Prioritizing Autonomy

I taught a 4 hour class on developing treatment plans for substance abusing clients last week.  The first half of the class was focused on philosophy; justifying the need for a plan and working through the theoretical reasons why it’s important to allow clients to have a say in the development of their plan.

“Autonomy,” I said, “is a value I hold to – even when I know what’s best.”  My students know the call and response when I say, “Who is the expert on the client?”  THEY ARE, they say in unison.  “Who’s the expert in behavioral health?” WE ARE, they respond.  And I repeat, “Hopefully we are.”  (They politely chuckle at this point.).  It’s my assertion that we have to work together to best design, develop, and help them get better.

After our lunch break, I asked the class to verbally show me how they might begin the conversation about treatment planning with a mock client.  I was pretending to be a man who had two DUIs, was on probation, and didn’t believe he needed treatment.

The first person suggested that they use his screening tool to show him what was wrong with him.  The second gave a lengthy, wordy explanation of why treatment would be good for him despite his lack of desire.  It reminded me that many of us who help have difficulty letting go of control.  It’s hard to trust the process, no matter how many hours of motivational interviewing training we attend, isn’t it?

But why?  Why is it so hard for us to let our clients direct their care?

  1. We actually do know better. And I would hope so.  Given that we are the experts in behavioral health, we ought to know what will work for a client and what won’t.  But knowing more than someone doesn’t give us the right to take away control of their choices from them.  It means more if our client’s choose the right path than if we choose it for them.
  2. It’s easier.  It’s so much easier to write up a treatment plan and hand it to a client and ask them to sign it.  After all, if the client knew what they needed to do to get better, they wouldn’t need us, right?  But treatment works best when its collaborative – and treatment planning is a crucial element of that collaboration.
  3. There’s pressure to produce outcomes.  As managed care continues to grow, there is increased emphasis on demonstrating outcomes in order to increase or justify payment.  If a client does not make progress, its more difficult to justify those insurance claims.  So it might be better to just make them do things our way, right?

Unfortunately, many people see the short-sighted side of this issue. It’s easier to treat patients and clients from a compliance-perspective.  It’s more difficult and I would argue more rewarding to empower people to make their own choices, set their own goals, and collaborate with them on what progress will look like for them as individuals.

For me as a provider of help, autonomy is the only way.

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