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Substance Abuse:

Clinical Issues in Intensive


Outpatient Treatment

A Treatment
Improvement
Protocol
TIP
47
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov INTENSIVE
OUTPATIENT
TREATMENT
Substance Abuse:
Clinical Issues in Intensive
Outpatient Treatment
Robert F. Forman, Ph.D.
Consensus Panel Chair

Paul D. Nagy, M.S., LCAS, LPC, CCS


Consensus Panel Co-Chair

A Treatment
Improvement
Protocol

TIP
47
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment

1 Choke Cherry Road


Rockville, MD 20857
Acknowledgments considered substitutes for individualized cli-
ent care and treatment decisions.
Numerous people contributed to the develop-
ment of this Treatment Improvement Protocol
(TIP) (see pp. xi–xiv as well as appendixes C, Public Domain Notice
D, and E). This publication was produced
by JBS International, Inc. (JBS), under the All materials appearing in this volume except
Knowledge Application Program (KAP) those taken directly from copyrighted sources
contract numbers 270-99-7072 and 270-04- are in the public domain and may be repro-
7049 with the Substance Abuse and Mental duced or copied without permission from
Health Services Administration (SAMHSA), SAMHSA/CSAT or the authors. Do not repro-
U.S. Department of Health and Human duce or distribute this publication for a fee
Services (DHHS). Christina Currier served as without specific, written authorization from
the Center for Substance Abuse Treatment SAMHSA’s Office of Communications.
(CSAT) Government Project Officer, and
Andrea Kopstein, Ph.D., M.P.H., served as Electronic Access and Copies
Deputy Government Project Officer. Lynne
MacArthur, M.A., A.M.L.S., served as the JBS of Publication
KAP Executive Project Co-Director. Barbara Copies may be obtained free of charge from
Fink, RN, M.P.H., served as the JBS KAP SAMHSA’s National Clearinghouse for
Managing Project Co-Director. Other KAP Alcohol and Drug Information (NCADI), (800)
personnel included Dennis Burke, M.S., M.A., 729-6686 or (301) 468-2600; TDD (for hearing
and Emily Schifrin, M.S., Deputy Directors for impaired), (800) 487-4889; or electronically
Product Development; Patricia A. Kassebaum, through www.ncadi.samhsa.gov.
M.A., Senior Writer; Elliott Vanskike, Ph.D.,
Senior Writer/Publication Manager; Candace
Baker, M.S.W., Senior Writer; Wendy Caron, Recommended Citation
Editorial Quality Assurance Manager; Frances Center for Substance Abuse Treatment.
Nebesky, M.A., Quality Assurance Editor; Substance Abuse: Clinical Issues in
Leah Bogdan, Junior Editor; and Pamela Intensive Outpatient Treatment. Treatment
Frazier, Document Production Specialist. In Improvement Protocol (TIP) Series 47. DHHS
addition, Sandra Clunies, M.S., ICADC, served Publication No. (SMA) 06-4182. Rockville,
as Content Advisor. Dixie M. Butler, M.S.W., MD: Substance Abuse and Mental Health
and Paddy Shannon Cook were writers. Services Administration, 2006.

Disclaimer Originating Office


The opinions expressed herein are the views of Practice Improvement Branch, Division of
the consensus panel members and do not nec- Services Improvement, Center for Substance
essarily reflect the official position of CSAT, Abuse Treatment, Substance Abuse and
SAMHSA, or DHHS. No official support of or Mental Health Services Administration, 1
endorsement by CSAT, SAMHSA, or DHHS Choke Cherry Road, Rockville, MD 20857.
for these opinions or for particular instru-
ments, software, or resources described in this DHHS Publication No. (SMA) 06-4182
document is intended or should be inferred. NCADI Publication No. BKD551
The guidelines in this document should not be Printed 2006
Contents
What Is a TIP?.............................................................................................................................. ix

Consensus Panel .......................................................................................................................... xi

KAP Expert Panel and Federal Government Participants ........................................................ xiii

Foreword ......................................................................................................................................xv

Executive Summary .................................................................................................................. xvii

Chapter 1—Introduction ............................................................................................................... 1


Forces Affecting IOT and the Contents of This TIP .................................................................................. 2
Terminology and Definitions ....................................................................................................................... 3
Summary of This TIP .................................................................................................................................... 5

Chapter 2—Principles of Intensive Outpatient Treatment ........................................................... 7


Principle 1: Make Treatment Readily Available ........................................................................................ 8
Principle 2: Ease Entry ................................................................................................................................. 9
Principle 3: Build on Existing Motivation ................................................................................................. 9
Principle 4: Enhance Therapeutic Alliance ............................................................................................. 10
Principle 5: Make Retention a Priority .................................................................................................... 10
Principle 6: Assess and Address Individual Treatment Needs .............................................................. 11
Principle 7: Provide Ongoing Care ............................................................................................................ 11
Principle 8: Monitor Abstinence ............................................................................................................... 12
Principle 9: Use Mutual-Help and Other Community-Based Supports ................................................ 12
Principle 10: Use Medications if Indicated .............................................................................................. 13
Principle 11: Educate About Substance Use Disorders, Recovery, and Relapse ................................. 14
Principle 12: Engage Families, Employers, and Significant Others .................................................... 14
Principle 13: Incorporate Evidence-Based Approaches ......................................................................... 15
Principle 14: Improve Program Administration ...................................................................................................15

Chapter 3—Intensive Outpatient Treatment and the Continuum of Care ................................. 17


Overview of a Continuum of Care ............................................................................................................. 17
Conceiving of a Continuum of Care ........................................................................................................... 18
Key Aspects of IOT (Level II) ...................................................................................................................... 19

iii
Key Aspects of Outpatient Treatment (Level I) ........................................................................................ 23
Continuing Community Care ..................................................................................................................... 24

Chapter 4—Services in Intensive Outpatient Treatment Programs ........................................... 27


Core Services ................................................................................................................................................ 27
Enhanced IOT Services ............................................................................................................................... 44
IOT Services: A Case Illustration ............................................................................................................... 46
Appendix 4-A. A Case Study of Intensive Outpatient Treatment .......................................................... 48
Appendix 4-B. Induction Protocol for Disulfiram ................................................................................... 56

Chapter 5—Treatment Entry and Engagement .......................................................................... 59


Elements of Engaging the Client in IOT ................................................................................................... 60
Collect Screening Information ................................................................................................................... 62
Assessing Barriers to Treatment ................................................................................................................ 64
Crises and Emergencies .............................................................................................................................. 67
Components of the IOT Admission Process ............................................................................................. 67
Sample Treatment Plans ............................................................................................................................ 76
Appendix 5-A. Substance Use History Form ............................................................................................ 84
Appendix 5-B. Instruments for Determining Substance-Related and Psychiatric Diagnoses ............ 85
Appendix 5-C. DSM-IV Criteria for Substance Dependence and Substance Abuse ............................ 87
Appendix 5-D. Supplements to the Six Assessment Domains in the ASI and Other Topics ................ 88

Chapter 6—Family-Based Services .............................................................................................. 93


Planning for Family Involvement .............................................................................................................. 94
Engaging the Family in Treatment ........................................................................................................... 95
Family Services ........................................................................................................................................... 98
Family Clinical Issues in IOT................................................................................................................... 102
Appendix 6-A. Format and Symbols for Family Genogram ................................................................. 107
Appendix 6-B. Family Social Network Map............................................................................................ 109
Appendix 6-C. Resources for Family-Based Services ............................................................................. 112

Chapter 7—Clinical Issues, Challenges, and Strategies in Intensive Outpatient Treatment ........ 115
Client Retention ......................................................................................................................................... 115

iv Contents
Relapse and Continued Substance Use .................................................................................................. 117
Substance Use by Family Members ......................................................................................................... 119
Group Work Issues..................................................................................................................................... 120
Safety and Security .................................................................................................................................... 125
Client Privacy ............................................................................................................................................. 128
Clients Who Work ...................................................................................................................................... 130
Boundary Issues ......................................................................................................................................... 132
Appendix 7-A. Instruments for Assessing Relapse Potential ................................................................ 135

Chapter 8—Intensive Outpatient Treatment Approaches ........................................................ 137


12-Step Facilitation Approach ................................................................................................................. 138
Cognitive–Behavioral Approach .............................................................................................................. 140
Motivational Approaches ......................................................................................................................... 141
Therapeutic Community Approach ......................................................................................................... 142
The Matrix Model ...................................................................................................................................... 146
Community Reinforcement and Contingency Management Approaches........................................... 148

Chapter 9—Adapting Intensive Outpatient Treatment for Specific Populations............................. 153


Justice System Population ........................................................................................................................ 153
Women ........................................................................................................................................................ 157
Populations With Co-Occurring Psychiatric Disorders ......................................................................... 162
Adolescents ................................................................................................................................................. 171
Young Adults .............................................................................................................................................. 175

Chapter 10—Addressing Diverse Populations in Intensive Outpatient Treatment .................. 179


What It Means To Be a Culturally Competent Clinician ...................................................................... 180
Principles in Delivering Culturally Competent IOT Services............................................................... 181
Issues of Special Concern ......................................................................................................................... 183
Clinical Implications of Culturally Competent Treatment .................................................................. 188
Sketches of Diverse IOT Client Populations........................................................................................... 189
Appendix 10-A. Cultural Competence Resources .................................................................................. 197

Contents v
Appendix A—Bibliography ........................................................................................................ 205

Appendix B—Urine Collection and Testing Procedures and


Alternative Methods for Monitoring Drug Use ......................................................................... 237

Appendix C—Resource Panel .................................................................................................... 247

Appendix D—Cultural Competency and Diversity Network Participants ................................ 249

Appendix E—Field Reviewers.................................................................................................... 251

Index ......................................................................................................................................... 255

CSAT TIPs and Publications Based on TIPs ............................................................................ 265

Exhibits
3-1 Goals, Duration, Activities, and Completion Criteria of Stage 1 .................................................. 21
3-2 Goals, Duration, Activities, and Completion Criteria of Stage 2 .................................................. 22
3-3 Goals, Duration, Activities, and Completion Criteria of Stage 3 .................................................. 25
3-4 Goals, Duration, Activities, and Completion Criteria of Stage 4 .................................................. 26
4-1 Core and Enhanced Services for IOT Programs ............................................................................. 28
4-2 Groups Conducted in Intensive Outpatient Treatment ................................................................. 29
4-3 Typical Sequence of Topics Addressed in Psychoeducational Group ......................................... 33
4-4 Case Management Services................................................................................................................ 39
4-5 Examples of 24-Hour Crisis Coverage Implementation ................................................................ 41
4-6 Alternatives to Traditional 12-Step Groups .................................................................................... 43
4-7 Key Features of a Hospital-Based Suburban IOT Program .......................................................... 46
4-8 A Protocol for Ambulatory Detoxification and Disulfiram Induction ......................................... 56
5-1 Effective Interviewing Techniques.................................................................................................... 63
5-2 ABC Model for Psychiatric Screening .............................................................................................. 66
5-3 The Six Dimensions of the ASAM PPC-2R for Level II.1 IOT ...................................................... 69
5-4 Brief Screening Instruments That Assess Motivational Stage ....................................................... 70
5-5 Mild Withdrawal Symptoms for Four Drug Classes That Can Be Managed in Level II.5
Ambulatory Detoxification ................................................................................................................ 71

vi Contents
6-1 Suggestions for Engaging Family Members at Intake ................................................................... 96
6-2 A Treatment Calendar for Family Members ................................................................................... 99
6-3 Social Network Grid Used in Conjunction With Network Map .................................................. 111
7-1 Examples of Immediate Safety Concerns and Counselor Responses ........................................ 126
8-1 Strengths and Challenges of 12-Step Approaches ........................................................................ 139
8-2 Strengths and Challenges of Cognitive–Behavioral Approaches ................................................ 141
8-3 Strengths and Challenges of Motivational Approaches ............................................................... 143
8-4 Strengths and Challenges of the Therapeutic Community Approach ....................................... 145
8-5 Strengths and Challenges of Matrix Model Treatment ................................................................ 147
8-6 Strengths and Challenges of Community Reinforcement and Contingency
Management Approaches ................................................................................................................ 151
9-1 Core Treatment Needs and Service Elements for Women .......................................................... 160
9-2 SAMHSA’s Service Coordination Framework for Co-Occurring Disorders ............................... 164
9-3 The Family Intervention Program .................................................................................................. 174
9-4 Characteristics and Behaviors of Adolescents and Treatment Suggestions .............................. 176
B-1 Urine Toxicology Detection Periods for Different Substances.................................................... 240
B-2 Effectiveness of Drug Detection Methods That Use Different Biological Products.................. 243

Contents vii
What Is a TIP?

Treatment Improvement Protocols (TIPs), developed by the Center for


Substance Abuse Treatment (CSAT), part of the Substance Abuse and
Mental Health Services Administration, within the U.S. Department of
Health and Human Services, are best-practice guidelines for the treat-
ment of substance use disorders. CSAT draws on the experience and
knowledge of clinical, research, and administrative experts to produce
the TIPs, which are distributed to facilities and individuals across the
country. The audience for the TIPs is expanding beyond public and
private treatment facilities to include practitioners in mental health,
criminal justice, primary care, and other health care and social service
settings.

CSAT’s Knowledge Application Program expert panel, a distinguished


group of experts on substance use disorders and professionals in such
related fields as primary care, mental health, and social services, works
with the State Alcohol and Drug Abuse Directors to generate topics for
the TIPs. Topics are based on the field’s current needs for information
and guidance.

After selecting a topic, CSAT invites staff from pertinent Federal agen-
cies and national organizations to be members of a resource panel that
recommends specific areas of focus as well as resources that should be
considered in developing the content for the TIP. These recommenda-
tions are communicated to a consensus panel composed of experts on
the topic who have been nominated by their peers. Consensus panel
members participate in a series of discussions. The information and
recommendations on which they reach consensus form the foundation
of the TIP. The members of each consensus panel represent substance
abuse treatment programs, hospitals, community health centers,
counseling programs, criminal justice and child welfare agencies, and
private practitioners. A panel chair (or co-chairs) ensures that the con-
tents of the TIP mirror the results of the group’s collaboration.

ix
A large and diverse group of experts closely between researchers and practitioners. The
reviews the draft document. Once the changes resulting focus on evidence-based treatment
recommended by these field reviewers have approaches informs most of the material
been incorporated, the TIP is prepared for in this TIP. The consensus panel presents
publication, in print and on line. TIPs can be 14 guiding principles of IOT, supported by
accessed via the Internet at www.kap.samhsa. research and clinical experience. This TIP
gov. The online TIPs are consistently updated also situates IOT within the continuum of
and provide the field with state-of-the-art care framework established by the American
information. Society of Addiction Medicine, including out-
patient treatment and continuing community
Although each TIP strives to include an evi- care. The volume describes the core services
dence base for the practices it recommends, every program should offer, the enhanced
CSAT recognizes that the field of substance services that should be available on site or
abuse treatment is evolving, and research through links with community-based services,
frequently lags behind the innovations pio- and the process of assessment, placement,
neered in the field. A major goal of each TIP and treatment planning that helps clinicians
is to convey “front-line” information quickly address each client’s needs. Based on research
but responsibly. For this reason, recommen- and clinical experience, the consensus panel
dations proffered in the TIP are attributed discusses major clinical challenges of IOT
to either panelists’ clinical experience or the and surveys the most common treatment
literature. If research supports a particular approaches used in IOT programs, including
approach, citations are provided. family-based services. More specialized sec-
This TIP, Substance Abuse: Clinical Issues in tions address treatment of specific groups of
Intensive Outpatient Treatment, was written clients: women; adolescents and young adults;
to help clinicians address the expansion of persons involved with the criminal justice
intensive outpatient treatment (IOT) repre- system; individuals with co-occurring disor-
sented by the development and adoption of ders; racial and ethnic minorities; persons
new approaches to treat a wider variety of with HIV/AIDS; lesbian, gay, and bisexual
clients. Researchers and clinicians have begun individuals; persons with physical or cogni-
to question the acute care model of treatment tive disabilities; rural populations; individuals
for substance use disorders; this reexamina- who are homeless; and older adults.
tion has led to a more robust collaboration

x What Is a TIP?
Consensus Panel

This TIP is a consensus-based document, developed by the experts listed below. Although all
panelists made significant contributions in the development of the TIP as a whole, some pan-
elists took on the additional responsibility as writers for upfront development of particular
chapters. Those chapters are listed after their names.

Chair Margaret K. Brooks, J.D.


Consultant
Robert F. Forman, Ph.D. 27 Warfield Street
Clinical Scientist Montclair, New Jersey
Medical Affairs Writer, chapter 9
Alkermes, Inc.
Cambridge, Massachusetts Frederick T. Chappelle, M.S.S.W., LCADC,
Formerly CCS
Senior Investigator Vice President and Financial Officer
Treatment Research Institute Chappelle Consulting and
Assistant Professor of Psychology in Training Services, Inc.
Psychiatry Middletown, Connecticut
School of Medicine
University of Pennsylvania Gerard J. Connors, Ph.D.
Philadelphia, Pennsylvania Director
Writer, chapters 1 and 2 Research Institute on Addictions
University of Buffalo
Co-Chair Buffalo, New York
Paul D. Nagy, M.S., LCAS, LPC, CCS Writer, chapters 4 and 5
Program Director
Duke Addictions Program Anita L. Crawford
Clinical Associate Chief Executive Officer
Department of Psychiatry and Roxbury Comprehensive Community
Behavioral Sciences Health Center
Duke University Medical Center Roxbury, Massachusetts
Durham, North Carolina
Writer, chapters 1 and 5 Chris B. Farentinos, M.D., CADC II,
NCDC II
Clinical Director
Consensus Panelists Change Point, Inc.
Fred Andes, D.S.W., M.P.A., LCSW Portland, Oregon
Assistant Professor of Sociology Writer, chapters 4, 7, 8, and 10
New Jersey City University
Jersey City, New Jersey
Writer, chapters 5 and 6

xi
Marco E. Jacome, M.A., LPC, Mary E. McCaul, Ph.D.
CSADC, CEAP Associate Professor
Executive Director Psychiatry and Behavioral Sciences
Healthcare Alternative Systems, Inc. Johns Hopkins University School of
Chicago, Illinois Medicine
Writer, chapter 10 Baltimore, Maryland
Writer, chapters 8 and 9
George Kolodner, M.D.
Medical Director Elizabeth A. Peyton
Kolmac Clinic Principal
Silver Spring, Maryland Peyton Consulting Services
Writer, chapter 4 Newark, Delaware
Writer, chapters 8 and 9
Felicity L. LaBoy, Ph.D.
Clinical Coordinator Richard A. Rawson, Ph.D.
Dual Diagnoses Program Associate Director
Substance Abuse Services UCLA Integrated Substance Abuse Programs
Bronx VA Medical Center Los Angeles, California
Bronx, New York Writer, chapter 2
Writer, chapters 3, 4, and 9
Candace M. Shelton, M.S., CSAS,
Janice Ogden Lipscomb, M.S., ACADC CADAC, CCS
Director Consultant
Mental Health and Chemical Dependency Tucson, Arizona
Community Based Programs Writer, chapter 10
Broadlawns Medical Center
Des Moines, Iowa
Writer, chapters 3 and 8

xii Consensus Panel


KAP Expert Panel and Federal
Government Participants

Barry S. Brown, Ph.D. Michael Galer, D.B.A., M.B.A., M.F.A.


Adjunct Professor Chairman of the Graduate School of Business
University of North Carolina at Wilmington University of Phoenix—Greater Boston Campus
Carolina Beach, North Carolina Braintree, Massachusetts

Jacqueline Butler, M.S.W., LISW, LPCC, Renata J. Henry, M.Ed.


