6 months ago

Look Inside Young Adult Road Map

2 Guiding Star Point

2 Guiding Star Point Two: Learn System Basics Code Words Clinical evaluation reports often include certain terms that are “code words” for things one provider tells another. They might contain sentences such as, “Jane was neatly groomed and appropriately dressed for the season.” This means Jane can care for herself. Tip: If, despite your best efforts, you show up at the evaluation very messy, in shoes full of holes or wearing shorts on a freezing day, explain why to the evaluator. (“I know it looks strange, but wearing long pants makes me feel too confined.”) If the hot water failed that morning and you couldn’t take a shower, explain this. Don’t be embarrassed, just frank. Remember, the clinician isn’t a mind reader; he or she knows the situation is difficult for you. Full information can only help. Tips for a First Clinician Visit 1. Pick up on the clues. When you see a clinical provider for the first time, pay attention to small cues that could mean a lot. A good clinician will usually begin by asking something such as, “Why are you here?” He or she will clearly explain methods for working together, payment arrangements, and what your role in treatment will be. For example, the clinician might say, “After I meet with you for about three weeks, I’ll want us to get together and review the treatment plan.” 2. What’s your comfort level? Pay attention to the person’s manner and the office environment. Does the clinician make you feel comfortable? Do you feel your concerns are being heard? If the person is sending text messages or reading from a file rather than making direct eye contact while you are speaking, that is not respectful of you as a partner. (Remember, you should not be texting or looking at your phone, either.) 3. Remember, you have a choice. If you receive services from a large agency, one person may conduct the evaluation, and a different person may give therapy. Others, such as a nurse or psychiatrist, may oversee medication management. If one of these persons doesn’t seem right to you, you can request someone else. Talk to your case manager if you don’t know how to do this. If necessary, ask an administrator within the clinic. Unfortunately, in some small cities and rural areas there aren’t many clinicians, therapists, or psychiatrists. If you really don’t think any of the providers seems right for you, find out whether it’s practical to go to a larger city. Of course, you may need to see the person for more than one visit before you make any final judgment. People don’t always “click” right away. Understanding the Treatment Plan Once the evaluation process is complete, the clinician will meet with you to develop a treatment plan. This can take several different forms. In some cases, there will be a written report, sometimes called a “Clinical Evaluation Report” or “Clinical Assessment Report.” This report will state the reason(s) you were referred, sum up your health history, explain test results, and make recommendations for treatment. Always be sure the evaluator gives you a dated copy of any report or treatment plan that concerns you. Often the clinician will go over a “draft” report so you can find any errors. READ THE REPORT CAREFULLY. Ask about any results or terms you don’t understand. Pay attention to anything in the report about your past medications, illnesses, or your family history. Mark your corrections clearly on your copy and file it in your binder. Ask when you can expect to receive a final copy of the report. When you receive it, make sure the corrections were made. Save this copy. If you don’t receive it when promised, ask again and keep asking. It’s very important to have an accurate evaluation report because it becomes part of your record. Other providers who treat you may use parts of it in their own reports. The real facts can get lost. 20

Treatment Plan Forms Large clinics, hospitals, and CMHAs often use a standard form for the treatment plan. Most plans contain this type of information: STATEMENT OF THE PROBLEM: This part should describe the problem or problems in plain words. It may also include the diagnosis. Example: “John is often physically aggressive with romantic partners. At home, John has been observed cycling rapidly between extreme irritation and sadness. Symptoms get worse in winter. Diagnosis: Bipolar disorder with rapid cycling and Seasonal Affective Disorder”. LONG-TERM GOALS: This is how the team pictures a good outcome of treatment. Example: “John will learn and practice successful methods for managing anger without aggression. John’s moods will be stable enough throughout the year to allow him to function at home.” SHORT-TERM GOALS: These are specific goals the team will work on immediately. If possible, there should be some way to measure whether progress toward the goals is being made. These goals should include a date to review whether the plan is working. Example: “Episodes of physical aggression will be decreased by at least one outburst weekly. John will show increased mood stability over a period of one month. Review progress with patient after one month from start of treatment.” (Remember: These are goals, not promises. It’s hard to predict whether or how soon a person’s behavior will change.) INTERVENTION PLAN: This plan describes actions you will take to reach your goals. An intervention plan should always list what will be done, who will do it, and how often actions will happen. It should list a start date and an estimated date to complete or review the actions. The plan should also include what you and your supporters will do. Example: a. “Medications to be prescribed by Doctor A for aggression and mood stability. Weekly medication management by Nurse B until John is stable for one month. Review medication as needed. b. Psychotherapy sessions with MSW Therapist C twice weekly. c. Visit with life coach every two weeks.” CRISIS PLAN: If your condition poses a threat to you or others, this crisis plan should describe what steps will be taken if things get a lot worse. The plan should tell someone (asking for you) whom to contact first, such as the number of the local Mental Health Crisis or Specialized Crisis Service, which hospital will accept you in a crisis, and who will communicate with the hospital. Sometimes this plan is put on a separate form. Make sure it includes all necessary medications. OTHER INFORMATION AND NEEDS: If you have special needs that affect the plan (such as a medical condition or disability), this should be stated on the treatment plan. If you don’t agree with something on the plan, state what the problems are and discuss them with your providers. Ask about alternatives. Remember to put a copy of this treatment plan in your binder. A Note About Private Clinicians Sometimes a clinician will prefer to see you for a while before developing a treatment plan. Some providers (especially those in private practice) don’t use written treatment plans. This may be okay. You must judge whether it’s comfortable for you. However, getting a plan on paper ensures there are fewer misunderstandings. Also, it provides a way to see if progress is being made. In addition, it includes estimated times to review and change treatment. You can send copies to your primary care provider. If your clinician or case manager doesn’t offer any form of treatment plan, ask why not. If you would prefer one, say so. 21