensitivity must be established to provide meaningful dialogue.  Based on human nature, degrees of empathy may also occur.  These relationships will, obviously, be different as we move from clinician to clinician and from client to client.  Perspectives and skills are needed to insure that a tough love atmosphere is part of all treatment programs.

Interventions – Treatment – Enabling

 Helping – can be – Hurtful   

38 years of association with treatment efforts that are related to legal/illegal drug use and dependency have resulted in a few conclusions:

  1. Ignoring that drug dependency is a disease and runs in families’ = kills’ people.
  2. Enabling destructive behaviors is common with family members = kills’ people.
  3. The K.I.S.S. principal needs to be adhered to – or – results will deteriorate.
  4. Keeping it simple means – staying unaffected by alcohol and drugs.
Trauma – DSM-5

Treatment for DSM-5 “trauma – disorders” would be classified as a supplement to the iMResponsible.com programs.  A principal focus of our programs is an effort to stay focused on daily behaviors that need to be changed.  Treatment for trauma disorders is important; however, it is our position that “trauma” treatment results are improved when an individual is sober, stable and working a solid program.

The DSM-5 has defines these trauma disorders as Stressor-Related Disorders :  Anxiety Disorder, Trauma- and Stressor-Related Disorders Acute Stress Disorder, Adjustment Disorder, Posttraumatic Stress Disorder, Reactive Attachment Disorder and Dissociative Identity Disorder.  Physical or medical issues – such as brain trauma, etc., must also be considered.


TEAM Interventions conducted to develop righteous and doable treatment plans provide the client with a feeling of group support.  The Intervention also provides the TEAM with an indication that definitive objectives have been established.  “Enabling” behaviors by friends and family are minimized as TEAM objectives are definitive and have been agreed to by all participants.

As an aside, all 5 Step clients do not win.  It has been proven, however, that a TEAM Intervention will assist those who fail to meet treatment contract conditions.  This assistance takes place when the next crisis occurs.  Personal denial is reduced or eliminated and the next try at wellness is enhanced.  20 years of Interventions in Idaho schools has statistically proven that the percent of student violations has reduced since these Intervention practices were initiated.


Enabling ones’ destructive behaviors to continue from Intervention – through Treatment is normally a family issue.

 John Southworth has been an Interventionist for several decades and was one of the developers of the 5 Step Intense monitoring solutions.  Last week we met, went to an AA meeting and then had lunch.  John showed me a “no name” copy of a letter he had just received – thanking him for his efforts – with the senders – father.  The letter advised John that the father had died and was found by the family as they visited their vacation home.  John explained that the “father” was participating in an intense treatment and monitoring program that John had recommended.  All was going well.  The client and his wife convinced treatment management that all was going well and they could manage their behaviors in a less intense program.  This new program did not work. The patient died.  John indicated that family enabling is the most consistent anti wellness effort he runs into.

During our discussion, John also indicated that finding treatment facilities that had a treatment priority, higher than the bottom line priority, was becoming more difficult. It seems that business tasks, administrative requirements, regulations, HR matters and finances share time and resources with treatment.


Gotcha’s keep coming up – Even in a well designed Program!


The combination of administrative, strategic and relationship conditions associated with each client and clinician affect the results of treatment.  Based on the subjective nature of counseling, it is also difficult to determine when clinical actions are resulting in degrees of dependency or independence.

In our view, anything that interferes with the clients’ acceptance of personal responsibility for treatment tasks is suspect.  The 5 Step program has been designed to emphasis “objective” analysis of treatment elements.  Clients’ become more responsible at case communications and data entry.  TEAM members are provided with forms that enable efficient and effective submission of case information.  Communications via mobile devices are automatically entered into iMR case files.

 Monitoring processes provide quantifiable evidence of how an individuals’ program is working.  These processes also provide an accurate treatment effectiveness score.  This beats the heck out of emergency phone calls just before the reports are due.

One Step at a time!  One Day at a time!  One Life at a time!

I am Responsible!

Team Enabling Tough Love

Client Role – Treatment



30 years of experience with Behavioral Healthcare Treatment has resulted in a collection of perspectives that, I believe, are sound.  As I try to intellectually integrate these insights with the mountain of professional treatment programs being offered to client’s throughout the country, it can get a little confusing.

What is consistent, and not too confusing, is that the primary focus of treatment is satisfying organizational or entity objectives – not user treatment objectives.  Entity needs are revenues, costs, regulations, internal human relations, administrative processes, legal, etc..  Client treatment and case management processes are a lower priority and are standardized to fit organizational needs.

A review of State statistics will show that the majority of historical behavioral treatment referrals are from the Department of Corrections and Justice.  The following exhibits provide samples of objectives and processes that are used by these agencies.

Exhibit A – Corrections/Judicial Objectives

Exhibit B – Sample of Probation Order

The conditions shown are the same for all individuals; regardless of the individual’s abilities to complete the required tasks.  These examples conflict with Federal Treatment Guidelines (SAMHSA) that recommends “Individually based” treatment plans and tasks.

This wasn’t covered in our Study Guide!