CCDC III, CJS Director
Professor of Clinical Psychiatry Division of Alcoholism, Drug Abuse, and
College of Medicine Mental Health
University of Cincinnati Delaware Department of Health and
Cincinnati, Ohio Social Services
New Castle, Delaware
Deion Cash
Executive Director Joel Hochberg, M.A.
Community Treatment and Correction President
Center, Inc. Asher & Partners
Canton, Ohio Los Angeles, California

Debra A. Claymore, M.Ed.Adm. Jack Hollis, Ph.D.


Owner/Chief Executive Officer Associate Director
WC Consulting, LLC Center for Health Research
Loveland, Colorado Kaiser Permanente
Portland, Oregon
Carlo C. DiClemente, Ph.D.
Chair Mary Beth Johnson, M.S.W.
Department of Psychology Director
University of Maryland Baltimore County Addiction Technology Transfer Center
Baltimore, Maryland University of Missouri—Kansas City
Kansas City, Missouri
Catherine E. Dube, Ed.D.
Independent Consultant Eduardo Lopez, B.S.
Brown University Executive Producer
Providence, Rhode Island EVS Communications
Washington, D.C.
Jerry P. Flanzer, D.S.W., LCSW, CAC
Chief, Services Holly A. Massett, Ph.D.
Division of Clinical and Services Research Academy for Educational Development
National Institute on Drug Abuse Washington, D.C.
Bethesda, Maryland

xiii
Diane Miller Nedra Klein Weinreich, M.S.
Chief President
Scientific Communications Branch Weinreich Communications
National Institute on Alcohol Abuse and Canoga Park, California
Alcoholism
Bethesda, Maryland Clarissa Wittenberg
Director
Harry B. Montoya, M.A. Office of Communications and Public Liaison
President/Chief Executive Officer National Institute of Mental Health
Hands Across Cultures Bethesda, Maryland
Espanola, New Mexico
Consulting Members
Richard K. Ries, M.D.
Director/Professor of the KAP Expert Panel
Outpatient Mental Health Services Paul Purnell, M.A.
Dual Disorder Programs Social Solutions, L.L.C.
Seattle, Washington Potomac, Maryland

Gloria M. Rodriguez, D.S.W. Scott Ratzan, M.D., M.P.A., M.A.


Research Scientist Academy for Educational Development
Division of Addiction Services Washington, D.C.
New Jersey Department of Health
Thomas W. Valente, Ph.D.
and Senior Services
Director, Master of Public Health Program
Trenton, New Jersey
Department of Preventive Medicine
School of Medicine
Everett Rogers, Ph.D.
University of Southern California
Center for Communications Programs
Alhambra, California
Johns Hopkins University
Baltimore, Maryland Patricia A. Wright, Ed.D.
Independent Consultant
Jean R. Slutsky, P.A., M.S.P.H. Baltimore, Maryland
Senior Health Policy Analyst
Agency for Healthcare Research and Quality
Rockville, Maryland

xiv KAP Expert Panel and Federal Government Participants


Foreword

The Treatment Improvement Protocol (TIP) series supports SAMHSA’s


mission of building resilience and facilitating recovery for people with
or at risk for mental or substance use disorders by providing best-
practices guidance to clinicians, program administrators, and payers
to improve the quality and effectiveness of service delivery and thereby
promote recovery. TIPs are the result of careful consideration of all
relevant clinical and health services research findings, demonstration
experience, and implementation requirements. A panel of non-Federal
clinical researchers, clinicians, program administrators, and client
advocates debates and discusses its particular areas of expertise until
it reaches a consensus on best practices. This panel’s work is then
reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIPs’ panelists and review-
ers bring to this highly participatory process have helped bridge the
gap between the promise of research and the needs of practicing clini-
cians and administrators who serve, in the most current and effective
ways, people who abuse substances. We are grateful to all who have
joined with us to contribute to advances in the substance abuse treat-
ment field.

Eric B. Broderick, D.D.S., M.P.H.


Acting Deputy Administrator
Assistant Surgeon General
Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM


Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration

xv
Executive Summary

This volume, Substance Abuse: Clinical Issues in Intensive Outpatient


Treatment, and its companion text, Substance Abuse: Administrative
Issues in Outpatient Treatment, revisit the subject matter of
Treatment Improvement Protocol (TIP) 8, Intensive Outpatient
Treatment for Alcohol and Other Drug Abuse, published in 1994
(CSAT 1994c). When TIP 8 was published, one volume of about 100
pages sufficed to address relevant topics in intensive outpatient treat-
ment (IOT). Today, the same task requires two volumes, each devoted
to a distinct audience, clinicians and administrators. The primary
audience for this volume is clinicians working in IOT programs.

The Changing IOT Landscape


Arnold M. Washton (1997) points out that the first large expan-
sion of IOT took place during the 1980s, when White, middle-class
individuals with cocaine addiction, many of whom were business
professionals, sought treatment and did not want to take time away
from work or face the stigma of checking into a residential treatment
facility. A second expansion of IOT was ushered in by managed care
with a focus on cost containment. Throughout the 1990s, IOT grew,
becoming the dominant setting for most clients with substance use
disorders. This growth was spurred by the expansion of IOT’s popu-
lation from clients with a moderate range of problems to include
clients who are homeless, adolescents, and persons with co-occurring
mental disorders, all of whom formerly were considered too difficult
for IOT programs to treat successfully. This expansion in clients and
services means that IOT clinicians must keep abreast of a broaden-
ing array of treatment approaches and services provided beyond
their programs. The current volume’s focus on clinicians reflects
both the increased treatment options available and the expanded
range of knowledge and skills required.

xvii
Defining Substance clinical challenges, and treatment approach-
es and adaptations. In their focus on client
Abuse Treatment and engagement and retention, individualizing
IOT treatment, using the entire continuum of
care, and reaching out to families, employ-
For most of the 20th century, substance ers, and the community, the 14 principles
abuse was considered an acute disorder. help define the IOT program’s contemporary
Viewing substance abuse more like pneu- role.
monia than like chronic diseases such as
hypertension or diabetes had shaped the
expectations and treatment choices of clini- Continuum of Care
cians. As McLellan and colleagues (2000)
point out, regarding substance abuse as a and IOT Services
chronic disorder means realigning treat- An IOT program is most effective at help-
ment and outcome expectations so that they ing its clients if it is part of a continuum
resemble those for other chronic disorders. of care. The American Society of Addiction
Today, many IOT programs are involved Medicine has established five levels of care:
in treatment beyond the traditional 4 to 12 medically managed intensive inpatient,
weeks. Increasingly, IOT programs focus on residential, intensive outpatient, outpa-
ongoing care that addresses many areas of tient, and early intervention. In addition,
clients’ lives through case management and continuing community care (e.g., 12-Step
the involvement of other service providers support groups), which a client participates
and families and communities. in after the conclusion of formal treatment,
is another important level of service. A con-
A parallel development has been the fre- tinuum of care ensures that clients can enter
quent application of research findings into substance abuse treatment at a level appro-
practice in the field of substance abuse priate to their needs and step up or down
treatment. Research has yielded new under- to a different intensity of treatment based
standing about the complexity of substance on their responses. Clinicians enhance the
use disorders that takes into account bio- capabilities of their programs when they are
chemical processes, learning, spirituality, informed about and willing to refer clients to
and environment. IOT programs are integral other treatment providers. Close monitoring
to the process of translating scientific find- of clients’ progress toward treatment goals
ings into clinically effective treatments. The is key to determining when they are ready
collaboration between research and practice for the next appropriate level of care. Any
has moved some treatments out of research transition in treatment increases the likeli-
centers and into IOT programs. Cognitive– hood that a client will drop out. A step-up
behavioral interventions, relapse prevention or stepdown in treatment intensity in the
training, motivational enhancement, and same program or a referral to a nonaffiliated
case management are used in community- provider can be disruptive for the client.
based treatment settings as a result of the Mee-Lee and Shulman (2003) recommend
cross-fertilization of research and treatment. that a continuum of care feature seamless
One result of the convergence of research transfer between levels, congruence in treat-
and practice is the development of evidence- ment philosophy, and efficient transfer of
based principles that shape and guide records. Clinicians need to be thoroughly
substance abuse treatment. The consensus familiar with local treatment options, includ-
panel recommends 14 principles for IOT ing support groups, so that they can orient
programs. These principles lay a theoretical clients as the clients transition to new treat-
foundation for discussions of IOT services, ment situations.

xviii Executive Summary


Services integral to all IOT programs are vate them to enter and continue treatment.
core services. The consensus panel believes Clinicians should begin to establish a
that these core services, such as group and therapeutic relationship as soon as clients
individual counseling, psychoeducational present themselves for treatment. Any bar-
programming, monitoring of drug use, riers to treatment must be addressed. Based
medication management, case manage- on screening and assessments, clients should
ment, medical and psychiatric examinations, be matched with the best treatment modal-
crisis intervention coverage, and orienta- ity and setting to support their recovery. An
tion to community-based support groups, individualized treatment plan should be
are indispensable and should be available developed with the cooperation of the client
through all IOT programs. Additional ser- to address the client’s needs.
vices that are offered at the program site or
through links with partner organizations are Client retention is a priority throughout
enhanced services. This concept is flexible, treatment. The consensus panel draws on
and what might be considered enhanced research and the experience of practiced cli-
services for some programs may be essential nicians to address the issues of engagement
services for a program with a different client and retention. Clients can become distracted
population. (Clients whose first language is from recovery if family members continue
not English might need language classes to to use substances, boundaries between cli-
find work and participate in mutual-help ents and staff are not established clearly,
groups, whereas a program that primar- work conflicts with treatment, or they receive
ily serves native speakers would have little incompatible recommendations from differ-
call for such a service.) Enhanced services ent service systems. Clinicians need to know
include adult education classes, recreational how to ensure the privacy of their clients and
activities, adjunctive therapies (e.g., biofeed- the safety and security of the program facil-
back, acupuncture, meditation), child care, ity while maintaining open and productive
nicotine cessation treatment, housing, trans- therapeutic relationships with their clients.
portation, and food. Clinicians also need to be familiar with com-
mon issues that can derail clients in group
therapy such as intermittent attendance and
Entry, Engagement, other clients who are disruptive, ambivalent,
or withdrawn. When clinicians understand
and Treatment Issues and prepare for these problems, their clients
Many clients who enter substance abuse have a better chance of being retained in
treatment drop out in the early stages and benefiting from treatment. A major fac-
(Claus and Kindleberger 2002). Entry and tor in client retention is the quality of the
engagement are crucial processes; how an relationship between client and counselor.
IOT program addresses them can influ- The client is more likely to do well in treat-
ence strongly whether clients remain in ment if a strong therapeutic alliance exists.
treatment. Client intake and engagement
can involve contradictory processes such as
collecting intake information from clients Treatment Approaches
while initiating a caring, empathic relation-
ship. Balancing administrative tasks and
Used in IOT
therapeutic intervention is a challenge cli- IOT is compatible with different treatment
nicians face during a client’s first hours in approaches. Involving clients’ families
an IOT program. To help clinicians achieve in their recovery is an effective strategy.
that balance, the consensus panel recom- Substance-using behavior may be rooted
mends assessing potential clients’ readiness in part in a client’s family history—whether
for change and using strategies that moti- family of origin or family of choice. Families

Executive Summary xix


can play a crucial role in a client’s recov- Motivational approaches, such as moti-
ery. Providers should prepare for family vational interviewing and motivational
involvement, education, and other services enhancement therapy, also rely on extensive
so that family members can support recov- staff training and high levels of client self-
ery. Family involvement in treatment has awareness. Through empathic listening,
been linked to positive outcomes for clients counselors explore clients’ attitudes toward
in substance abuse treatment (Rowe and substance abuse and treatment, supporting
Liddle 2003). For IOT providers, adopting past successes and encouraging problemsolv-
a family systems approach means including ing strategies. These approaches are client
family members in every stage of treatment: centered and goal driven and encourage cli-
the intake interview, counseling sessions, ent self-sufficiency.
family dinners or weekends, and gradua-
tion celebrations. If family members are to Therapeutic community approaches are
support a client’s recovery, they must be dis- used most often in residential settings but
abused of unrealistic expectations and learn have been adapted for IOT. In therapeutic
about relapse prevention. IOT providers community approaches, a structured com-
should consider offering family education munity of clients and staff members is the
groups, multifamily groups, and family sup- main therapeutic agent—peers and counsel-
port groups. If family therapy (which in most ors are role models, the work at the facility is
States requires a licensed, master’s-level used as therapy, and group sessions focus on
clinician) is warranted and an IOT clinic self-awareness and behavioral change. The
cannot offer it, referral relationships can be intensity of the treatment calls for extensive
developed with an organization that provides staff training and can result in high client
individual family therapy, couples therapy, dropout. However, therapeutic communities
and child-focused therapy. have proved successful with difficult clients
(e.g., those with long histories of substance
Providers should be familiar with the use and those who have served time in
strengths and challenges of different treat- prison).
ment approaches so they can serve their
clients better by modifying and blending The Matrix model integrates a number
approaches as necessary. The 12-Step facili- of other treatment approaches, including
tation approach is common in the treatment mutual-help, cognitive–behavioral, and moti-
environment. Twelve-Step-oriented treat- vational interviewing. A strong therapeutic
ment helps clients achieve abstinence and relationship between client and counselor
understand the principles of Alcoholics is the centerpiece of the Matrix approach.
Anonymous and other 12-Step groups Other features are learning about with-
through group counseling, homework assign- drawal and cravings, practicing relapse
ments, and psychoeducation. The 12-Step prevention and coping techniques, and sub-
approach emphasizes cognitive, behavioral, mitting to drug screens.
spiritual, and health aspects of recovery Contingency management and community
and is effective with many different types of reinforcement approaches encourage cli-
clients. ents to change behavior; these approaches
Cognitive–behavioral therapy focuses on reinforce abstinence by rewarding some
teaching clients skills that will help them behaviors and punishing others. Programs
understand and reduce their relapse risks select a goal that is reasonable, is attain-
and maintain abstinence. Clients must be able, and contributes to overall treatment
motivated and counselors must be trained objectives and then reward small steps the
extensively for cognitive–behavioral therapy client makes toward that goal. Contingency
to succeed. management and community reinforcement

xx Executive Summary
approaches have been successful with clients provides comprehensive services to care for
who have chronic substance use disorders, both disorders. Programs that do not adopt
when the costs for staff training and incen- an integrated approach are advised to coor-
tives can be addressed. dinate services with mental health providers.

A comprehensive approach to services also


Treating Different is important for adolescents who are using
substances. Adolescents experience incred-
Populations ible upheaval in their lives and often need
Many of the approaches used in IOT pro- habilitation rather than rehabilitation. Many
grams were developed to treat substance are in treatment for the first time and need
use disorders in White, middle-class men. to be oriented to treatment culture. Because
Adaptations to these approaches are neces- adolescents often are living at home, fam-
sary to treat a variety of clients such as those ily involvement is crucial. A behavioral
in the justice system, women, clients with co- contract—stipulating desired behaviors and
occurring disorders, and adolescents. rewards—and case management—addressing
medical, social, and psychological needs—are
Increasing numbers of people with substance also beneficial treatment tools.
use disorders are involved with the justice
system. Justice agencies and treatment pro- IOT programs are being called on to serve
viders need to work closely with each other, an increasingly diverse client population.
communicating clearly and coordinating Almost one-third of Americans belong to an
their efforts. Cooperation of a different kind ethnic or racial minority group, and more
must exist between clinicians and clients. than 10 percent of the U.S. population was
Therapeutic alliance is especially important born outside the country (Schmidley 2003).
when working with clients in the justice Although there is widespread agreement that
system who may have difficulty trusting a cli- clinicians should be culturally competent,
nician and forming meaningful relationships no consensus exists about what cultural
outside the criminal environment. competence means. As a starting point, clini-
cians should understand how to work with
The number of treatment programs for someone from outside their own culture and
women is increasing. These programs add strive to understand the specific culture of
enhanced services designed to address sub- the client being served. Whereas the ability
stance abuse in the context of pregnancy and to treat clients from outside one’s culture
parenting, self-esteem issues, and histories is an extension of the skills of a good clini-
of physical, sexual, and emotional abuse. To cian, understanding the cultural context
treat women, clinicians often avoid confron- of individual clients is more demanding.
tational techniques and focus on providing a Clinicians need to strike a balance between a
safe and supportive environment with clearly broad cultural background and the specific
established boundaries between client and cultural context of a client’s life; an observa-
counselor. tion that is applicable to a large group may
be misleading or harmful if applied to an
Many people with co-occurring mental and
individual.
substance use disorders are not receiving
appropriate care (Watkins et al. 2001) and For foreign-born clients, level of accultura-
find themselves shuttling between psychiat- tion often is an issue. Most research shows
ric and substance abuse treatment, caught that the more acculturated clients are, the
between two systems (Drake et al. 2001). more their substance use approximates U.S.
Integrated treatment attends to both disor- norms. Programs that serve substantial num-
ders together, adapts standard interventions bers of foreign-born clients may consider
to allow for clients’ cognitive limitations, and

Executive Summary xxi


offering language-specific programs and link- assessing policies and practices to spot
ing clients to language classes, job training, potential barriers for diverse clients, train-
and employment services. Clients from other ing staff members in cultural competence,
cultures may be averse to the emphasis on providing materials at an appropriate read-
self-disclosure and self-sufficiency in sub- ing level or translating materials into clients’
stance abuse treatment. Counselors must be languages, and using outreach to promote
prepared to work within the client’s value awareness of the program.
system, which may be at odds with values
promoted by the treatment program. The consensus panel offers an extensive
list of resources for further research as well
Likewise, programs should ensure that pro- as demographic, substance use, and treat-
gram practices and materials do not pose ment information on members of racial and
a barrier to clients of non-Christian faiths. ethnic groups; persons with physical or cog-
Many mutual-help programs have a strong nitive disabilities; persons with HIV/AIDS;
Christian element; clients from other faiths persons who are lesbian, gay, or bisexual;
should be informed of this orientation and rural populations; and homeless popula-
provided with information about secular or tions. These resources are found in appendix
religion-specific mutual-help groups. 10-A.

Other general guidelines for programs that


treat clients from other cultures include

xxii Executive Summary


1 Introduction

The current volume addresses clinical issues and a companion vol-


ume, TIP 46, Substance Abuse: Administrative Issues in Outpatient
In This Treatment (CSAT 2006f), discusses administration. Together, these
TIPs break new ground as the first two-volume TIP issued by the
Chapter... Center for Substance Abuse Treatment (CSAT). This volume rep-
resents the most extensive discussion in a TIP of clinical issues for
Forces Affecting intensive outpatient treatment (IOT) programs.
IOT and
the Contents of Several developments in health care and the treatment of substance
This TIP use disorders have prompted this full revision of TIP 8, Intensive
Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT
Terminology and 1994c). Since the original TIP was published, substantial changes
Definitions have occurred in almost every aspect of how treatment services are
Summary of conceptualized and delivered. By the late 1990s, IOT had moved
This TIP from being a peripheral and relatively circumscribed clinical ser-
vice, serving a small range of clients, to a robust, multidimensional
treatment modality that plays a central role in the care of many
individuals with substance use disorders. TIP 46, Substance Abuse:
Administrative Issues in Outpatient Treatment (CSAT 2006f), provides
a full history of IOT.

As with all TIPs sponsored by CSAT, this volume represents the


thinking, experience, and work of a consensus panel. The rapidity
of recent changes in the IOT field and the variety of challenges and
opportunities that accompany them compelled this TIP’s consen-
sus panel to draw on its clinical experience and current research to
create a TIP that is both practical and evidence based. Substance
Abuse: Clinical Issues in Intensive Outpatient Treatment examines
significant and sometimes perplexing issues facing IOT providers
and offers analytical discussions and incisive opinions. In writing
the TIP, the consensus panel attempted to reflect the changes of the
past decade and anticipate directions that IOT may take.

