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12-Step Centers Can Handle Complex Cases

September 1, 2006
by Anne M. Felton, RN, ND
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Behavioral care plans can yield effective, individualized care

The traditional 12-Step based residential treatment center is evolving both to support scientific advances in addiction and to meet the needs of patients with co-occurring conditions. 12-Step principles provide a strong, cohesive framework for residential treatment, but advances in neurobiology and pharmacology also offer an opportunity for facility administrators to broaden their thinking.

One of the resources available to all high-quality residential treatment centers in this new environment is the addiction registered nurse (ARN). Nurses are trained in managing crises, assessing acute behavioral changes, and providing supportive education to patients. Yet too often in residential treatment facilities that offer detoxification services, the roles of nurses and counselors become disjointed. Counselors remain in their comfort zone until detox is over, and nurses are seldom used as a resource for complex problems once the patient has left “their area.” Nurses can and should serve as valuable liaisons as more treatment centers answer the crucial need to treat patients with co-occurring conditions and to explore what the advances in science really mean to addiction treatment.

The time for collaborative addiction treatment centers is now. This does not mean that centers abandon fundamentals. Residential treatment centers grounded in 12-Step principles are in an ideal space to integrate the skills of various disciplines working in the field. Using brief, solution-focused therapeutic approaches, collaborative teams can build “behavioral care plans” (BCPs) to manage patients that a traditional 12-Step based treatment center may run the risk of losing.

A BCP is an integrative action tool used to address and manage specific problem behaviors or symptoms. The primary objective in building a BCP is to increase the patient's awareness of how symptoms may create conflicts and lead to ineffective coping. This level of awareness can allow the patient to participate actively in a traditional 12-Step program, rather than be forced into a program that is more psychiatric in nature. Examples of patients who often do not fare well in traditional 12-Step agencies include patients with chronic pain, patients experiencing ongoing perceptual disturbances, patients with persistent difficulty sleeping, and patients with traits of borderline personality disorder.

Studies have shown that nurses are comfortable and competent working within a solution-focused therapy framework. Psychiatric nurses are especially well-equipped to manage the co-occurring conditions seen in treatment centers. Using solution-focused therapy to build collaborative BCPs melds well with 12-Step work, because solution-focused therapy emphasizes change and motivation.

Often when patients in traditional 12-Step programs begin to develop difficult symptoms, program rules call for punitive consequences. Counselors and nurses alike become frustrated as patients are labeled “obstinate,” “goal-less,” “crazy,” and “med-seeking.” At this point it is absolutely essential that a solution-focused, collaborative BCP be designed to assist patient and staff in managing symptoms as a team and keeping the patient in treatment.

Building collaborative plans

Bari K. Platter, MS, RN, CNS, educator at the University of Colorado Hospital, has worked extensively with behavioral health teams throughout this health system to implement BCPs. The BCP is different from a multidisciplinary treatment plan or plan of care—it is a working component of the treatment plan. The BCP is solution-focused and action-oriented. All disciplines working with the patient must be involved in its development. While the ARN often leads in BCP development because of comfort working in a solution-focused therapy environment managing complex symptoms, patient participation is also critical to success. The patient and the staff member who reviews the plan must sign and date it.

A BCP should be broken down into four sections (see sidebars):

  • Warning signs. These should be progressive (mild, moderate, severe). The language used should be neutral and nonjudgmental. These lists should include specific behaviors the patient has demonstrated that are disrespectful, unsafe, and not allowed in the facility.

  • Expectations of behavior. These should remain positive and solution-focused, and should correspond to the warning signs. “Do not” lists should be avoided and restructured into positive language.

  • Staff interventions. These also must be positive and reflect the expectations for patient behavior. They should be concise and enforceable.

  • Positive reinforcers. These should be meaningful to the patient, realistic, and use a recipe format with set time frames.

Anticipating complex withdrawal

Many traditional treatment programs are becoming expert at treating and managing ongoing psychiatric and medical symptoms. Because of advances in pharmacology and treatment, we also are able to manage more complex withdrawal safely. Many cases that would have required hospital intervention a decade ago can be safely treated in high-quality residential treatment centers. Still, this means that our cases are more complex, and protracted withdrawal in these cases is not unusual.