An objective of Departments of Corrections is that the public must be protected from harm that could occur from certain individuals’ actions.  Control is the tool used to accomplish this objective.  It is unclear if diagnosis techniques used can determine what specific risks are present for each individual, what controls are necessary and how treatment plans can be structured.  Since blanket treatment directives are provided to most clients’, it could be assumed that treatment based on improving individual human behaviors could be at cross purposes with current agency objectives.  It might also be true that the “criminal” behavioral profile used by some provides a basis for justifying programs that have not been effective.  Another provocative question is:  – “Is it in the State Agencies internal best interest to reduce inmate populations and existing supporting staffs” – if programs begin to work?

The treatment centers and clinicians handling these referrals are indirect subjects of these agencies policies and requirements.  The treatment entities have their own priorities which are designed to insure they stay in business.  They can only provide treatment services if they have the revenues needed to pay rent, wages, taxes, insurance, legal, overhead, etc.   After these factors are considered, the treatment needs of the individual clients are then covered.

Historical federal statistics validate that these practices have been ineffective.  Correction statistics show that approximately 50% of all released individuals are confined again within three years.  No statistics are available for behavioral treatment efforts that are handled directly with individuals and their professionals.

New ACA/CMS/HIPAA guidelines are resulting in additional referrals from the medical community.  These policies and program solutions are being developed as these services are initiated.  Traditional behavioral and mental health treatment has been handled by individual clinicians, clinics and private and public agencies. Each of these entities has specific policies and practices that insure they can stay in business – to provide needed services.


 Although the current emphasis on Oxycodone and other pain relievers is receiving a great deal of media attention, alcohol and other prescription drug use must be considered as behavioral treatment plans are developed.   Behavioral Treatment Plans should be based on accurate diagnosis of real symptoms.  This would seem to indicate that alcohol and drug use should be considered during a diagnosis.  If clients’ are not abstinent from alcohol or drugs, any diagnosis should be flagged as being questionable.   Side effects for all drugs are extensive.


This author and this site are fans of 12 step programs that focus on improving destructive behaviors.  These programs include no “entity” needs. They are a result of people – who have been there – who care – who are helping others – who need to get there.  Unless you have participated in these sessions, you may have no concept of the personal empathy and skills displayed by the participants.  I have been to thousands of meetings; and, never to a bad one.  I carried away a positive message from each one of them.  The Steps and Traditions are unique and profound as are the results of meeting attendance and participation.


In order to look at objectives and solutions for “human needs” focused treatment, let’s look at what one noted psychologist wrote about the individual life areas that need to be dealt with.  (i.e. Abraham Maslow – humanistic psychologist – “self-actualization”)

He emphasized belongingness, love, affection, respect for others and building self-respect.   These are “outside” the money economy and available to all families and individuals.

 THE BEST MANAGERS increase the health of the clients whom they manage, via gratifying both basic needs and meta-needs.

NEEDS IN THE HIERARCHY INCLUDE:  (iMR focused on “highlighted needs”)

  • Physiological: food, water, air, sleep, sex. (Sobriety | Drug Free = iMR)
  • Safety: Security, stability, protection, order, freedom from fear and anxiety. For healthy persons, safety needs are not overwhelming or compulsive. If a person does not feel safe, growth becomes a secondary factory as safety needs dominate.
  • Belongingness and love needs: Intimate, caring relationships; affiliation with a group.
  • Esteem needs: Esteem from others – precedes self-esteem. It’s hard to think well of ourselves unless we believe that others think well of us.
  • Need for self-actualization: The Army slogan “Be all you can be” borrowed from Maslow’s view. The full use of all our qualities and capacities, the full development of our abilities.
  • Needs to know and understand.

ESTEEM AND SELF-ESTEEM NEEDS ARE UNIVERSAL. Everyone prefers to feel important, needed, useful, successful, proud, respected, rather than unimportant, interchangeable, autonomous, wasted, unused, expendable, disrespected.

I am assuming that these famous man’s thoughts will be echoed by other psychologists. Because, if human needs are defined by each practitioner, suitable treatment design becomes impossible.

Self-actualizer has needs that aren’t as satisfied as, say, food, water, shelter or companionship. He or she seems to require ‘metaneeds’:
Unity, wholeness, and transcendence of opposites
Perfection and necessity
Justice and order


Ugliness and vulgarity
Arbitrariness or forced choices
Deadness or the mechanization of life
Bland uniformity
Sloppiness, inconsistency, or accident
Injustice and lawlessness
Unnecessary complexity
Environmental impoverishment
Grim, humorless, drudgery
We, as humans, have a lot of needs.  A program designed to fill all of our needs would require a permanent relocation to Nirvana – which is not practical for most of us.

A quick review of our uplifting needs will confirm that few of these needs are part of current “entity treatment plans”.  A quick review of the negative features shows that some of these are occurring during current treatment practices. All in all, these conclusions are confirmed by a lack of effectiveness for these programs during the last few decades.

iMResponsible.com – CLIENT SOLUTIONS

The Image Below depicts how “entity” based programs – by default – become responsible for an individual’s behaviors.  It also depicts how these processes can be fixed to provide workable solutions.

The iMR 5 Step – TEAM Behavioral Treatment Program – attempts to realistically consider user needs. The 5 Step Elements are designed to assist the client in becoming responsible for their behaviors and accountable for the results of these behaviors.

I’m Ready for Anything!

Note:  Next post will include information on the iMR PITA Program.  Personalized – Individual – Treatment – Alternatives