1
Forces Affecting IOT use disorders are complex illnesses with
important biological—as well as social, psy-
and the Contents of chological, and spiritual—dimensions. IOT
This TIP programs play a central role in translating
scientific findings into clinically meaningful
information and treatments.
Chronic Disease Management
Recognizing that substance abuse is a chron- The discussions of treatment and the clinical
ic disorder similar to diabetes, hypertension, recommendations in this TIP are informed
and asthma led the panel to question the by the links between practice and research
acute care model of service delivery that that are becoming the norm in the IOT field.
has characterized substance abuse treat-
ment for the past 50 years (McLellan et al. New Treatment Approaches
2000). Panel members felt strongly that
IOT providers—like providers in the rest of A growing interest in evidence-supported
the health care system—should rethink the interventions has led practitioners to exam-
acute care approach to treating substance ine long-held assumptions about treatment
use disorders. Increasingly, IOT programs and the recovery process. Several therapeutic
are involved in substance abuse treatment approaches, previously applied primarily
beyond the initial 4 to 12 weeks. Much of the in university-based research centers, have
discussion in this volume is devoted to con- begun to emerge as viable and effective
tinuing care and to finding ways to include interventions that can be implemented suc-
case management service providers, families, cessfully in community-based treatment
communities, and mutual-help groups in the settings. Discussions on cognitive–behavioral
ongoing care of individuals with substance interventions, relapse prevention training,
use disorders. motivational enhancement therapy, the
use of incentives, and case management
approaches have been incorporated into this
Practice–Research TIP. Similarly, the TIP describes the benefits
Collaboration of integrating pharmacotherapies into IOT
to help manage withdrawal and stabilize
In the past decade, emphasis on the blend- people with co-occurring disorders.
ing of evidence-based interventions with
community-based service delivery has
increased. The longstanding divide between Convergence of Systems
practitioners and researchers needed to be Approximately 10 years ago, substance
bridged. This disparity, described in the abuse treatment services were viewed widely
Institute of Medicine 1998 report, Bridging as specialty services that interacted with a
the Gap Between Practice and Research, variety of other important stakeholders, such
was a major impetus behind the creation as the mental health, welfare, and criminal
of the National Institute on Drug Abuse’s justice systems. A profound and important
(NIDA’s) Clinical Trials Network and CSAT’s change affecting the delivery of IOT services
Addiction Technology Transfer Centers and is the convergence of these previously distinct
Practice Improvement Centers. Research systems and the substance abuse treatment
has resulted in new knowledge about how system. The divisions among services have
biochemical processes, learning, spirituality, long been based on administrative conve-
and environment affect people who abuse nience and funding streams, not the clinical
substances. These advances may make it needs of clients. Programs must be prepared
easier for clinicians, clients, family members, to treat clients who simultaneously may be
and the public to understand that substance receiving public welfare, have children in

2 Chapter 1
protective services, and be under criminal agreed to use the
justice supervision. Each system may place term “intensive Increasingly, IOT
substance abuse treatment requirements outpatient treat-
on the client, and, as a consequence, these ment” (“IOT”) to programs are involved
systems can play an important role in sup- refer to this level of
porting the goals of treatment. This TIP care instead of the
in substance abuse
addresses the importance of simultaneously equally acceptable
working with multiple systems. term “intensive
outpatient pro- treatment beyond the
gram.” Because
Client and Program Diversity of the variety of initial 4 to 12 weeks.
IOT programs serve a greater variety of cli- definitions applied
ents than they did when TIP 8 was published by clinicians and
in 1994. The current volume makes a broad- researchers to “intensive outpatient treat-
er and deeper study of how individual ment,” IOT studies cited in this volume also
differences affect treatment needs. Ten years include day treatment, day hospital treat-
ago IOT was offered primarily to privately ment, and partial hospitalization programs,
insured clients with mild-to-moderate levels in addition to IOT programs.
of dysfunction. Since then, IOT programs
have adjusted their models to treat adoles-
cents, clients who are homeless or Outpatient Care vs. Aftercare
economically disadvantaged, clients with vs. Continuing Care
mental disorders, clients involved with the The term “aftercare” is avoided through-
criminal justice system, clients who are dis- out this TIP in favor of “continuing care.”
abled, and those with other special needs Research literature occasionally uses the
once considered beyond the scope of IOT term “aftercare” when discussing traditional
programs. Most programs also are respond- outpatient treatment that follows residential
ing to the needs of increasingly diverse racial or intensive outpatient treatment. Others use
and ethnic client populations. Many IOT the term “aftercare” when discussing clients’
programs now incorporate onsite ambulatory participation in mutual-help groups after
detoxification services, medication manage- formal treatment is completed. In this vol-
ment, and infectious disease interventions. ume, the term “continuing care” designates
the mutual-help groups (including 12-Step
and other support groups) available in the
Terminology and community after formal treatment ends.
Definitions Even during the continuing community care
phase or treatment, many clients return to
the IOT clinic for occasional followup visits,
IOT vs. IOP similar to regular medical checkups for other
Just as the treatment field has yet to settle chronic diseases.
on a commonly accepted name for itself (e.g.,
“substance abuse” versus “addiction” versus
“substance use disorder” versus “chemical Substance Abuse Treatment
dependence”), there is also no agreed-on vs. Mutual-Help Groups
term to describe this intensive level of care.
The distinction between substance abuse
Because use of the terms “intensive outpa-
treatment programs and mutual-help groups,
tient treatment” and “intensive outpatient
such as 12-Step support groups, often is
program” (IOP) varies by region, for the
misunderstood by managed care organiza-
sake of consistency, the consensus panel
tions and the public. The American Medical

Introduction 3
Association (1998) What Constitutes IOT?
has adopted a
...mutual-help groups Although IOT traditionally has consisted of
policy stating
at least 9 hours of treatment per week, usu-
that clients with
are an important ally delivered in three 3-hour sessions, some
substance use dis-
programs have substantially longer hours
orders should be
and others provide only 6 contact hours per
component of treated by qualified
week. The consensus panel agrees that a
professionals and
program that schedules treatment daily, for
treatment, but they that mutual-help
6 hours per day, should be considered a par-
groups should
tial hospitalization program. But does such
cannot substitute serve as adjuncts
a program differ by kind or just by degree
to a treatment plan
from an IOT program? At what point does
for substance abuse devised within the
an IOT service become a partial hospitaliza-
practice guidelines
tion program? Programs in which clients
of the substance
treatment... attend sessions 9 hours per week are clearly
abuse treatment
more intensive than once-a-week outpatient
field. Likewise, the
programs. But where does outpatient end
American Psychiatric Association, American
and IOT begin? According to ASAM’s Patient
Academy of Addiction Psychiatry, and
Placement Criteria, IOT programs provide
American Society of Addiction Medicine
9 or more hours of structured programming
(ASAM) have issued a joint policy statement
per week; ASAM does not specify a minimum
that asserts that treatment involves at least
duration of treatment (Mee-Lee et al. 2001).
the following (American Society of Addiction
Medicine 1997): This TIP is intended to be equally useful
to all IOT programs, regardless of the num-
• A qualified professional is in charge of
ber of contact hours per week. But for the
treatment.
discussions and guidelines in this TIP to
• A thorough evaluation is performed to
be meaningful, IOT must be delimited. The
determine the stage and severity of illness
consensus panel agreed that IOT has the fol-
and to screen for medical and mental
lowing features:
disorders.
• A treatment plan is developed. • Contact hours per week: 6 to 30
• The treatment professional or program • Stages: Stepdown and step-up stages of
is accountable for the treatment and for care that vary in intensity and duration
referring the client to additional services, if • Duration: Minimum of 90 days followed
necessary. by outpatient continuing care
• The treatment professional or program • Core features and services:
maintains contact with the client until
recovery is completed. – Program orientation and intake
– Comprehensive biopsychosocial
According to the policy statement adopted by assessment
these treatment professionals’ associations, – Individual treatment planning
mutual-help groups are an important compo- – Group counseling
nent of treatment, but they cannot substitute – Individual counseling
for substance abuse treatment as outlined – Family counseling
above. – Psychoeducational programming
– Case management
– Integration of clients into mutual-help
and community-based support groups
– 24-hour crisis coverage

4 Chapter 1
– Medical treatment of care for clients and addresses the impor-
– Substance use screening and monitoring tance of transitioning clients to continuing
(urine or breath tests) community care.
– Vocational and educational services
– Psychiatric evaluation and Chapter 4—Services in Intensive Outpatient
psychotherapy Treatment Programs describes the core
– Medication management services a program should provide and
– Transition management and discharge enhanced services that often are delivered
planning on site or through established links with
community-based providers. Core services
• Enhanced services: include group counseling and therapy,
individual counseling, psychoeducational
– Adult education programming, pharmacotherapy and medi-
– Transportation cation management, monitoring substance
– Housing and food use, case management, 24-hour crisis cov-
– Recreational activities erage, induction into community-based
– Adjunctive therapies support groups, medical treatment, psychi-
– Nicotine cessation treatment atric screening and therapy, and vocational
– Child care training and employment services. Enhanced
– Parent skills training services include adult education, transpor-
tation, adjunctive therapies, and parenting
classes.
Summary of This TIP
The following topics are covered in this Chapter 5—Treatment Entry and
volume: Engagement addresses the complex and
critical processes of screening and diagnosis,
Chapter 2—Principles of Intensive placement, assessment, and treatment plan-
Outpatient Treatment presents 14 guid- ning. The desired result of these processes is
ing principles of IOT and the research that the client’s engagement in treatment at the
supports them. The principles combine the appropriate level of care and the implemen-
findings of substance abuse research with tation of treatment that addresses his or her
the experiences of practiced clinicians. The needs. This chapter discusses specific steps
principles are drawn from NIDA’s Principles in the IOT admission process, including
of Drug Addiction Treatment (National engaging and screening the client, assess-
Institute on Drug Abuse 1999), but the ing barriers to treatment, and attending to
chapter focuses on issues that are critical to crises; it also illustrates them in two case
effective delivery of IOT services. studies.
Chapter 3—Intensive Outpatient Treatment Chapter 6—Family-Based Services discusses
and the Continuum of Care places IOT a family systems approach to IOT that
within a broad substance abuse treatment acknowledges and supports the important
continuum that includes outpatient treat- role and influence of family members on
ment and continuing community care. This treatment outcomes. The chapter includes
chapter situates IOT within the framework goals and outcomes of family-based services
of ASAM’s levels of care and discusses goals, and strategies for engaging families in treat-
intensity and duration of treatment, treat- ment. The chapter also describes various
ment setting, and stages for Level I and types of family services (family education,
Level II care. The chapter discusses IOT multifamily groups, family therapy, retreats,
as both an entry point for substance abuse support groups) and clinical issues that often
treatment and a stepdown or step-up level arise when including families in treatment,

Introduction 5
such as unrealistic expectations and sabo- with co-occurring disorders, and adolescents
tage of the client’s recovery. and young adults. The chapter provides a
demographic overview of each group and
Chapter 7—Clinical Issues, Challenges, and discusses implications for IOT programming
Strategies in Intensive Outpatient Treatment as well as clinical issues and strategies to use
looks at issues and problems that arise in with each population.
clinical practice and offers solutions ground-
ed in research and clinical experience. The Chapter 10—Addressing Diverse Populations
chapter covers client retention, relapse and in Intensive Outpatient Treatment exam-
continued substance use, family members ines the importance of cultural competence
who abuse substances, group work issues, to substance abuse treatment. Reviewing
safety and security, client privacy, conflicting research that supports the need for indi-
mandates, clients who work, and boundary vidualized treatment, the chapter describes
issues. principles for the delivery of culturally com-
petent services and explores topics of special
Chapter 8—Intensive Outpatient Treatment concern: foreign-born clients, women from
Approaches provides detailed descriptions other cultures, and religious considerations.
of established IOT program models and Sketches of diverse populations include
approaches. The chapter describes 12-Step Hispanics/Latinos; African-Americans;
facilitation, cognitive–behavioral, moti- Native Americans; Asian Americans and
vational, therapeutic community, Matrix Pacific Islanders; persons with HIV/AIDS; les-
model, and community reinforcement and bian, gay, and bisexual individuals; persons
contingency management approaches. with physical or cognitive disabilities; rural
The descriptions address the key aspects, populations; individuals who are homeless;
research outcomes, and strengths and chal- and older adults. The sketches describe each
lenges of each approach. group’s demographic characteristics, statistics
Chapter 9—Adapting Intensive Outpatient on substance use, clinical considerations, and
Treatment for Specific Populations high- implications for IOT. A chapter appendix
lights the flexibility and adaptability of the contains an extensive list of resources on cul-
IOT model to meet the diverse needs of spe- turally competent treatment and on treating
cific populations: those involved with the members of each population.
criminal justice system, women, individuals

6 Chapter 1
2 Principles of Intensive
Outpatient Treatment

This chapter presents 14 principles that integrate the findings of


In This addictions research with the opinion of the consensus panel. By
synthesizing research and practice, the consensus panel will assist
Chapter... clinicians in applying these principles to the clinical decisions they
face daily. The 14 principles are expressed throughout this TIP in
Principle 1: Make Treatment the form of specific recommendations. They are summarized here to
Readily Available
provide a concise overview of effective intensive outpatient treatment
Principle 2: Ease Entry (IOT) principles.
Principle 3: Build on The Principles of Drug Addiction Treatment: A Research-Based Guide
Existing Motivation (National Institute on Drug Abuse 1999) offers a valuable start-
Principle 4: Enhance ing point for the principles that are described in this chapter. The
Therapeutic Alliance National Institute on Drug Abuse (NIDA) principles pertain to the
full spectrum of addiction treatment modalities, not only to IOT. The
Principle 5: Make consensus panel chose to accentuate the principles that are critical
Retention a Priority
to effective IOT.
Principle 6: Assess and Address
Individual Treatment Needs The 14 principles described in this chapter are

Principle 7: Provide Ongoing Care 1. Make treatment readily available.


Principle 8: Monitor Abstinence
2. Ease entry.
3. Build on existing motivation.
Principle 9: Use 4. Enhance therapeutic alliance.
Mutual-Help and Other
Community-Based Supports 5. Make retention a priority.
6. Assess and address individual treatment needs.
Principle 10: Use
Medications if Indicated
7. Provide ongoing care.
8. Monitor abstinence.
Principle 11: Educate About 9. Use mutual-help and other community-based supports.
Substance Use Disorders,
Recovery, and Relapse 10. Use medications if indicated.
11. Educate about substance abuse, recovery, and relapse.
Principle 12: Engage Families,
Employers, and Significant Others
12. Engage families, employers, and significant others.
13. Incorporate evidence-based approaches.
Principle 13: Incorporate 14. Improve program administration.
Evidence-Based Approaches

Principle 14: Improve Program


Administration
7
Principle 1: Make IOT programs have adjusted successfully to
the challenges of working with many special
Treatment Readily population groups that include
Available • Clients who are economically
disadvantaged (Gruber et al. 2000;
Accommodate a Wide Milby et al. 1996)
Spectrum of Clients Who Are • Clients who are psychiatrically com-
promised (Drake et al. 1998a, 1998b;
Substance Dependent Rosenheck et al. 1998)
Clinical research and practice have estab- • Pregnant women (Eisen et al. 2000; Howell
lished that IOT is an effective and viable way et al. 1999)
for individuals with a range of substance • Individuals involved with the criminal jus-
use disorders to begin their recovery. In the tice system and other clients coerced into
1980s, it commonly was believed that only treatment
clients who were relatively high functioning,
employed, and free of significant co-occurring IOT programs have modified their treat-
psychiatric disorders could benefit from IOT ment models to be responsive to the needs of
and that IOT was not effective with clients adolescents (Jainchill 2000) and women with
who were compromised by significant psy- children (Nardi 1998; Volpicelli et al. 2000).
chosocial stressors such as homelessness or In addition, panel members have described
co-occurring disorders. Today substantial the benefits of IOT programs with culturally
research and clinical experience indicate specific components for Native American
that IOT can be effective for clients with a and Spanish-speaking clients and IOT ser-
range of biopsychosocial problems, particu- vices for clients at various stages of treatment
larly when appropriate psychiatric, medical, readiness. The unique needs of specific cli-
case management, housing, and other sup- ent populations often can be met in IOT by
port services are provided. adding services and creating linkages with
other service providers.

Comparing Inpatient Treatment With


Intensive Outpatient Treatment
Several studies comparing intensive outpatient treatment with residential treatment have
found no significant differences in outcomes (Guydish et al. 1998, 1999; Schneider et al. 1996).
Finney and colleagues (1996), however, in a review of 14 studies, found that the available evi-
dence tended to favor inpatient slightly over outpatient treatment. The consensus panel has
concluded that clients benefit from both levels of care and that comparing inpatient with out-
patient treatment is potentially counterproductive because the important question is not which
level of care is better but, rather, which level of care is more appropriate at a given time for
each client. Matching clients with enhanced services also improves client outcomes. McLellan
and colleagues (1998) found that compared with control subjects, clients with access to case
managers who coordinated medical, housing, parenting, and employment services had less
substance use, fewer physical and mental health problems, and better social function after
6 months. It is in the best interest of clients to have a broad continuum of treatment options
available. Some clients entering IOT may be able to engage in treatment immediately, whereas
others may need referral to a long-term residential program or a therapeutic community. Some
clients can be detoxified successfully in an ambulatory setting, whereas others need residential
services to complete detoxification successfully.

8 Chapter 2
Principle 2: Ease Entry field is the notion that people have to
“hit bottom” before they can be helped.
Studies indicate that individuals who enter
Make Access to treatment for “the wrong reasons” (e.g.,
Treatment Straightforward complying with external pressures) have out-
and Welcoming comes that are comparable with outcomes
of those who come into treatment for the
IOT programs need to examine policies and “right reasons” (e.g., personal commitment
procedures to remove unnecessary hurdles to recovery) (Lawental et al. 1996).
in the admission process. From the moment
a client or family member first contacts Internal or external pressures drive people to
the program, efforts should be made to enter treatment. Reasons include negative con-
communicate that IOT exists to serve the sequences related to substance use such as an
client. Delays in the admission process con- arrest for driving under the influence, pressure
tribute significantly to premature dropout from family or friends, fear that substance use
from treatment (Festinger et al. 2002). IOT is out of control, despair, job insecurity, or a
programs should strive to make the initial trauma. An IOT program should accept that
appointment available on demand. a client’s presence in its office indicates some
desire for treatment services.
Programs should address the following:
Regardless of how well or poorly motivated
• Can the admission process be streamlined clients appear at treatment entry, their moti-
without hurting revenues? vation is likely to waver repeatedly over time.
• Are the program’s hours convenient for Both IOT programs and clients benefit when
clients? counselors keep clients mindful of what led
• How can the program facilitate transporta- them to treatment. Counselors should try
tion for clients? to understand what clients care about and
• How can the program accommodate clients connect client concerns with addressing
with childcare responsibilities? substance use. For example, if a client talks
• Is the program individualizing treatment frequently about her daughter, the counselor
for each client? might ask the client to consider how substance
The initial encounter with the IOT program use affects her relationship with the child.
should help the client feel like a welcomed Because of the central importance of motiva-
participant who is responsible for his or her tion in substance abuse treatment, strategies
recovery. IOT programs need to develop a to enhance and maintain client motivation
strong customer-focused orientation, making have been a priority in substance abuse
entry into treatment a positive and therapeu- research. Two well-researched approaches
tic experience. offer insights into and strategies for maxi-
mizing client motivation:
Principle 3: Build on • Contingency management and related
Existing Motivation behavioral interventions use incentives
to increase client retention in treatment
and abstinence. Contingency management
Employ Strategies That in addiction treatment has been studied
Enhance the Client’s for more than 30 years, but recent stud-
Motivation ies have focused on how its principles can
be applied in community-based settings
One of the oldest, yet still surviving, miscon- (Budney and Higgins 1998; Higgins and
ceptions in the substance abuse treatment Silverman 1999; Katz et al. 2001; Kirby et

Principles of Intensive Outpatient Treatment 9


al. 1999a; Petry 2000). These behavioral • The client’s capacity to work on his
intervention studies show that motivation or her problem
is negotiable and can be increased when • The client’s emotional bond with the
incentives are applied strategically and sys- therapist
tematically. IOT programs are encouraged • The therapist’s empathic understanding
to find creative ways to use incentives to of the client
increase treatment adherence and enhance • The agreement between client and thera-
outcomes. pist on the goals and tasks of treatment
• Motivational enhancement and interview-
ing are techniques whereby the counselor Therapeutic alliance tends to be enhanced
responds to client denial and resistance when clinicians are active listeners, empath-
by proposing thoughtful and detailed ic, and nonjudgmental and approach
strategies that are designed to increase treatment as an active collaboration (Mercer
client readiness to change (CSAT 1999c; and Woody 1999).
Miller and Rollnick 2002; Prochaska and Clinical supervisors should consider the
DiClemente 1984). The approach is based counselors’ ability to establish and maintain
on the theory that clients being treated for a therapeutic alliance when hiring and eval-
substance use disorders go through five uating staff. Staff training and supervision
stages of change: precontemplation, con- should emphasize consistently that therapeu-
templation, action, relapse, and mainte- tic alliance is an important element of any
nance. Client resistance to treatment indi- clinical interaction. Performance monitor-
cates that the counselor may be attempting ing and quality improvement activities can
to move the client to the next stage too capture and measure data on therapeutic
quickly. alliance, so staff members can improve their
skills at fostering this important treatment
element (see CSAT 2006f).
Principle 4: Enhance
Therapeutic Alliance
Principle 5: Make
Implement Strategies Retention a Priority
That Build Trust Between
Counselor and Client Place a Premium on
In treating mental and substance use dis- Retaining Clients
orders, research repeatedly has found Early termination of treatment harms the
one factor to be particularly important in client and staff morale. When clients drop
influencing positive outcomes: therapeutic out of treatment prematurely, they are at
alliance (Martin et al. 2000). In fact, thera- increased risk of relapse. Completing a pre-
peutic alliance is one of the few aspects of scribed treatment episode is associated with
treatment that consistently has been linked better outcomes, regardless of the length of
with increased retention in treatment and the treatment (Gottheil et al. 1998).
improvement in a variety of treatment out-
comes. The achievement and maintenance Given the large number of clients who drop
of therapeutic alliance are high priorities in out in the first few weeks of treatment, pro-
treatment. grams should use strategies and approaches
that ensure that clients will complete treat-
Therapeutic alliance has four components ment, such as conducting preadmission
(Gaston 1991): interviews (Martino et al. 2000), delivering
phone reminders and mailed reminders,

10 Chapter 2
using phone orientations, and decreasing the those needs, out-
initial call-to-appointment delay (Stasiewicz comes improve The achievement
and Stalker 1999). (Hser et al. 1999;
McCaul et al. and maintenance of
A major strength of IOT is that clients have 2001; McLellan
the opportunity to cope with their illness et al. 1998, 1999).
and make changes in their behavior while therapeutic alliance
NIDA’s Principles
living at home. Individual differences in of Drug Addiction
how quickly clients adopt new behaviors call Treatment notes are high priorities
for clinical sophistication and flexibility on that “matching
the part of counselors and the program as a treatment settings, in treatment.
whole. It can be frustrating when clients do interventions, and
not accept immediately the clinical approach services to each
that the IOT program is using. Clients can be individual’s particular problems and needs
frustrated when they are forced into making is critical to his or her ultimate success in
major lifestyle changes that do not yet make returning to productive functioning in the
sense to them. Under such circumstances, family, workplace, and society” (National
clients may drop out. Programs need coun- Institute on Drug Abuse 1999, p. 3). IOT
seling approaches that help clients move programs need to find increasingly efficient
toward higher levels of healthy functioning. strategies for assessing treatment needs and
implementing individualized care plans.
Principle 6: Assess and
Address Individual Principle 7: Provide
Treatment Needs Ongoing Care
Match Treatment Services Employ a Chronic Care Model,
to Clients’ Needs Adjusting Intensity According
At intake, treatment providers gather pre- to Clients’ Needs
liminary information from clients; then, A substance use disorder is a complex bio-
shortly after admission, programs typically psychosocial illness that is not amenable to
complete a comprehensive biopsychosocial a quick fix. In addition to their substance
assessment. Many programs administer use disorders, clients often have significant
standardized assessments, such as the psychiatric disorders, criminal involvement,
Addiction Severity Index (McLellan et al. histories of physical and sexual trauma, seri-
1992a, 1992b) as well as other specific and ous medical illnesses, or profound economic
multidomain assessments. After collecting challenges or are homeless. IOT programs
detailed information about clients’ histories contribute to society when they successfully
and future goals, programs need to use this assist clients in improving their ability to
information to tailor treatment services to function in the community, in the workplace,
clients. and in their families. The successful initia-
tion and maintenance of this transformation
When clients have unmet psychiatric, medi- require sustained and conscientious efforts
cal, legal, housing, social, family, or other by the client, his or her support system, and
personal needs, their ability to focus on a clinical team.
recovery can be compromised. When pro-
grams match the individual treatment needs Substance abuse is a chronic illness similar
of clients to treatment services that address in many respects to other chronic diseases

Principles of Intensive Outpatient Treatment 11


such as asthma, diabetes, and hyperten- term outcomes (McKay et al. 1999). Although
sion (McLellan et al. 2000). During the early it is true that not all clients readily can
phase of treatment, intensive interventions achieve abstinence without relapsing a few
may be required, including hospitaliza- times, it also is true that outcomes are best
tion. As the client’s condition changes, the for those clients who have stopped using
intensity of treatment gradually can be drugs and have submitted a drug-free urine
increased or decreased depending on the sample before entering treatment (Ehrman
client’s condition. Eventually client care may et al. 2001). To monitor abstinence, IOT
be reduced to periodic checkups that evalu- programs should use urine drug screens,
ate the client’s status and adjust treatment Breathalyzer™ tests, or other laboratory tests
accordingly. A substance use disorder often to confirm self-reported abstinence. Urine
is treated as if it were an acute illness that drug screens can be an effective adjunct in
responds to a brief, acute course of treat- treatment and can contribute to improved
ment. Frequently, a 6-week IOT experience treatment outcomes (National Institute on
is not followed by a stepped-down phase of Drug Abuse 1999). Although cost consider-
counseling sessions. For many clients, this ations may limit the frequency of urine drug
abrupt shift from intensive treatment to dis- screens and Breathalyzer tests, the consensus
charge is destabilizing. Because substance panel strongly encourages the use of these
abuse is a chronic condition and relapse objective measures of abstinence.
is always a possibility, IOT programs are
encouraged to examine how they can provide
smoother stepdown processes and continu- Principle 9: Use
ing care services that are responsive to the
chronic nature of substance use disorders.
Mutual-Help and
Following their successful completion of
Other Community-
an intensive phase of treatment, clients Based Supports
should be evaluated for their readiness to
be transferred to less intensive levels of care. Assist Clients in Successfully
Gradually, clients should be transitioned
from several therapeutic contacts per week
Integrating Into Mutual-Help
to weekly contact to semimonthly contact and Other Community-Based
and so on. The concept of graduation should Support Groups
be reframed to convey clearly—as it is in col-
Participation in mutual-help programs, such
leges and universities—not an ending but a
as 12-Step programs and treatment pro-
commencement or a new beginning.
grams that facilitate 12-Step membership,
is associated with better outcomes than par-
Principle 8: Monitor ticipation in types of treatment that do not
facilitate 12-Step membership (Humphreys
Abstinence et al. 1997; Moos et al. 1999; Project
MATCH Research Group 1997; Vaillant
Recognize the Progress That 1983; see McCrady and Miller 1993, for a
review of the Alcoholics Anonymous [AA]
Clients Make in Achieving and research literature). Clients who become
Maintaining Abstinence involved in 12-Step programs after they step
Programs might consider requiring 30 days down from IOT tend to do significantly bet-
of abstinence before transitioning clients to ter than those who do not participate in such
a less intense level of care because extended programs (Moos et al. 1999). IOT programs
abstinence is associated with positive long- should facilitate clients’ becoming integrated

12 Chapter 2
successfully into healthy, community-based
mutual-help groups, such as AA
Principle 10: Use
(www.alcoholics-anonymous.org) and Medications if
Narcotics Anonymous (NA) (www.na.org),
during treatment. IOT programs should
Indicated
assist clients directly in locating a home
group and a sponsor and in becoming ori- Use Appropriate Medications
ented to the culture of 12-Step programs. To Manage Co-Occurring
It is not sufficient simply to refer clients to Substance Use and
AA or other 12-Step groups. Just as a physi- Psychiatric Disorders
cian works with patients to find the right A substantial percentage of clients with sub-
medication and dosage, counselors need to stance use disorders also have co-occurring
help clients identify the right type of meeting psychiatric conditions (Kessler et al. 1996;
and frequency of attendance (Forman 2002). Marlowe et al. 1995). Psychiatric medications
Just as patients often have unwanted side are critically important in the treatment of
effects from medications, particularly when these co-occurring conditions (Carroll 1996a;
they first start taking them, clients who begin Drake et al. 1998b; Minkoff 1997). Ideally,
attending 12-Step and other mutual-help IOTs should provide psychiatric evaluation
groups often experience some minor side and medication management on site. If fund-
effects. IOT programs can help clients mini- ing limitations make it impossible to offer
mize the negative side effects by providing this care on site, then efficient and function-
orientation and support as clients adjust to ing links with mental health providers need
this important treatment element. (There are to be maintained.
many 12-Step meetings for the family, such
as Al–Anon/Alateen [www.al-anon.alateen. Resistance to the use of psychiatric medi-
org] and Nar-Anon [naranon.com], as well as cations by substance abuse treatment
groups for compulsive behaviors such as sex, clinicians is gradually being replaced by
gambling, spending, and eating.) an appreciation for the valuable role these
medications can
Many individuals who are substance depen- play when used
dent find abstinence through participation appropriately. Substance abuse
in faith-based organizations, and many reli- Likewise, both NA
gious groups offer support for individuals and AA historically
who are seeking recovery. Other individuals is a chronic illness
had been averse to
have benefited from support groups such as medications of any
Rational Recovery (www.rational.org), Smart similar...to other
kind, but both have
Recovery (www.smartrecovery.org), or Women published state-
for Sobriety (www.womenforsobriety.org) ments supporting chronic diseases such
that offer an alternative to 12-Step meetings. the appropriate
Giving clients a choice of support groups is use of medica- as asthma, diabetes,
empowering because it enables them to make tions (Alcoholics
informed decisions. Anonymous and hypertension.
World Services
1991; Narcotics
Anonymous 1998).

A number of pharmacotherapies have been


shown to be effective adjuncts to the treat-
ment of substance abuse. Naltrexone has

Principles of Intensive Outpatient Treatment 13


been effective with some people who are sources mentioned throughout this volume,
alcohol dependent (Guardia et al. 2002). but a good starting place is chapter 4 of
However, a multisite study by Krystal and TIP 33, Treatment for Stimulant Use
colleagues (2001) found that naltrexone was Disorders (CSAT 1999e). IOT programs
not effective in treating men with chronic, are encouraged to develop recovery curricula
severe alcohol dependence. Under certain for clients (or use one already developed)
conditions, naltrexone has been effective and to facilitate opportunities for clients
in treating individuals addicted to opioids to practice recovery skills while in treat-
(Cornish et al. 1997). Similarly, disulfiram ment. Substance refusal training, stress
(Antabuse®) has been an effective adjunct management, assertiveness training, relapse
in the treatment of alcoholism (O’Farrell et prevention, and relaxation training are
al. 1998). Some IOT programs have imple- important behavioral techniques that can
mented treatment be incorporated into IOT programs (Carroll
tracks for cli- 1998; CSAT 1999e; Daley 2001, 2003; Marlatt
ents maintained and Gordon 1985; Mercer and Woody 1999).
Ideally, IOTs Clients should be provided with up-to-date
on methadone.
Buprenorphine information about the biology of substance
should provide (Ling et al. 1998; use disorders, mutual-help programs, and
O’Connor et appropriate use of medications.
psychiatric evaluation al. 1998) and
Given the significant body of informa-
buprenorphine
and medication tion that clients might need to support
combined with nal-
their recovery, programs are encouraged
oxone (Fudala et al.
to explore the use of videotapes, written
management on site. 1998; Mendelson et
materials, and Web-based resources to help
al. 1999) are now
clients understand addiction and recovery.
available for the
Consideration should be given to multiple
treatment of opioid dependence and can be
approaches to educating clients, including
prescribed at IOT programs that have medi-
lectures, discussions, workbook assignments,
cal personnel on staff.
behavioral rehearsals or role plays, and
daily logs or journals. Evaluation processes,
Principle 11: Educate such as feedback sessions, that monitor the
clients’ comprehension of key recovery skills
About Substance Use are needed.
Disorders, Recovery,
and Relapse Principle 12: Engage
Families, Employers,
Provide Clients and Family
Members With Information and Significant Others
About Substance Use Include Others Throughout
Disorders, Recovery Skills, and the Treatment Process
Relapse Prevention
The therapeutic involvement of families
An important task in IOT is educating clients throughout the recovery process is associ-
about substance use disorders and the skills ated with improved treatment outcomes
they need to live comfortably in recovery. A (Epstein and McCrady 1998; McCrady et
wealth of accurate, free information about al. 1999; O’Farrell and Fals-Stewart 2003;
substance abuse and recovery skills is avail- Szapocznik and Williams 2000; White et al.
able to clinicians through Web sites and other

14 Chapter 2
1998; Winters et al. 2002). Families can be • 12-Step facilitation (Nowinski et al. 1992)
a vital resource and a source of support and • Case management (McLellan et al.
encouragement. Conversely, families also 1998, 1999)
can influence the client adversely and under-
mine recovery. All clients are part of a group IOT programs can adopt methods from these
that functions as a “family” and as such are various treatment interventions. NIDA, the
subject to the values, traditions, and culture National Institute on Alcohol Abuse and
of that family. IOT programs can marshal Alcoholism (NIAAA), and the Center for
families’ powerful positive influences or Substance Abuse Treatment (CSAT) have
counter their negative influences by educat- published manuals about these approaches,
ing, counseling, and providing therapeutic and most of these manuals are available
family services. Referrals to therapists and free of charge. A number of other evidence-
organizations that provide family therapy based manuals are listed throughout this
should be considered when family therapy is TIP, including documents from NIAAA
unavailable in the IOT program. Project MATCH and CSAT’s Addiction
Technology Transfer Centers and other
When an individual has been referred for CSAT publications.
treatment by an employee assistance or stu-
dent assistance program, representatives of Some counselors who enter the substance
the employer and school can play a potent abuse treatment profession do not have
role in supporting adherence to the treat- extensive training. For them, the needed
ment plan and ongoing recovery. skills are learned on the job. Evidence-
based manuals summarize the experience
of knowledgeable clinicians and research-
Principle 13: ers, passing on effective techniques and
approaches that have been refined over the
Incorporate Evidence- years. Not all IOT programs are the same—
Based Approaches some achieve better outcomes than others.
IOT programs can improve their outcomes
by successfully incorporating evidence-based
Seek Out Evidence-Based approaches. The consensus panel encourag-
Training Opportunities and es the use of evidence-based approaches as a
Materials means of improving treatment outcomes.
Over the past 30 years a number of treat-
ment approaches have been developed, Principle 14: Improve
tested, and demonstrated to be effective in
a variety of settings (see chapter 8 for more Program Administration
information). These approaches include
• Cognitive–behavioral therapy (Carroll 1998)
Focus on Financial,
• Motivational enhancement therapy Information, and Human
(CSAT 1999c; Miller and Rollnick 2002; Resource Management
Prochaska and DiClemente 1984)
Clinicians frequently are promoted into the
• Individual drug counseling (Mercer and
role of IOT program director without any
Woody 1999)
formal training in how to function as an
• Relapse prevention training (Carroll et al.
administrator. The tasks of management
1998; Daley 2001, 2003; Daley and Marlatt
differ significantly from those of a clinician,
1997; Daley et al. 2003)
and the transition from one role to the other
• Contingency management and incentives
is not always a smooth or natural one. IOT
(Budney and Higgins 1998; Petry 2000)

Principles of Intensive Outpatient Treatment 15


managers focus on the program’s finances, 46, Substance Abuse: Administrative Issues
regulatory compliance, human resource in Outpatient Treatment (CSAT 2006f),
management, information management, addresses the administrative issues that IOT
administrative report preparation, and a managers need to master to manage pro-
host of other tasks that were not in their grams effectively.
list of responsibilities as clinicians. TIP

16 Chapter 2
3 Intensive Outpatient
Treatment and the
Continuum of Care

Overview of a Continuum of Care


In This “Continuum of care” refers to a treatment system in which clients
enter treatment at a level appropriate to their needs and then step
Chapter... up to more intense treatment or down to less intense treatment as
needed. As outlined by Mee-Lee and Shulman (2003), an effective
Overview of a continuum of care features successful transfer of the client between
Continuum of Care levels of care, similar treatment philosophy across levels of care,
and efficient transfer of client records. The American Society of
Conceiving of a Addiction Medicine (ASAM) has established five main levels in a con-
Continuum of Care tinuum of care for substance abuse treatment:
Key Aspects of IOT • Level 0.5: Early intervention services
(Level II) • Level I: Outpatient services
Key Aspects • Level II: Intensive outpatient/Partial hospitalization services (Level
of Outpatient II is subdivided into levels II.1 and II.5)
Treatment (Level I) • Level III: Residential/Inpatient services (Level III is subdivided
into levels III.1, III.3, III.5, and III.7)
Continuing • Level IV: Medically managed intensive inpatient services
Community Care
These levels should be thought of not as discrete levels of care but
rather as points in a continuum of treatment services (Mee-Lee and
Shulman 2003).
From program to program, the treatment philosophy, services, set-
tings, and client characteristics may vary for any given level of care
because some aspects of treatment may be tailored to a specific
population. For instance, a rural residential program primarily treat-
ing women who are alcohol dependent would be quite different from
an urban residential program treating mostly men dependent on
stimulants. Despite variability in the specific features of intensive
outpatient treatment (IOT) or Level II care in programs across the
country, the continuum of care model tries to ensure consistency
throughout treatment and to ease the process of moving clients
through treatment.

17
In addition to the levels of care described by of ambulatory care that serves the following
ASAM, outpatient treatment can be broken functions:
down into four sequential stages that clients
work through, regardless of the level of care • An entry point into substance abuse
at which they enter treatment: treatment. The client comes to the IOT
program, an assessment reveals that the
• Stage 1—Treatment engagement client would benefit from IOT (see chap-
• Stage 2—Early recovery ter 5 of this TIP for placement criteria), a
• Stage 3—Maintenance treatment plan is developed, and services
• Stage 4—Community support are begun.

These stages are discussed later in the chap- • A stepdown level of care. The client is
ter in the context of IOT and outpatient transitioned to the IOT program from an
treatment. inpatient or residential facility. In this
case, the client may have been stabilized in
a hospital facility or residential treatment
Conceiving of a program and now needs intensive treat-
ment services to achieve or maintain absti-
Continuum of Care nence as well as address other problems.
To reinforce the idea of a continuum of
care, Mee-Lee and Shulman (2003) suggest • A step-up level of care. The client is
that clinicians and administrators “envi- referred to the IOT program if he or she
sion admitting the client into the continuum has been unsuccessful in outpatient treat-
through their program rather than admitting ment or continuing community care and is
the client to their program” (p. 456). This assessed as needing an intensive and struc-
early focus on mov- tured level of care to regain abstinence,
ing the client along work on relapse prevention skills, and
IOT is part of a the continuum also address other issues.
prompts clinicians
seamless continuum to look ahead to
the next step in a
Assisting the Client Along the
of levels of care. client’s treatment. Continuum
This, in turn, helps IOT is part of a seamless continuum of levels
clinicians engage of care. Moving the client along the continuum
in the treatment planning that is integral not may require the IOT provider to refer the cli-
only to the client’s ongoing care but also to ent to another treatment organization or may
the transition from one level of treatment to be the result of an internal transfer to another
the next. component of a comprehensive IOT program.

Any change of setting, staff, or peers inter-


IOT Programs and the jects a risk of the client’s dropping out of
Continuum of Care treatment. Experience suggests that the
administrative paperwork and approvals
IOT programs are diverse and flexible with
needed to transfer a client between levels
respect to the spectrum, intensity, and dura-
of care within the same organization can
tion of services and the settings in which
be accomplished with less disruption for the
services are delivered. They are, there-
client than a referral to a new provider
fore, well suited to meet the varied needs
organization. Consequently, when referrals
of persons with substance use disorders.
are made to a nonaffiliated provider
Conceptually, IOT is an intermediate level

18 Chapter 3
organization, coordination and case manage- al. 2001). Although IOT programs generally
ment needs increase. provide structured programming for 9 hours
or more per week spread over 3 to 5 days,
some IOT programs provide fewer hours. The
Key Aspects of IOT consensus panel recommends that the num-
(Level II) ber of programming hours be 6 to 30 hours,
based on client needs. Some clinicians find
After considering IOT from the broad that more frequent, shorter visits are of great-
perspective of the continuum of care, it is er benefit to the client than less frequent
necessary to look within Level II to under- but longer sessions. However, some clients
stand IOT’s particular goals, intensity, require longer treatment sessions, similar
duration, settings, and stages. in intensity to partial hospitalization. More
research is needed on optimal treatment
IOT Goals intensity and factors to be considered in
increasing or decreasing treatment intensity.
Goals of IOT programs vary based on such
factors as the treatment population, program
comprehensiveness, and the program’s phi- Duration of Treatment
losophy. Although programs differ, all IOT The recommended minimum duration of
programs attempt to address the following the IOT phase often is cited as 90 days.
general goals: Low-intensity outpatient treatment over a
• To achieve abstinence longer period may be a cost-effective means
• To foster behavioral changes that support to enhance treatment outcomes because this
abstinence and a new lifestyle approach is associated with less substance
• To facilitate active participation in use and better social functioning in clients
community-based support systems (e.g., (Moos et al. 2001). Duration of treatment
12-Step fellowship) should be increased or decreased based on
• To assist clients in identifying and address- the client’s clinical needs, support system,
ing a wide range of psychosocial problems and psychiatric status, among other factors.
(e.g., housing, employment, adherence to Longer duration of care is related to better
probation requirements) treatment outcomes (Moos and Moos 2003).
• To assist clients in developing a positive
support network Treatment Settings
• To improve clients’ problemsolving skills
and coping strategies IOT can be provided in any setting that
meets State licensure or certification criteria
(Mee-Lee et al. 2001). Programs offering IOT
Intensity of Treatment only and comprehensive programs offering
Relative to traditional outpatient treat- several levels of care may differ in structures
ment, IOT provides an increased frequency and services provided. IOT programs that are
of contact and services that respond to the part of a large hospital setting can provide
chronicity and severity of substance use medical detoxification services, pharmaco-
disorders and other problems experienced therapy, and treatment for other medical
by clients. The actual number of hours and and psychiatric conditions. IOT programs
days per week that clients participate in IOT located in prison facilities treat offenders
varies depending on individual client needs. with alcohol and drug problems and success-
State licensure bodies may require 9 treat- fully link offenders with stepdown services
ment hours; ASAM defines IOT as 9 hours in the community on release. Other IOT
of treatment per week for adults (Mee-Lee et programs may be located near vocational

Intensive Outpatient Treatment and the Continuum of Care 19


training sites so that welfare recipients and to substance abuse; physical, psychological,
others easily can attend both treatment and and social functioning; and social support
training sessions in homeless shelters and in network. Also, the counselor explains pro-
modified therapeutic community programs. gram rules and expectations and works to
stabilize any crises. Exhibit 3-1 presents the
goals, duration, counselor activities, and
Stages of Treatment completion criteria of this stage of IOT.
Within IOT or Level II care, treatment often
is delivered in sequential stages, with service Stage 2—Early recovery
intensity and structure lessening as clients
progress. As IOT services taper in intensity, Goals and duration. This stage is highly
the client assumes increasing responsibility structured with educational activities, group
and is provided less structure and supervi- involvement, and new behaviors to help the
sion from treatment staff. IOT programs client develop recovery skills, address lapses,
should have the flexibility to increase the and build a substance-free lifestyle. Exhibit
intensity of services if the client’s lack of 3-2 presents the goals, duration, counselor
progress indicates such a need. activities, and completion criteria of this
stage of treatment.
Sequenced IOT can motivate clients, help
them succeed in reaching recovery milestones
and in meeting the criteria for completing Transition to Outpatient
a treatment stage, and provide an incentive Treatment
for clients to grow and progress. Marking the Effective treatment in a continuum of
passage from one IOT stage to the next with care includes ongoing, less intensive, and
a celebration or ceremony also motivates tapered contact with treatment systems,
clients. Sequenced stages allow complex much as with other chronic health condi-
information to be broken into small units tions (McLellan et al. 2000). The client and
that can be modified and made appropriate counselor must prepare for the transition
for each client’s cognitive and psychological to less intensive treatment, a juncture that
functioning and stage of readiness. presents a high dropout risk. This stepdown
IOT may be conceptualized as having two level of care sometimes is provided as part of
core stages, which correspond with the a comprehensive IOT program by the same
client’s progress in treatment: stage 1—treat- staff and in the same facility. In other cases,
ment engagement and stage 2—early recovery. clients are transferred through formal link-
Definitions of IOT, such as those adopted by ages to outpatient treatment delivered by a
some States or health insurers, may include separate community-based program, often
additional or fewer stages or may blend simi- referred to as standard, traditional, or—in
lar goals and services within different stages. this TIP—simply outpatient treatment.

Stage 1—Treatment Compatible models of care


engagement The consensus panel believes that, when-
ever possible, the client should be referred
Goals and duration. One of the most to an outpatient treatment program with a
critical tasks for the counselor and clinic is treatment model (e.g., 12-Step, cognitive–
encouraging the client to remain in treat- behavioral, combined) that is compatible
ment. Many clients drop out of treatment with that offered by the IOT program to
after attending only a few sessions. During ensure that the client is not confronted
this initial stage, the counselor determines with significantly different treatment goals,
the client’s presenting problems with respect approaches, and philosophies. If a client is

20 Chapter 3
Exhibit 3-1

Goals, Duration, Activities, and Completion Criteria of Stage 1

Goals of the treatment engagement stage:


• Establish a treatment contract with the counselor that specifies treatment goals, client
responsibilities (e.g., attend group sessions, remain abstinent, submit urine samples),
and the counselor’s efforts to help clients meet treatment goals and responsibilities.
• Work to resolve acute crises.
• Engage in a therapeutic alliance.
• Prepare a treatment plan with help from the counselor.

Duration of the treatment engagement stage: A few days to a few weeks

Counselor activities of the treatment engagement stage:


• Confirm diagnosis, eligibility, and appropriate placement in this level of care.
• Assess biopsychosocial problems and match services to the most pressing problems.
• Determine readiness for treatment.
• Provide feedback about assessment findings and formulate an initial treatment plan
and treatment contract.
• Explain program rules, expectations, and confidentiality regulations.
• Address acute crises.
• Manage withdrawal symptoms.
• Resolve scheduling, payment, and counselor assignment issues.
• Obtain medical and psychological diagnoses and treatment, including
pharmacotherapy.
• Foster therapeutic alliances between client and counselor and client and
group members.
• Begin psychoeducational activities.
• Identify potential sources of social support.
• Initiate family contacts and education (with client’s permission).

Completion criteria: Clinical indications that support the client’s transition from the
treatment engagement stage to the early recovery stage include the client’s having
• Completed the assessment process
• Completed withdrawal from substance use
• Resolved immediate crises
• Completed orientation
• Established a treatment plan
• Attended scheduled sessions regularly

to be transferred to a program with a differ- confusing and the client can benefit from the
ent philosophy, the client should be oriented new program.
to the differences so that the transition is not

Intensive Outpatient Treatment and the Continuum of Care 21


Exhibit 3-2

Goals, Duration, Activities, and Completion Criteria of Stage 2

Goals of the early recovery stage:


• Maintain abstinence.
• Demonstrate ability to sustain behavioral changes.
• Eliminate drug-using lifestyle and replace it with treatment-related routines and drug-
free activities.
• Identify relapse triggers and develop relapse prevention strategies.
• Identify personal problems and begin to resolve them.
• Begin active involvement in a 12-Step or other mutual-help program.

Duration of the early recovery stage: 6 weeks to about 3 months


Counselor activities of the early recovery stage:
• Assist clients in following their individual plans to achieve and sustain abstinence.
• Assist clients in identifying relapse triggers and developing strategies to avoid or cope
with triggers.
• Support evidence of positive change.
• Initiate random drug tests and provide rapid feedback of results.
• Assist clients in successfully integrating into a 12-Step fellowship or other mutual-help
program.
• Help clients develop and strengthen a positive social support network.
• Encourage participation in healthful recreation and social activities.
• Continue pharmacotherapy, if appropriate, and other medical and psychiatric
treatments.
• Offer education on topics such as hepatitis C and HIV infection, anger management,
and parenting.
• Continue assessments for other issues requiring intervention.
• Educate clients and family members on addiction, the recovery process, and relapse.
• Provide family and multifamily counseling.
• Introduce families to 12-Step and other mutual-help programs appropriate for them;
help families integrate into support groups.

Completion criteria: Clinical indications that support the client’s transition from the
early recovery stage of IOT to the next level of care include the client’s having
• Sustained abstinence for 30 days or longer
• Completed goals as indicated in the treatment plan
• Created and implemented a relapse prevention and continuing care plan
• Participated regularly in a support group
• Maintained a sober social support network
• Obtained stable, drug-free housing
• Resolved medical, psychiatric, housing, and peer situations that may trigger relapse

22 Chapter 3
Transition planning Comparison of IOT and
An individual transition plan helps the Outpatient Treatment
client transition from one level of care to A study by McLellan and colleagues (1997)
another and provides an important link compared several components of 6 IOT pro-
between his or her current treatment pro- grams and 10 outpatient treatment programs.
vider and the next. To prepare an effective Both types of programs provided group and
transition plan, the IOT counselor can individual abstinence counseling, relapse
• Engage the client as an active participant prevention programming, and drug and alco-
in developing the plan early in IOT, includ- hol education. The IOT programs’ treatment
ing setting goals, establishing criteria for duration ranged from 30 to 90 days, and they
measuring progress, and identifying activi- provided 3 to 5 sessions per week. Hours per
ties that will be part of ongoing treatment. session ranged from 3 to 6. The outpatient
• Maintain a working knowledge of the ser- programs’ treatment duration ranged from
vices and resources that are available in 45 to 60 days, and they provided 1 to 2 ses-
the community. sions per week. Hours per session ranged from
• Develop strong working relationships with 1 to 2. Whereas the IOT programs provided
staff of key agencies (e.g., justice organiza- more substance abuse counseling than the
tions, employers) to facilitate the transi- outpatient treatment programs, the outpatient
tion, make special arrangements as need- treatment programs were more likely than
ed, and eliminate unnecessary barriers for IOT programs to offer medical appointments,
the client during transition. family therapy sessions, psychotherapy, and
• Obtain the client’s written consent and employment counseling (McLellan et al. 1997).
arrange for the smooth and timely transfer Although outpatient treatment duration is
of clinical information or documents to the typically 60 days, it is suggested strongly that
new treatment program. clients be scheduled for periodic followup ses-
The panel recommends that the responsibil- sions on a long-term basis. The best outcomes
ity for client care be transferred clearly before from treatment of substance use disorders
a provider relinquishes clinical responsibility. have been seen in clients who participate in
continuing care, such as methadone mainte-
nance or Alcoholics Anonymous-style support
Key Aspects of programs (McLellan et al. 2000). Because the
availability of funding for followup appoint-
Outpatient Treatment ments varies, outpatient treatment programs
(Level I) might consider strategies for establishing a
service model that supports the delivery of
For clients who are stepped down from IOT, followup sessions.
outpatient treatment offers the support they
need to continue developing relapse pre-
vention skills and resolving the personal, Stepdown Treatment
relationship, employment, legal, and other Clients who have completed stages 1 and 2
problems often associated with early recovery. of their treatment at the IOT level of care
can step down to outpatient treatment
Outpatient Treatment Goals programs and enter stage 3—maintenance,
having demonstrated a commitment to
The goals, strategies for treatment engage- change, been stabilized, become abstinent,
ment, and recovery services of outpatient and developed relapse prevention skills.
treatment are similar to those of IOT.
However, the intensity and duration of the
services differ from those provided in IOT.

Intensive Outpatient Treatment and the Continuum of Care 23


Stage 3—Maintenance services, and encouraging clients who drop
Goals and duration. Stage 3—maintenance out to reengage with treatment.
helps the client build on gains made during
stages 1 and 2. The goals, duration, counselor
activities, and completion criteria of this stage
Continuing
of treatment are presented in exhibit 3-3. Community Care
Continuing community care following
Transfer to Continuing IOT and stepdown care is essential for all
IOT clients, especially for those who may
Community Care have other long-term psychiatric, social, or
Having completed stage 3 of their treatment, medical issues. The process of rebuilding
clients are discharged from formal treat- a healthy, productive, and stable life takes
ment to continuing community care. Clients years, and maintaining gains made over time
who remain within a system of ongoing may require continuous support for some
care relevant to their needs are more likely individuals.
to maintain their gains in abstinence and
overall lifestyle changes. Participation in Once the client maintains abstinence and
continuing community care is related to an has begun to address other serious problems
increase in positive outcomes (Miller et al. that could threaten recovery, the client can be
1997; Ritsher et al. 2002). Continuing care discharged into continuing community care.
planning is therefore a central task for IOT Stage 4—community support consists of the
program staff whose clients remain in step- client’s participating in 12-Step or other mutual-
down care within the program. IOT programs help groups and meeting with psychologists,
that refer clients to separate programs for a case managers, or staff from community-based
stepdown level of care must ensure, through agencies, with limited support and involve-
their referral agreements and procedures, ment from the treatment program.
that the outpatient treatment program agrees
to engage in continuing care planning.
Services in Continuing
Continuing community care in the form of Community Care
12-Step support groups, faith fellowship,
As part of continuing care services, programs
or other community-based organizations is
can sponsor alumni meetings and provide
sometimes neglected by treatment provid-
booster or checkup counseling sessions at
ers because of the difficulties of remaining
the IOT or outpatient treatment facility.
engaged with clients after formal treatment
Periodic telephone contact also may be valu-
is completed. Still, the benefits of carefully
able (McKay et al. 2005). Other aspects of
planning for transferring clients into com-
continuing care include involvement with
munity support groups are such that added
selected community resources as needed,
attention should be given to these tasks. To
such as vocational training, recreational
ensure client access to a full continuum of
therapy, family therapy, or medical care.
care, treatment programs need to be aware
of support groups and other community
resources and introduce this information to Stage 4—Community support
clients early in the treatment process. Other Goals and duration. This stage is based on
key responsibilities for providers include a detailed and individualized discharge plan
ensuring transition of case management for continuing recovery in the community
responsibilities, supporting clients’ early using available resources. Exhibit 3-4 presents
engagement in continuing community care, the goals, duration, counselor activities, and
contributing to the expansion of community completion criteria of this stage.

24 Chapter 3
Exhibit 3-3

Goals, Duration, Activities, and Completion Criteria of Stage 3

Goals of the maintenance stage:


• Solidify abstinence.
• Practice relapse prevention skills.
• Improve emotional functioning.
• Broaden sober social networks.
• Address other problem areas.

Duration of the maintenance stage: About 2 months to 1 year

Counselor activities of the maintenance stage:


• Continue teaching and helping clients practice relapse prevention skills and refine
plans to address relapse triggers.
• Help clients acknowledge and quickly contain “slips” to keep them from becoming full-
blown relapses.
• Support clients as they work through painful feelings (e.g., sadness, anxiety, loneliness,
shyness, shame, guilt).
• Teach clients new coping and problemsolving skills that increase self-esteem and
improve interpersonal relationships, including better communication skills, anger man-
agement skills, and making amends.
• Help clients identify vocational or educational needs, improve work-related functioning,
resolve family conflicts, and initiate new recreational activities.
• Facilitate client linkages with community resources that foster clients’ interests and
offer needed services for accomplishing life goals.
• Assist clients in making and sustaining positive lifestyle changes.
• Encourage continuing participation in support groups and ongoing work with a sponsor.
• Emphasize the importance of spirituality or altruistic values that help clients see
beyond themselves and work for community goals.
• Continue monitoring random drug test results and providing feedback on results.
• Continue pharmacotherapy, as needed, and other medical or psychiatric assistance.
• Avoid complacency.
Completion criteria: Clinical indications that support the client’s transition from the
maintenance stage to continuing care include the client’s having

• Sustained abstinence (30 days or longer)


• Improved relationships with family, friends, and significant others
• Improved coping and problemsolving skills
• Obtained drug-free, stable housing
• Continued participation in a support group
• Obtained ongoing assistance with other problems, if necessary

Intensive Outpatient Treatment and the Continuum of Care 25


Exhibit 3-4

Goals, Duration, Activities, and Completion Criteria of Stage 4

Goals of the community support stage:


• Maintain abstinence.
• Maintain a healthy lifestyle.
• Develop independence from the treatment program.
• Maintain social network connections.
• Establish strong connection with support groups and pursue healthy community activities.
• Establish recreational activities and develop new interests.

Duration of the community support stage: Years, ongoing

Counselor activities of the community support stage:


• Assist clients in developing a realistic, comprehensive, and individualized plan for con-
tinuing recovery.
• Acquaint clients with local resources that allow them to

– Sustain abstinence
– Continue participating in 12-Step or other mutual-help groups
– Obtain medical or psychotherapeutic assistance as needed
– Continue pharmacotherapy as needed
– Start or continue vocational or educational training or other courses
– Seek and obtain employment
– Strengthen social support networks
– Manage stress
– Prevent or respond to relapse
– Enjoy abstinence
• Provide information about and encourage attendance at alumni or booster sessions at
the IOT or outpatient treatment program to review recovery status.
• Provide a biannual checkup during which a comprehensive assessment is conducted of
clients’ recovery and status.

Completion criteria: Clients may need community support for the rest of their lives to
remain abstinent or recover from relapses.

Intensity and Duration of often means that individuals may remain in


Continuing Community Care this level of care for many months or years,
relapse, return to outpatient treatment or
The duration of continuing community IOT care, regain abstinence, and return to
care varies for each individual. The chronic continuing community care.
relapsing nature of substance use disorders

26 Chapter 3
4 Services in Intensive
Outpatient Treatment
Programs

A set of core services is essential to all intensive outpatient treatment


(IOT) efforts and should be a standard part of the treatment package
In This for every client. Enhanced services often are added and delivered
either on site or through functional and formal linkages with
Chapter... community-based agencies or individual providers.
Core Services This distinction between core and enhanced services is somewhat
flexible. What would be considered enhanced services for the general
Enhanced IOT treatment population may be core services for a particular client
Services group. For example, a program that serves primarily working moth-
IOT Services: A ers of young children may view providing child care and arranging
Case Illustration transportation as core program elements. These same services are
unlikely to be needed by most clients in an IOT program that treats
mostly employed single men who do not have children living with
them.

This chapter describes many of the core and enhanced elements of


IOT. Each description includes the purpose and the key aspects of
the service. Exhibit 4-1 lists core and enhanced services for IOT pro-
grams. Some core services are discussed in other chapters, as noted
in exhibit 4-1.

Core Services
Group Counseling and Therapy
Groups form the crux of most IOT programs. Several recent stud-
ies confirm that, for delivering relapse prevention training, a group
approach is at least as effective as a one-on-one format (McKay et
al. 1997; Schmitz et al. 1997). Group counseling allows programs to
balance the cost of more expensive individual counseling services. A
group approach supports IOT clients by

27
Exhibit 4-1

Core and Enhanced Services for IOT Programs

Core IOT Services Provided On Site

• Group counseling and therapy • Vocational training and employment


• Individual counseling services
• Psychoeducational programming • Family involvement and counseling*
• Pharmacotherapy and medication • Comprehensive biopsychosocial
management screening and assessment†
• Monitoring alcohol and drug use • Program orientation and
• Case management intake/admission†
• 24-hour crisis coverage • Individual treatment planning and
• Community-based support groups review†
• Medical treatment • Transition management and discharge
• Psychiatric examinations and planning‡
psychotherapy
*Discussed in chapter 6. †Discussed in chapter 5. ‡Discussed in chapter 3.

Enhanced IOT Services


Delivered On Site or Via Functional Linkages

• Adult education • Adjunctive therapies


• Transportation services • Nicotine cessation treatment
• Housing and food • Licensed child care
• Recreational activities • Parent skills training

• Providing opportunities for clients to devel- • Providing a venue for group leaders to
op communication skills and participate in transmit new information, teach new skills,
socialization experiences; this is particular- and guide clients as they practice new
ly useful for individuals whose socializing behaviors
has revolved around using drugs or alcohol
• Establishing an environment in which cli- Types of groups
ents help, support, and, when necessary,
confront one another Most IOT programs place clients in several
• Introducing structure and discipline into different types of groups during the course of
the often chaotic lives of clients treatment. Broadly speaking, these include
• Providing norms that reinforce healthful psychoeducational, skills-development, sup-
ways of interacting and a safe and supportive port, and interpersonal process groups.
therapeutic milieu that is crucial for recovery These classifications are far from rigid; each
• Advancing individual recovery; group type of group borrows ideas and techniques
members who are further along in recovery from others. Some IOT programs also add
can help other members specialized groups and clubs for job-seeking
or recreational activities. TIP 41, Substance

28 Chapter 4
Abuse Treatment: Group Therapy (CSAT groups in the context of a treatment pro-
2005f), contains specific guidance on how to gram. Exhibit 4-2 highlights groups
organize and conduct different types of commonly conducted in IOT.

Exhibit 4-2

Groups Conducted in Intensive Outpatient Treatment

Psychoeducational groups

These groups provide a supportive environment in which clients learn about substance
dependence and its consequences. These time-limited groups may be initiated at the
beginning of treatment. They feature
• Low-key rather than emotionally intense environment.
• Rational problemsolving mechanisms to alter dysfunctional beliefs and thinking
patterns.
• Various forms of relapse prevention and skills training. Didactic components often are
supplemented by videos or slides to accommodate different learning styles.

Skills-development groups

These groups offer clients the opportunity to practice specific behaviors in the safety of
the treatment setting. Common types of skills training include
• Drug or alcohol refusal training. Clients act out scenarios in which they are invited to
use substances and role play their responses.
• Relapse prevention techniques. Using relapse prevention materials, clients analyze
one another’s personal triggers and high-risk situations for substance use and deter-
mine ways to manage or avoid them.
• Assertiveness training. Clients learn the differences among assertive, aggressive, and
passive behaviors and practice being assertive in different situations.
• Stress management. Clients identify situations that cause stress and learn a variety of
techniques to respond to stress.

Support groups (e.g., process-oriented recovery groups)

These groups include clients in the same recovery stage—usually a middle to late phase
of treatment—who are working on similar problems. Members focus on immediate issues
and on

• Pragmatic ways to change negative thinking, emotions, and behavior


• Learning and trying new ways of relating to others
• Tolerating or resolving conflict without resorting to violence or substance use
• Looking at how members’ actions affect others and the function of the group

(continued)

Services in IOT Programs 29


Exhibit 4-2 (continued)

Groups Conducted in Intensive Outpatient Treatment

Interpersonal process groups


• Single-interest groups. These groups—usually organized at a later stage of treatment—
focus on an issue of particular significance to and sensitivity for group members. The
issues include gender issues, sexual orientation, criminal offense, and histories of physi-
cal and sexual abuse.
• Family or couples groups. These groups assist clients’ relatives and other significant
individuals in learning about the detrimental effects of substance use on relationships
and how these effects can be ameliorated or resolved. Additional information on family
services is presented in chapter 6 and TIP 39, Substance Abuse Treatment and Family
Therapy (CSAT 2004c).

Key aspects of groups IOT programs can organize homogeneous


Organization of groups. IOT programs groups based on a therapeutically relevant
often use open-ended heterogeneous groups issue for a subset of clients or based on
that provide clinicians the flexibility of demographic commonalities among clients.
assigning new clients to ongoing groups. Therapeutically relevant issues that might
With the client census often difficult to call for single-issue groups include single
predict from week to week, this flexibil- parenting, HIV/AIDS, gender issues, drug
ity permits immediate responsiveness to of choice, or histories of physical violence
client needs. Members of open-ended het- and sexual abuse. Special groups based on
erogeneous groups have varying degrees of demographic similarities include those for
recognition and acceptance of their prob- women, men, elderly persons, members of
lems, and those on the road to recovery offer minority populations, clients with common
hope to those just beginning. socioeconomic or legal statuses, or clients
who have particular professions or are unem-
Although it may seem desirable to keep ployed. Clients in these homogeneous groups
clients in the same group as they progress can use their common perspective as a basis
through the treatment process, the experi- for working together. Additional information
ence of the consensus panel has been that associated with programming for diverse pop-
this is seldom possible because individuals ulations is presented in chapters 9 and 10.
have different responses to treatment and
progress toward recovery at different rates. Client-specific adaptations. Clients
Hence, the composition of the group to which with temporary or permanent cognitive
a client is initially assigned at admission is impairments, literacy deficits, or language
unlikely to remain constant throughout the problems need special attention or assign-
treatment episode. Some clients progress rap- ment to special groups. IOT programs should
idly to the next stage, whereas others need to assess whether their treatment orientation
cycle back to an earlier treatment intensity if and relapse prevention materials are appro-
they relapse or encounter other problems. priate for clients with cognitive impairments
or learning disabilities. Chapter 10 provides
additional information.

30 Chapter 4
Clients not yet ready to pursue abstinence requires participants to have a minimum of
(those uninterested in change—precontem- 9 hours of therapeutic contact per week—at
plators—or those thinking about a change in least in the initial treatment stage (Mee-Lee
the near future—contemplators) often come et al. 2001). A typical IOT program schedules
to the program after being mandated to 3 hours of treatment on 3 days or evenings
treatment by another agency. These clients each week. This might entail 2 evenings
could be assigned to a separate, pretreat- of back-to-back 90-minute groups (one for
ment group in which counselors raise the members in the same recovery stage to share
clients’ awareness about substance use dis- day-to-day concerns and the other to study
orders through education and motivating a psychoeducational topic). A third evening
interviews (Washton 2000). might include 30 minutes of individual
counseling, a 90-minute family session, and
Clients who should not participate in cer- an hour-long skills training group. Some IOT
tain groups. Some clients should never be programs meet 5 days or evenings per week.
assigned to the same groups. Perpetrators
and victims of domestic violence must be IOT programs vary considerably in the antic-
in separate groups. Neighbors, relatives, ipated length of stay or expected duration
spouses, or significant others also should of active treatment. Many courses of treat-
not be assigned to the same group (with the ment span 12 to 16 weeks before clients step
exception of family therapy). down to a less intensive (maintenance) stage.
Clients may remain in the maintenance
Clients who violate the principles of group phase for 6 months or more.
therapy by failing to honor group agree-
ments or dropping out continually and Group size and format. The optimal size of
clients who cannot control their impulses a group in most IOT programs is between 8
might respond better to individual therapy. and 15 members. Process-oriented groups
may function more effectively if member-
Some socially anxious or very introverted ship is limited to 6 to 8 members, whereas
clients cannot tolerate groups. These clients psychoeducational groups with considerable
should be offered individual counseling until didactic content can be somewhat larger.
they are comfortable participating in group
sessions (Hoffman et al. 2000) or lower Most counseling guidelines suggest structur-
intensity group sessions that focus on coping ing group time (Mercer 2000; Owen 2000).
skills training (Avants et al. 1998). Some cli- Some groups use a “rule of thirds” wherein
ents with severe psychiatric disorders, such the first third of the session is used to solicit
as schizophrenia or antisocial personality each member’s current issues or experiences,
disorder, may be unable to participate in the second third is used to discuss a particu-
groups and may be able to attend individual lar issue or skill, and the final third is used
therapy only. to sum up the meeting and assign an exer-
cise (Kadden et al. 1995). Another approach
Duration and frequency of group ses- uses a standard problemsolving process in
sions. IOT group counseling sessions often which an issue of concern to the group is
are scheduled for 90 minutes, although identified, a variety of solutions is offered,
shorter and longer timeframes also are used. each option is explored, a decision is made
Psychoeducational group sessions often are about the course to follow, an action plan
only half that long (e.g., a 30-minute lecture is developed, and affected group members
followed by 15 minutes for questions) because agree to pursue this path and report the out-
they focus on instruction instead of interaction. comes (Gorski 2000).
The American Society of Addiction Many recovery groups have traditional
Medicine’s (ASAM’s) definition of IOT opening and closing rituals that are meant

Services in IOT Programs 31


to increase members’ commitments to one use, and ask whether there are any urgent
another and to the group as a whole. issues. The counselor helps the client review
reactions to recent group topics, reviews
Group leaders’ roles and qualifications. treatment plans and coping strategies,
IOT programs usually specify the roles, addresses fears and anxieties related to the
responsibilities, qualifications, and per- change process, provides personalized feed-
sonal characteristics of counselors who lead back on urine toxicology and Breathalyzer™
groups. Chapter 2 of TIP 46, Substance results, and probes into sensitive issues
Abuse: Administrative Issues in Outpatient that are difficult to discuss in the group.
Treatment (CSAT 2006f), discusses these Counselors also help clients access services
issues in detail. they need that are outside the treatment
program’s capabilities and plan the transi-
Individual Counseling tion to another level of care or discharge. A
counseling session usually ends with a sum-
In IOT programs, individual counseling is mary of the client’s plans and a schedule for
an important, supportive adjunct to group the next few days (Carroll 1998; Gorski 2000;
sessions but not the primary form of treat- Mercer 2000).
ment. Whereas concurrent psychiatric
interventions and addiction counseling are
appropriate for clients with co-occurring Psychoeducational
substance use and mental disorders (CSAT Programming
1994b, 2005e; Daley and Thase 2002), most
individual counseling in IOT programs Psychoeducational groups are more didac-
addresses the immediate problems stemming tic than process-oriented recovery groups
from clients’ substance use disorders and and involve a straightforward transmission
their current efforts to achieve and maintain of facts. The counselors who deliver these
abstinence. Counseling typically does not services need to be knowledgeable about
address the client’s underlying, longstand- the subject matter. They also need to know
ing conscious and subconscious conflicts where and how to obtain additional infor-
that may have contributed to substance mation to support their presentations and
use. Many of the readily available counsel- give members of the group other references
ing manuals for substance abuse treatment and resources. These sessions, like recov-
have enhanced components for individuals ery groups, stimulate discussion that helps
or orient the entire approach to individual participants relate the topic to personal
counseling (Kadden et al. 1995; Mercer and experience and foster emotional and behav-
Woody 1999; Nowinski et al. 1992). ioral change (Washton 2000).

A 30- to 50-minute individual counseling ses- Exhibit 4-3 lists typical topics that are cov-
sion is typically a scheduled part of the IOT ered in psychoeducational groups and the
program and occurs at least weekly during treatment stage at which they are introduced.
the initial treatment stage. A client is assigned
a primary counselor who strives to establish a Pharmacotherapy and
close, collaborative therapeutic alliance.
Medication Management
An individual counseling session frequently Pharmacotherapy and medication man-
follows a standard format. A counselor may agement are critical adjuncts to effective
ask the client about reactions to the recent substance abuse treatment that should not
group meeting, explore how the client spent be ignored or separated from other therapies,
time since the last session, ask how the client psychosocial supports, and behavioral contin-
is feeling, inquire about drug and alcohol gencies. Medications target only specific and

32 Chapter 4
Exhibit 4-3

Typical Sequence of Topics Addressed in Psychoeducational Group

Treatment • Understanding motivation and committing to treatment


engagement • Counteracting ambivalence and denial
• Determining the seriousness of the drug or alcohol problem
• Conducting self-assessment, setting goals, and self-monitoring progress
• Overcoming common barriers to treatment

Early • Learning about biopsychosocial disease and recovery processes


recovery • Understanding the effect of specific drugs and alcohol on the brain
and body
• Placing symptoms of substance use disorders in the context of other
behavioral health problems
• Learning about early and protracted withdrawal symptoms for specific
drugs and alcohol
• Knowing the stages of recovery and the client’s place in the continuum
of care
• Learning strategies for quitting and finding the motivation to stop
• Minimizing risks of HIV/AIDS, hepatitis C, and sexually transmitted
diseases (STDs)
• Identifying high-risk situations that are cues or triggers to substance
use: people, places, and things
• Identifying peer pressures and compulsive sexual behavior as triggers
• Understanding cravings and urges, learning to extinguish thoughts
about substance use, and coping with cravings
• Structuring personal time
• Coping with high-risk situations
• Understanding abstinence and the use of prescription and over-the-
counter medications
• Understanding the goals and practices of various 12-Step or other
mutual-help groups
• Identifying and using positive support networks

(continued)

limited aspects of substance use disorders. ents’ compliance. IOT programs should give
Pharmacotherapy, by itself, does not change serious consideration to providing phar-
lifestyles or restore the damaged functioning macotherapy and medication management
that accompanies most drug dependence. services

IOT programs that require attendance 3 to 5 • To provide ambulatory detoxification and


days per week are ideal settings for identify- relief of withdrawal symptoms for some
ing clients in need of medication, initiating clients
medication regimens, and monitoring cli-

Services in IOT Programs 33


Exhibit 4-3 (continued)

Typical Sequence of Topics Addressed in Psychoeducational Group

Maintenance and • Understanding the relapse process and common warning signs
continuing care • Identifying tools to prevent relapse
• Developing personal relapse plans
• Counteracting euphoria and the desire to test control
• Improving coping and stress management skills
• Learning anger management and relaxation techniques
• Enhancing self-efficacy for handling risky situations
• Responding safely to slips and avoiding escalation
• Finding recovery resources
• Structuring leisure time and finding recreational activities
• Knowing the importance of personal health: diet, exercise,
hygiene, and checkups
• Taking a personal inventory
• Handling shame, guilt, depression, and anxiety
• Understanding family dynamics: enabling and sabotaging behaviors
• Rebuilding personal relationships
• Understanding sexual dysfunction and healthy sexual behavior
• Developing educational and vocational skills
• Learning daily living skills: money management, housing,
and legal assistance
• Embracing spirituality and recovery and finding meaning in life
• Recognizing grief and loss and the relationship to substance use
• Learning about parenting: basic needs of children and their
developmental stages and developmental tasks
• Maintaining balance in life

• To prevent relapse by reducing craving, by Ambulatory detoxification


potentially precipitating an aversive reac- ASAM criteria (Mee-Lee et al. 2001) include
tion, or by blocking the reinforcing effects provisions for ambulatory detoxification
of drugs when specific program and environmental
• To reduce the medical and public health supports are in place for persons who are
risks from use or injection of illicit drugs at low risk for severe withdrawal. IOT pro-
with medical maintenance grams should have written medical protocols
• To ameliorate the underlying psychopa- or guidelines for specific detoxification
thology that may contribute to substance procedures, as well as formal affiliations
use disorders with appropriate general medical and psy-
• To monitor treatment of some medical chiatric treatment facilities and laboratory
conditions associated with substance use testing and toxicology services. (This TIP is
disorders not intended to provide detailed informa-
tion about detoxification and the medical
management of detoxification. For more

34 Chapter 4
information on detoxification see appendixes cations, and other supports (see the case
4-A and 4-B and chapter 5 of this volume illustration and appendix 4-A). Medical staff
and TIP 45, Detoxification and Substance members in IOT programs must use their
Abuse Treatment [CSAT 2006e]). best judgment or rely on the program’s writ-
ten procedures.
IOT programs can institute ambulatory
detoxification safely for appropriate clients The CIWA-Ar also is used to monitor the cli-
if they ent’s response to administered medications
at 30- to 60-minute intervals. Symptom-
• Make arrangements for immediate and triggered doses are given only when trained
continuous supervision or consultation by staff members observe withdrawal signs of
a qualified physician, with provisions for a specified intensity. Appropriate use of the
hospitalization or alternative detoxifica- CIWA-Ar has been shown to reduce both
tion, if necessary. the numbers of clients receiving withdrawal
• Have medically trained staff (e.g., regis- medications and the amount of medica-
tered nurses, nurse practitioners, licensed tion administered (Reoux and Miller 2000;
practical nurses, physician’s assistants) on Wiseman et al. 1998). The instrument has
site to conduct initial physical examina- been adapted for monitoring benzodiazepine
tions, obtain medical histories, inform cli- withdrawal (Busto et al. 1989) and for assess-
ents about medication effects, adjust dos- ing opioid withdrawal (Bradley et al. 1987).
ages, and monitor clients for several hours (See chapter 5 for information about other
or longer each service day. screening instruments.)
The consensus panel recommends that fam- Detailed guidelines and resources regarding
ily members be involved in monitoring and ambulatory detoxification are available in
reporting adverse events for the client under- TIP 24, A Guide to Substance Abuse Services
going detoxification. for Primary Care Clinicians (CSAT 1997a),
Using the CIWA-Ar scale. The Clinical and TIP 45, Detoxification and Substance
Institute Withdrawal Assessment–Alcohol, Abuse Treatment (CSAT 2006e). Internet
Revised (CIWA-Ar) scale commonly is used resources include articles from the American
to determine which clients who are alcohol Family Physician (www.aafp.org), ASAM
dependent can receive ambulatory detoxi- materials such as Principles of Addiction
fication and which should be referred for Medicine (www.asam.org), and Detoxification
inpatient care. The CIWA-Ar can be admin- Clinical Practice Guidelines developed by the
istered reliably in a few minutes by a staff New South Wales Health Department (www.
member with a minimum of 3 hours of druginfo.nsw.gov.au/home).
training (for more information about the
CIWA-Ar, see chapter 5). Pharmacotherapies for
Some disagreement exists among physicians addiction
about the cutoff points on the CIWA-Ar for Research supports the effectiveness of
conducting ambulatory detoxification or medication-assisted treatment for alcohol
referring a client for inpatient care. Many and opioid addiction. Despite promis-
physicians seem to concur that clients with ing leads, extensive laboratory research,
scores of 20 or higher should be treated in and many clinical trials, no compelling
an inpatient medical facility. Other experi- evidence exists of effective medications
enced addiction specialists find that clients for treating dependence on cocaine and
with scores up to the low 20s can be man- other stimulants, marijuana, inhalants, or
aged safely in an outpatient setting with hallucinogens.
proper monitoring, supervision of medi-

Services in IOT Programs 35


Preventing relapse to alcohol. Disulfiram who frequently do not respond to other
(Antabuse®) and naltrexone (ReVia®) have forms of substance abuse treatment, can be
been used successfully to assist clients who maintained effectively on certain longer act-
are alcohol dependent with avoiding relapse. ing opioid medications that enable them to
An IOT program is an ideal setting to initi- function productively. These opioid medica-
ate disulfiram treatment because doses are tions include methadone, buprenorphine,
effective for 3 days. Clients can receive their and levo-alpha acetyl methadol (LAAM).
doses during a session, with double doses or (Although LAAM is still approved by the U.S.
take-home doses provided for the weekends. Food and Drug Administration for treatment
of certain clients dependent on opioids, the
Early research studies suggested that naltrex- U.S. manufacturer of LAAM ceased produc-
one did not reduce the frequency of alcohol ing it in 2005.)
use relapses but appeared to shorten the
duration of relapse and to lessen the amount Treatment with methadone and LAAM cur-
of alcohol drunk during a relapse episode rently must take place in specially approved
(O’Malley et al. and licensed programs or, under special cir-
1992; Volpicelli et cumstances, in a physician’s office. Because
Whenever al. 1992). However, new clients must attend these programs
recent data suggest a minimum of 5 days a week, methadone
medication is used to that naltrexone maintenance programs are ideal settings
might be ineffective for introducing many components of IOT
in limiting drink- programming.
support abstinence, ing for men with
chronic, severe Buprenorphine alone and a
clients need to be alcohol depen- buprenorphine-naloxone combination are
dence (Krystal et al. alternative medications for maintenance
educated about the 2001). Clinicians of individuals dependent on opioids.
who are interested Buprenorphine was approved by the U.S.
drug prescribed. in naltrexone for Food and Drug Administration in 2002
clients who use for the treatment of opioid dependence
alcohol are referred and is scheduled as a Class III narcotic.
to TIP 28, Naltrexone and Alcoholism Buprenorphine can be dispensed or pre-
Treatment (CSAT 1998c). scribed by physicians in office-based
practices or in health care facilities that are
Acamprosate (Campral®) was approved by not specially licensed, provided they obtain
the U.S. Food and Drug Administration in a waiver from the Substance Abuse and
2004 for postwithdrawal maintenance of Mental Health Services Administration. IOT
alcohol abstinence. In nearly two decades of programs with a physician on staff or readily
use in Europe, acamprosate has been found available are eligible to dispense or prescribe
to be safe and effective for treating alcohol buprenorphine. Buprenorphine is safer for
dependence (Mann et al. 2004; Tempesta treating opioid dependence than methadone
et al. 2000). Treatment with acamprosate or LAAM because it is more difficult to over-
has been shown to decrease the amount, dose (Jaffe and O’Keefe 2003; Johnson et al.
frequency, and duration of alcohol consump- 2003) and, in combination with naloxone,
tion in clients who relapse to alcohol use reduces the risk of diversion (Johnson and
(Chick et al. 2003; Tempesta et al. 2000) McCagh 2000; Mendelson and Jones 2003).
and to reduce cravings, even in clients who TIP 40, Clinical Guidelines for the Use of
resume drinking (CSAT 2005a). Buprenorphine in the Treatment of Opioid
Addiction (CSAT 2004a), provides more
Medication maintenance for opioid information. Information about Web-based
dependence. Clients dependent on opioids, and onsite training about buprenorphine

36 Chapter 4
can be obtained by clicking on Medication • Side effects and how they can be ame-
Assisted Treatment on the CSAT Web site liorated (e.g., laxatives for the commonly
(buprenorphine.samhsa.gov/training_main. experienced constipation produced by
html). TIP 43, Medication-Assisted Treatment methadone)
for Opioid Addiction in Opioid Treatment • Cross-tolerance and synergistic or other
Programs (CSAT 2005b), offers guidance interactive effects when mixed with other
about methadone, LAAM, and opioid drugs, especially drugs for such chronic
pharmacotherapy. conditions as high blood pressure, diabe-
tes, high cholesterol, and asthma
Co-occurring disorders. Many clients who • The time usually needed for the full effect of
enter substance abuse treatment have co- medications, such as antidepressants, to be felt
occurring mental disorders. ASAM patient
placement criteria recommend that indi- The way in which a medication is introduced
viduals with moderate-severity disorders be and explained can affect clients’ willingness
treated in IOT programs that are designed to comply with the dosing schedule and their
primarily for clients who abuse substances; chances of receiving its full benefits. When
the placement criteria also recommend clients begin a medication regimen, it may
that IOT programs be capable of coordina- be useful to hold educational groups for
tion and collaboration with mental health clients and their family members. Accurate
services. These programs can provide psy- information can be imparted, and the ques-
chopharmacologic monitoring, psychological tions of both clients and their families can
assessment and consultation, and treatment be answered. If clients are given take-home
of substance use disorders to clients with doses, the inclusion of family members in
moderate-severity mental disorders. Clients such educational groups may be helpful for
with symptomatic, high-severity psychiatric encouraging compliance with the medication
diagnoses should be treated in programs that protocol.
treat co-occurring disorders by integrating
mental health and substance use treatment Medication-assisted IOT programs must
and that have cross-trained staff (Drake et al. build time into the treatment schedule for
1998b; Ries et al. 2000). (Moderate-severity administering medications, monitoring the
co-occurring mental disorders include stable effects, and providing appropriate education
mood or anxiety disorders. High-severity about medications. The program can sched-
disorders include schizophrenia, mood disor- ule the administration of medications to
ders with psychotic features, and borderline minimize the effect of withdrawal symptoms
personality [Mee-Lee et al. 2001].) Chapter 9 on the client’s participation in psychosocial
provides additional information on treating treatment and to maximize treatment atten-
individuals with co-occurring disorders. TIP dance and retention.
42, Substance Abuse Treatment for Persons Infectious diseases. Of paramount concern
With Co-Occurring Disorders (CSAT 2005e), is encouraging client compliance with medi-
also addresses this issue. cation regimens to treat, control, or cure
Clinical strategies and approach. infectious diseases. Several TIPs address
Whenever medication is used to support this issue, including TIP 6, Screening for
abstinence, clients need to be educated Infectious Diseases Among Substance Abusers
about the drug prescribed. It is important (CSAT 1993b); TIP 18, The Tuberculosis
for clients to understand Epidemic: Legal and Ethical Issues for
Alcohol and Other Drug Abuse Treatment
• Expected effects of the drug prescribed, Providers (CSAT 1995c); and TIP 37,
interactions with other licit and illicit Substance Abuse Treatment for Persons With
drugs, and adverse reactions that should HIV/AIDS (CSAT 2000c).
be reported at once to the medical staff

Services in IOT Programs 37


Monitoring Alcohol When programs are asked to report urine
and Drug Use test results to the criminal justice system, an
employer, or a children’s protection agency,
Routine monitoring of clients’ illicit drug it is important to consider the negative effect
and alcohol consumption to determine reporting can have on treatment. Knowing
whether the selected therapy is having the that a positive test result may lead to pun-
desired effect is a standard part of all IOT ishment can inhibit a client’s forthrightness
programs. Some programs rely on clients’ in self-disclosure and encourage treatment
self-reports. However, most programs use dropout. Clients need to be informed fully
objective tests of biological specimens—usu- that their test results will be disclosed and
ally urine samples, but also breath, saliva, that testing positive may trigger serious con-
sweat, blood, or hair samples. The results of sequences (CSAT 2004b).
these scientifically established procedures
help program staff members reliably and Procedures for collecting and testing urine
accurately monitor a client’s treatment and a chart showing cutoff times for detect-
course, recognize clients’ success in remain- ing various drugs are provided in appendix
ing abstinent, and increase the accuracy of B (page 237). (Note: Alcohol is hard to test
clients’ self-reporting. Monitoring drug and for because it may be eliminated from the
alcohol use helps clinicians determine the client’s system rapidly.) Appendix B lists
need for treatment plan modifications, helps methods and screening tests for detecting
families reestablish trust, helps clients avoid alcohol and illicit drugs, using a number of
slips or lapses, and discourages them from tests in addition to urinalysis.
substituting a different drug or alcohol for
their primary drug of choice.
Case Management
Testing in the IOT program is designed to Individuals who abuse substances are likely
deter clients from using substances, not to to have significant and interrelated prob-
punish or induce shame and guilt. Programs lems in addition to their use of psychoactive
might use drug-free urine test results as a substances. Services to address these needs
contingency for receiving specified rewards, often are fragmented across many agencies.
reinforcing desired behaviors rather than Services may be difficult to access without
punishing continued drug use (see Budney the assistance of a case manager who is
and Higgins 1998). knowledgeable about service providers and
can help clients access these services (exhibit

Qualifications and Roles of Case Managers


• Many IOT programs hire professionally trained case managers, such as social workers or
counselors whose sole function is case management. Other IOT programs may expect treat-
ment counselors to assume case management responsibilities as well as counseling duties.
In some programs, peer counselors or indigenous workers augment the work of professional
staff members.
• Case managers in IOT programs develop and maintain an accurate list of local and regional
services that clients may need.
• Case managers facilitate transfers to other treatment services as dictated by the clients’ needs.
• Case managers in IOT programs participate in developing written memorandums of under-
standing and interagency agreements to ensure that these documents specify services offered,
staff qualifications, number of available slots, costs, lines of authority, and referral procedures.

38 Chapter 4
4-4). Case managers help clients identify and formal arrangements with the following
prioritize needs that cannot be met by the types of local services:
IOT program and access and participate in
additional services to meet those needs. • Social service and child welfare agencies
• Vocational rehabilitation
Examples of client populations that might be • Training and employment assistance
aided by case management services include programs
pregnant women, people who are homeless, • Preventive health care; inpatient, outpa-
clients with HIV/AIDS and other serious tient, and community health care services
medical conditions, people with severe men- (e.g., visiting nurses; home health aides;
tal disorders, long-term welfare enrollees, physicians; specialty programs for HIV/
people with physical disabilities, and people AIDS, hepatitis C, STDs, or tuberculosis
involved in the criminal justice system. [TB]; and prenatal and pediatric care)
• Inpatient and outpatient psychiatric treat-
IOT programs—particularly those serv- ment and mental health services
ing publicly funded clients—need to have • Recovery support groups
detailed, up-to-date resource directories or

Exhibit 4-4

Case Management Services

Functions
• Provide a core set of social services that includes assessment, planning, linkage, moni-
toring, and advocacy.
• Provide the client with a single contact person who is responsible for finding and mobi-
lizing needed resources, negotiating formal systems, and bartering informally with
other service providers to gain access to appropriate services.
• Respond to client’s needs, tailoring resources to the individual rather than fitting the
client into existing services.
• Intervene with many systems and providers on behalf of the client.
• Operate in the community and transcend facility boundaries.
• Focus on pragmatic, immediate ways to meet needs (e.g., clothing, shelter).
• React sensitively and competently to clients’ ethnic, gender, and cultural differences.
Models

• Single agency model. Case managers personally establish relationships with counter-
parts in other agencies to find and access services for individual clients.
• Informal partnership model. Staff members from several agencies link into collabora-
tive teams or networks that consult about individual cases and share services.
• Formal consortium model. Case managers and service providers are joined through
written agreements or contracts that define roles, responsibilities, shared services, and
costs. This model usually is organized by a lead agency that has primary responsibility
and receives most or all of the funding.

Services in IOT Programs 39


• Faith-based institutions appropriate for outcomes than clients in traditional outpa-
the client population tient treatment. The investigators concluded
• Food banks and clothing distribution that both addiction-focused services and
centers supplemental social supports are necessary
• Recreational facilities and programs of for effective, long-term rehabilitation.
many types
• Adult education programs, including In another study, case management for
instruction in adult literacy and English as pregnant women enrolled in specialized
a second language women’s outpatient substance abuse treat-
• Child care ment included regular phone calls and home
• Parent training programs visits, written referrals to social service agen-
• Volunteer transportation services cies, staff advocacy for clients’ with social
• Family therapy and couples counseling service agencies, and free transportation
• Housing resources, including U.S. to and from treatment. Case management
Department of Housing and Urban and transportation services were significant
Development Section 8 housing, shelters predictors of retention in drug treatment
for homeless persons and battered women, (Laken and Ager 1996). In a followup
and recovery houses study, treatment retention was associated
• Legal assistance with decreased drug use and increased
infant birth weight (Laken et al. 1997).
Providers of heavily used services should be TIP 27, Comprehensive Case Management
visited by IOT staff members to maintain for Substance Abuse Treatment, provides
close working relations. detailed information (CSAT 1998a).

Research outcomes and 24-Hour Crisis Coverage


findings Many clients in IOT programs develop
Several studies suggest that case manage- problems that require immediate attention
ment services increase client retention, outside working hours. Arrangements are
improve clients’ occupational and social needed for 24-hour, 7-day-a-week coverage by
functioning, and ameliorate their psychiatric trained personnel (exhibit 4-5). The benefits
symptoms (Siegal et al. 1996, 2002). Case of this coverage include reducing unneces-
management services have been found to be sary hospitalizations and providing fail-safe
a low-cost enhancement that improve client options for clients and families to head off
retention in some publicly funded, mixed- crises.
gender substance abuse treatment programs
(Schwartz et al. 1997). A study by McLellan IOT programs should ensure that clients are
and colleagues (1998) provides support for aware of the afterhours coverage and that
adding case management services to IOT the coverage is listed in published materi-
programs. This study evaluated the effective- als. Clients need clear, written instructions
ness of case-managed social services added regarding emergencies—whether to go imme-
to public-sector substance abuse treatment diately to a hospital or to call 911.
programs that served inner-city clients who
were severely impaired. Case management Community-Based Support
consisted of coordinating and expediting cli-
ents’ use of medical screening, employment Groups
counseling, drug-free housing, parenting IOT programs should foster active participa-
classes, and recreational and educational tion in community-based 12-Step and other
services. Clients who received enhanced mutual-help groups as part of the treatment
services had significantly better treatment process. This effort is extremely important

40 Chapter 4
Exhibit 4-5

Examples of 24-Hour Crisis Coverage Implementation

• Hotline services. In some programs, afterhours calls are forwarded to a hotline or


other crisis intervention service. This service can provide advice and referrals or, if indi-
cated, can contact an IOT program staff member.
• Oncall clinicians. A few large IOT programs that serve a particularly troubled popula-
tion (e.g., persons with severe co-occurring mental disorders) may have rotating, oncall
clinicians who answer and screen inquiries.
• Agreement with 24-hour professional service providers. In some areas, afterhours
calls to the IOT program are transferred to a detoxification or inpatient rehabilitation
unit that is staffed 24 hours a day.

for clients because formal substance abuse mat of Alcoholics Anonymous (AA), Narcotics
treatment is a relatively brief step in the long Anonymous (NA), Cocaine Anonymous (CA),
journey to recovery. In addition, clients need or other groups.
to develop a support network of positive role
models and friends who can help guide their Counselors should be familiar with the dif-
continuing recovery. Support groups serve as ferences between various support groups in
an important adjunct to structured therapy. the community and help their clients select
At a minimum, clients need to be introduced an appropriate group meeting to attend.
to the basic tenets of a 12-Step or similar Counselors should match clients with groups
mutual-help group. Most IOT programs attended by persons who have similar social,
encourage participation in group meetings ethnic, economic, and cultural backgrounds
and give clients options about the type of and experiences. The substances clients
community-based group they can attend. abuse, as well as other factors, also may
affect the match (Forman 2002).
Key aspects of community
The 12-Step fellowship
support groups
Twelve-Step fellowships are the most com-
An IOT program often can facilitate volun- monly recognized and widely attended
tary attendance in support groups by helping groups for continuing recovery support.
clients understand more about local sup- Involvement in 12-Step groups such as
port groups through group discussion and AA, NA, or CA is correlated positively with
individual counseling. At a minimum, IOT both retention in treatment and abstinence
programs should give clients a thorough (Fiorentine 1999). Twelve-Step groups
introduction to mutual-help programs, help include a spiritual focus, espouse principles
clients overcome any resistance by encour- of conduct, and provide ongoing sup-
aging their attendance with other group port for as long as an individual wishes to
members or program alumni, and leave the participate.
decision about joining a group to the clients.
Programs also can invite support groups to Twelve-Step groups are available through-
hold open meetings on site; these meetings out the country. There are different types
allow clients to become familiar with the for- of meetings (e.g., open speaker meetings,

Services in IOT Programs 41


Step meetings, open and closed discussion Medical Treatment
meetings). Basic AA texts include Alcoholics
Many IOT clients enter treatment with undi-
Anonymous (the “Big Book”), Twelve
agnosed or untreated medical conditions
Steps and Twelve Traditions, and Living
that require immediate and continuing care
Sober. Basic texts of NA include Narcotics
by a physician. All IOT programs need to
Anonymous and It Works: How and Why.
have preplanned arrangements with a com-
Information about AA and fellowship
munity health center or a local hospital that
meetings is available from the General
can handle any overdose or withdrawal-
Services Offices of Alcoholics Anonymous
related emergencies. Relationships need to
(www.gso.org) and from World Services,
be in place with medical providers that will
Inc. (www.alcoholics-anonymous.org).
test for and treat infectious diseases, includ-
Information on AA meetings can be obtained
ing STDs, HIV infection, TB, hepatitis B and
from the central offices in each State and
C, and other health conditions. Programs
the District of Columbia. A list of contacts
serving women who are pregnant or of child-
in the central offices can be found at www.
bearing age need to have arrangements in
aa.org/en_find_meeting.cfm. The Narcotics
place for obstetric and gynecological care.
Anonymous Meeting Search function at
www.na.org helps people locate an NA meet-
ing throughout the United States and its Psychiatric Examinations and
territories. The CA Web site provides contact
Psychotherapy
information for meetings throughout the
United States, Canada, and Europe (www. IOT programs need to evaluate clients’ men-
ca.org/phones.html). Nowinski and col- tal and psychiatric status and to refer those
leagues (1992) and Daley and colleagues with signs and symptoms indicating that a
(1999) also offer guidance on conducting 12- thorough evaluation is warranted. Chapter
Step-oriented counseling. 5 provides guidance on conducting psycho-
logical evaluations. Chapter 9 discusses the
Some clients may be more comfortable in needs of persons in IOT with co-occurring
12-Step groups that have been adapted to psychiatric disorders; additional informa-
meet participants’ needs. Depending on the tion is provided in TIP 42, Substance Abuse
geographic location, there may be gay- and Treatment for Persons With Co-Occurring
lesbian-identified groups, women’s groups, Disorders (CSAT 2005e). Ideally, IOT pro-
groups for people who are hearing impaired, grams have relationships with mental health
men’s meetings, Spanish-language meetings, centers and with individual psychiatrists for
meetings for agnostics, young people’s meet- consultation and referral.
ings, and beginners’ meetings.

Special 12-Step groups have been organized Vocational Training and


by people with both substance use and Employment Services
psychiatric disorders (see chapter 9). These
groups have been shown to reduce substance Unemployment or underemployment is often
use and increase compliance in clients taking a problem for individuals in early recovery.
prescribed medications (Laudet et al. 2000a). Clients entering IOT programs often have
issues that impede their ability to be employed
fully, such as limited formal education, poor
Alternatives to community- work readiness, and skill deficits. Few IOT pro-
based 12-Step groups grams are prepared to address these barriers
to employment; hence, specialized vocational
Community support groups exist for clients and employment counseling and related ser-
who may be uncomfortable with traditional vices on site or through case-managed referral
12-Step groups (see exhibit 4-6). are an optimal part of an IOT program.

42 Chapter 4
Exhibit 4-6

Alternatives to Traditional 12-Step Groups

• Self-Management and Recovery Training (www.smartrecovery.org) groups were devel-


oped during the 1980s as alternatives to the 12-Step model. These groups address recov-
ery within a cognitive–behavioral framework. Preliminary studies suggest this approach
can be a viable alternative for individuals who are reluctant to attend 12-Step meetings,
although further study is needed (Connors and Dermen 1996; Godlaski et al. 1997).
Atheists and agnostics are less likely than clients who describe themselves as spiritual
or religious to initiate and sustain AA attendance. However, clients who identify them-
selves as atheist and agnostic and who persist in AA attendance show no difference in
days abstinent or drinking intensity when compared with clients who identify them-
selves as spiritual or religious (Tonigan et al. 2002; Winzelberg and Humphreys 1999).
• Secular Organizations for Sobriety (www.secularhumanism.org) and Save Our Selves
(www.secularsobriety.org) promote individual empowerment, self-determination, and
self-affirmation and offer groups for women and members of minority groups in addi-
tion to open groups.
• A variety of support groups can be accessed through national organizations such as
Women for Sobriety, Inc. (www.womenforsobriety.org), the Women’s Action Alliance,
the Institute on Black Chemical Abuse (www.aafs.net/ibca/ibca.htm), the National
Black Alcoholism and Addictions Council (www.nbacinc.org), the Hispanic Health and
Human Services Organization, the Hispanic Health Council (www.hispanichealth.com),
and the National Association of Native American Children of Alcoholics.
• Clients who are former inmates may respond positively to community-based support
services that address their special needs. Programs such as the Fortune Society (www.
fortunesociety.org) and the Safer Foundation, which provide assistance to former
inmates, are located in several large cities.
• Religious institutions are frequently a significant community-based support system for
many recovering individuals, particularly within African-American communities (CSAT
1999b). Many IOT programs encourage interested clients to become involved with com-
munity religious groups. For example, JACS (Jewish Alcoholics, Chemically Dependent
Persons, and Significant Others) helps members reconnect with one another and
explore resources within Judaism that enhance recovery.
• Some IOT programs run support groups for former clients on an indefinite basis.
Generally, participation in these alumni groups does not require payment to the IOT
program. The groups often are supported at minimal cost by the program as part of a
continuum of care for clients who successfully complete treatment. Typical support pro-
vided by the IOT program for alumni groups includes meeting space, refreshments, and
promotion of the group to clients. Some clients attend both 12-Step meetings and other
support groups.

IOT programs need to stay abreast of local counselors at these agencies. Many com-
vocational training and employment munities offer specific vocational resources
resources and to develop relationships for persons with disabilities, veterans,
with these agencies and with individual women, criminal justice clients, and other

Services in IOT Programs 43


groups. TIP 38, Integrating Substance Abuse Other group-living houses are available to
Treatment and Vocational Services (CSAT special populations, such as persons infected
2000a), presents more information. with HIV or individuals with psychiatric
diagnoses, and professional staff members
usually are in residence or readily available.
Enhanced IOT Services
Many temporary shelters for homeless persons
offer recovery support or more formal and staged
Adult Education substance abuse treatment. The Salvation Army,
Clients who have educational deficits need for example, operates halfway houses or sup-
encouragement to enroll in local adult edu- portive living residences for recovering persons.
cation classes, literacy programs, or general Some shelters for homeless people also incor-
equivalency diploma programs. Those who do porate short-term recovery support. Homeless
not speak English well should be encouraged populations and other low-income clients in IOT
to attend English-as-a-second-language courses. programs may need the assistance of food banks
If a sufficient number of clients do not have or access to surplus food that may be supplied
high school diplomas or use a language other by local merchants or other community agencies.
than English at home, an IOT program might
recruit volunteers to conduct classes on site.
Recreational Activities
Organized recreational activities can be a valu-
Transportation Services able part of treatment, helping clients find
The transportation needs of clients may be healthful, substance-free interests to replace a for-
met in several ways, including providing pub- mer focus on substance use. Scheduled exercise
lic transportation tokens or passes. This simple (including walking, sports, weight training, and
accommodation should be considered by all aerobics) has been shown to be an important
programs that serve low-income clients as a way aspect of substance abuse treatment (Kremer et
to encourage retention in treatment. Alternatives al. 1995). Exercise can relieve underlying depres-
that are likely to involve insurance liability sion and anxiety (Paluska and Schwenk 2000).
include using staff or volunteers to drive vans. Organized sports, games, arts and crafts, and
walks can have therapeutic benefits.
Housing and Food
Housing programs in many cities provide Adjunctive Therapies
room and board for recovering persons. These Groups in which clients use various nonverbal,
recovery homes usually are not licensed treat- creative media (e.g., music, dance, drama, crafts,
ment facilities but rather are financially and arts such as painting, drawing, sculpture,
self-sustaining organizations that offer housing and collage) can be therapeutic and helpful to
for a limited time. The homes often are estab- recovery. Other alternative therapies that might
lished or staffed by recovering individuals and are help clients include acupuncture and stress
available for a nominal weekly or monthly rent. reduction by means of biofeedback therapy
(Richard et al. 1995).
The ground rules for residence are
abstinence, regular rent payments, and Various forms of meditation (mindfulness,
appropriate conduct. Some recovery houses visualization, breath meditation, and tran-
require attendance at house meetings and scendental meditation) have been used to
community-based 12-Step meetings. Some treat diseases such as cancer and AIDS
recovery houses actively encourage ongoing (Marlatt and Kristeller 1999). As an adjunct
substance abuse treatment and employment to substance abuse treatment, meditation
by the end of the first 30 days of residence. can be used with the goal of reducing the

44 Chapter 4
frequency and intensity of cravings and Nicotine replacement is available in prescrip-
improving clients’ emotional and psycho- tion (inhaler, spray) and nonprescription (gum,
logical function (CSAT 1994a). Meditation patch) forms. Clients may need to try several
is consonant with the philosophy of AA and different products of the same type (e.g., differ-
other 12-Step support groups (CSAT 1999c). ent brands or dosages of gum) or try different
delivery mechanisms before they find a prod-
uct that works for them. Researchers have
Nicotine Cessation Treatment found that inhalers, sprays, gum, and patches
Clinical experience indicates that the are more effective than placebo in helping
majority of people who are drug or alco- clients quit smoking (Schmitz et al. 1998). The
hol dependent also smoke cigarettes. More antidepressant medications bupropion and
people in this group die from tobacco-related nortriptyline have shown promise in dimin-
causes than from their alcoholism or drug ishing cravings for nicotine and improving
dependence (Hurt et al. 1996). Despite quit rates, probably because they help allevi-
the health risks associated with smoking, ate depression—a major cause of relapse (da
substance abuse treatment staff members Costa et al. 2002; Richmond and Zwar 2003).
persistently believe that smoking cessation
may be detrimental to clients’ abstinence
from other drugs. However, believing that Licensed Child Care
the best time to quit smoking would be dur- IOT programs that serve women who have
ing treatment was the main factor in clients’ young children should have appropriate child-
accepting nicotine cessation treatment at care facilities on site or nearby to facilitate
admission to substance abuse treatment the mothers’ participation in treatment. For
(Seidner et al. 1996). In one study, fewer liability and therapeutic reasons, childcare
than 10 percent of clients objected to a clin- arrangements should be provided by licensed
ic’s smoking ban when nicotine replacement childcare professionals, not by untrained
therapy was available along with substance counselors or volunteers. IOT programs
abuse treatment (Zullino et al. 2003). should check with their county government or
Single State Authority about local regulations.
The relapse rate for smokers in the general
population who are trying to quit is high.
Frank and colleagues (1991) found that fewer Parent Skills Training
than 4 percent of smokers who succeed in Many clients need to learn parenting skills,
quitting did so with the help of a physician. children’s developmental stages, and appro-
Smokers who are trying to quit achieve the priate disciplinary strategies for each stage.
highest success rates when they participate in Parents also may benefit from practical
behavioral therapy in combination with nico- information about obtaining vaccinations,
tine replacement therapy (Glover et al. 2003). diets for youngsters, listening skills, and
These findings suggest that IOT programs are attention-increasing activities that prepare
good settings for smoking cessation efforts toddlers for school. Training in parenting
because they offer a structured environment skills is essential for parents who have sur-
in which clients’ efforts to quit smoking can vived emotional, physical, and sexual abuse
be supported by behavioral and medication- in their own childhoods. Without interven-
assisted interventions and other clients. Strong tion, these clients may perpetuate this type
associations have been shown between reduc- of harmful behavior with their own children.
tions in cigarette smoking and reductions
in other substance abuse during treatment IOT programs can help enroll clients’ young
(Kohn et al. 2003; Shoptaw et al. 2002). children in Head Start programs (where
available) and facilitate their attendance
(visit the Web site of the National Head

Services in IOT Programs 45


Start Association, www.nhsa.org). Focus on (starting on page 48) presents a case study
Families, a training program for parents in illustrating the treatment course for one of
opioid treatment programs, has involved par- its clients. This IOT program offers com-
ents successfully in treatment, decreased their prehensive services for diverse groups of
use of illicit substances, and reduced the risk clients. The treatment philosophy integrates
factors and enhanced the protective factors the disease concept of chemical dependence
for future drug use among their children; with cognitive–behavioral approaches, moti-
however, few significant changes have been vational counseling, and the principles of
seen in children’s behavior at 1-year followup 12-Step fellowship programs and similar
(Catalano et al. 1997, 1999). Information mutual-help community support groups.
about Strengthening American Families and
other age-specific model parent and family The facility is located within a hospital but
training programs evaluated by the Office of has a separate entrance. It is close to pub-
Juvenile Justice and Delinquency Prevention lic transportation and has ample parking.
can be found at www.strengtheningfamilies. The reception room feels welcoming, and
org. Information about programs, such as rooms for group sessions are furnished with
the National Center on Substance Abuse and upholstered couches and chairs, soft light-
Child Welfare and Starting Early, Starting ing, and pleasant artwork. Several group
Smart, that focus on children and families rooms double as offices for the counselors
in the context of substance abuse prevention and onsite medical staff. This IOT program
and treatment can be found at www.samhsa. serves clients who are dependent on a vari-
gov/Matrix/programs_children.aspx. ety of substances. Many clients have both
substance use and mental disorders. The
programming and schedules are sufficiently
IOT Services: A Case flexible to serve the needs of professionals,
blue-collar workers, students, single-parent
Illustration families, stay-at-home parents, and retirees.
Exhibit 4-7 describes a suburban, hospital-
based IOT program, and appendix 4-A

Exhibit 4-7

Key Features of a Hospital-Based Suburban IOT Program

• Qualified medical staff members make the initial assessment of applicants’ withdrawal
potential; these medical staff members prescribe and dispense medications for symp-
tomatic relief and monitor clients’ reactions for up to 10 hours.
• Medications can be administered on site.
• Staff members provide continuing assessment of other potential psychiatric problems
that may contribute to clients’ substance use disorders; a psychiatrist in the hospital’s
psychiatric unit is available for medication evaluation and monitoring when needed.
• Whenever possible, family members (with the consent of the client) are involved in the
initial assessment, treatment planning, and psychoeducational activities.

(continued)

46 Chapter 4
Exhibit 4-7 (continued)

Key Features of a Hospital-Based Suburban IOT Program

• Randomized, monitored urine testing is used as a clinical tool for deterring clients’ use
of mood-altering substances.
• Clients are expected but not required to participate in 12-Step fellowships or other
mutual-help groups early in treatment.
• Clients attend groups for both therapeutic and educational purposes. Most therapy
groups are co-led by two counselors. Group members examine the ways in which their
thoughts, emotions, and behaviors contribute to, or detract from, a satisfying lifestyle
or recovery. The clinician is responsible for ensuring a psychologically and physically
safe environment that provides support and maintains therapeutic pressure for posi-
tive change. Counselors are flexible in setting limits; they maintain order while allowing
spontaneity and growth. The emphasis is on giving all group members an opportunity
to participate as equals.
• Three 3-hour IOT sessions are organized into sequential groups. Issues identified dur-
ing the first highly structured group are explored in depth during the second, less
structured group therapy session. The third, didactic group session can be tailored to
particular issues identified during the therapeutic discussions or to the basic interests
of the group. These sessions, which use lectures and videos as well as written materials,
address an array of topics, including basic information about alcohol and drugs, the
12 Steps of AA or NA fellowships and other support groups, and a cognitive–behavioral
relapse prevention approach.
• The client’s transition from the rehabilitation (early recovery) to the continuing care
(maintenance) phase of treatment is carefully planned so that the client continues with
the rehabilitation group while “trying out” the continuing care group. The client usu-
ally knows several members of the new group and, sometimes, a co-leader of the new
group. The group meets in the facility in which earlier treatment was conducted and
the structure of the sessions is similar to that of the primary treatment phase. Step-up
care is used flexibly so that clients who have relapsed move to a more structured sched-
ule until they are restabilized.
• Programming is structured to respond to individual client needs, including a variable,
rather than a fixed, length of stay.
• Three levels of IOT services are offered in overlapping phases to reduce attrition and
facilitate long-term recovery:

– Partial hospitalization (ASAM Level II.5) for up to 10 hours per day for medically
monitored ambulatory detoxification.
– Intensive outpatient (ASAM Level II.1) for 3 hours per day for rehabilitation. Clients
initially are seen 5 days per week. The frequency gradually is tapered to once weekly
for a total of 10 to 30 sessions, depending on clinical need. Separate individual and
family sessions also are scheduled.
– Nonintensive outpatient (ASAM Level I) once weekly for 2 hours for continuing care
for up to 2 years.

Services in IOT Programs 47


Appendix 4-A. A Case Study of Intensive
Outpatient Treatment
Case Presentation Commentary
Initial Contact
Tom, a 45-year-old African-American Because the referral was initiated by an
accountant, has been referred to the EAP, it is important for staff members
program by his supervisor through his com- to stay in close contact with the EAP
pany’s employee assistance program (EAP) representative.
because of repeated Monday-morning tardi-
ness and complaints by co-workers that his
work is increasingly “sloppy” and he often
smells of alcohol.
An EAP representative telephoned and made A trained intake worker screens all appli-
an appointment for Tom for 9 a.m. the next cants to ascertain their eligibility and
day. Tom has health insurance, has not had whether there is any psychiatric or medical
previous treatment, and is married with a emergency that cannot wait for a regularly
family. Tom was asked to invite his wife to scheduled appointment.
come with him.

Stage 1: Treatment Engagement


During the intake interview, Tom reports Family members are invited to participate in
that he has been drinking “about a six intake interviews.
pack” of beer daily for the past 5 years, with
“maybe 10 or 15 beers” on weekend days. He Many treatment applicants initially mini-
denies other drug use and any major prob- mize the extent or intensity of substance use
lems, although he was charged with driving and associated problems. However, Tom
while intoxicated (DWI) 2 years ago, at clearly has a substance use disorder that is
which time his blood alcohol level (BAL) was affecting his functioning.
.22 mg/dl. He says he was “put out” that the
After confidentiality regulations are
judge sent him to alcohol education classes
explained, Tom consents to the program’s
and AA meetings, even though he “wasn’t
requesting a transcript of the records of his
really drunk or unable to drive.” His doc-
DWI charge and his involvement with the
tor told him at his last checkup about a year
alcohol education classes. His claim of not
ago that his liver function tests were slightly
really being drunk despite a .22 mg/dl BAL
elevated and he should stop drinking.
suggests a high tolerance.

He also agrees that his internist can be


asked to forward medical records and con-
duct additional tests or examinations, if they
are indicated.
Tom says he stopped drinking for a while but Tom’s history indicates that his drinking
started again and hasn’t been back to see the may be complicated possibly by underlying
doctor since then. When asked about this depression, even though he blames others
period of abstinence, Tom says it probably for his return to alcohol and does not, appar-
lasted 4 months and that he felt ently, yet see his drinking as a problem.

48 Chapter 4
Case Presentation Commentary
depressed during that time. “It’s hard having He agrees, however, to participate in the pro-
a teenage daughter,” he offers as an excuse gram because his job is in jeopardy.
for drinking again. He says it was pretty easy
to stop drinking then and would be now. He
claims he has no withdrawal symptoms and is
“healthy as a horse.”
When asked about Tom’s drinking, his wife, Gloria provides a more accurate description
Gloria, reports that he actually consumes of Tom’s drinking pattern and confirms both
1½ to 2 six-packs a day and 20 or more his physiological dependence and the possi-
beers per day on weekends. She’s certain of bility of underlying depression. She appears
this because she “picks up after him every to be supportive of her husband although
night” after he falls asleep in his chair. She’s distressed by his continued drinking and its
been complaining and worrying about Tom’s effects on the family.
drinking for years and begged him to get
help. She reports that his teenage daugh-
ter complains of how “mean” he gets when
drinking. There has been no violence, but he
shouts at the girl a lot. Gloria observes that
Tom has “terrible shakes” in the morning
until he has a beer. She recalls that he was
pretty blue and unhappy when he stopped
drinking and “couldn’t sleep, either.” She
has begged him to go back to the doctor and
says Tom never mentioned his “liver prob-
lems” to her before.

Ambulatory Detoxification
Asked to stretch out his arms, Tom has slight The estimated BAL for last night is consis-
but visible tremors in his hands and fingers. tent with the DWI report and documents a
A Breathalyzer test at 9 a.m. yields a reading high tolerance.
of .10 mg%, indicating his BAL last night at
9 p.m. when he drank his last beer was an
estimated .34 mg%.
Tom is asked to submit an observed urine All newly admitted clients provide a urine
sample. sample.
He is assigned a counselor who performs
a thorough assessment. Over the next few
weeks, the counselor and Tom develop a
treatment plan.

The counselor administers the CIWA-Ar, and Staff members determine that Tom can be
a physician’s assistant conducts a brief exam detoxified safely on an outpatient basis. He
and draws blood for new liver function tests. agrees to remain on site during the day for
The counselor discusses the results of the monitoring, and he has a responsible wife
assessments with Tom and Gloria and clearly who can drive him home and monitor him.
explains Tom’s assessed need for

Services in IOT Programs 49


Case Presentation Commentary
supported detoxification and the program’s
ambulatory detoxification process. The
counselor also discusses the program’s policy
of encouraging all clients to begin taking
disulfiram as soon as possible. The counselor
ascertains that no contraindications exist for
Tom, explains the mechanism by which disul-
firam works, and provides Tom and Gloria
with written information. Tom agrees to
begin taking disulfiram once the medication
is approved by his physician.
Tom is given 50 mg of chlordiazepoxide Clients with CIWA-Ar scores in the low 20s
(Librium®) that will be repeated every hour have been detoxified successfully with this
until he appears mildly sedated. He takes 3 protocol in this setting.
doses on the first morning.
Tom attends his first group meeting in the Immediate introduction to group treatment
morning. In the afternoon when there are on the day of admission circumvents resis-
no group meetings, Tom watches TV, reads, tance to treatment beyond detoxification. It
or sleeps in a lounge chair in a quiet room also allows group members to see the client
where he can be observed by the medical at his worst so he cannot deny the severity of
staff. his withdrawal reactions once he is sober.
At 2 p.m., when his regularly monitored BAL
reaches 0, Tom is given 125 mg of disulfiram.
(For this program’s protocol, see appendix
4-B.)

By 4 p.m., Tom is feeling very anxious again


and is given another 50 mg of chlordiazepox-
ide, which relieves his symptoms. He is asked
to sit through another 3-hour evening group
session and have his wife pick him up at 8:30
p.m. when the program closes.
As he leaves for home, Tom is given three Clients are given 50 mg doses of take-home
50 mg doses of chlordiazepoxide to be taken chlordiazepoxide for up to 3 nights, but the
hourly at bedtime until he falls asleep. He medication is under the control of a respon-
and Gloria are reminded that he has disulfi- sible family member. The number of pills
ram in his system and should not drink. supplied should be monitored carefully. If
the client has a history of dependence on
sedatives, such medications are not appro-
priate for unmonitored administration.
The next morning, Tom reports that he
needed only two doses of chlordiazepoxide
to sleep, and he returns the extra dose. He is
given another 125 mg of disulfiram. He is not
given chlordiazepoxide during the second

50 Chapter 4
Case Presentation Commentary
day but is given two more 50 mg doses for
the second night. He needs only one and
returns the other. On the third night, Tom
takes home one dose of chlordiazepoxide but
returns it the next day.

Stage 2: Early Recovery


On the third day, Tom returns to his full- Clients who work days attend evening ses-
time job. Because Tom works days, he is sions. The 3-hour psychoeducational group
scheduled for the evening program, which sessions have a standard format: the first
he will attend on the next 5 weekdays for 3 hour consists of a structured group during
hours each session. He will be scheduled for which each of the 6 to 14 members is asked
one individual session with his primary coun- individually to report significant emotional
selor each week. In addition to providing or behavioral events since the last meet-
treatment planning and individual counsel- ing (e.g., moods, sleep patterns, activities,
ing, his counselor will provide ongoing case AA attendance, stress, cravings); a second
management. The hospital’s social workers hour is devoted to a modified form of group
are available to assist the counselor with therapy that focuses on issues of particular
Tom’s case management needs if necessary. relevance to members and encourages their
interactions; and a third hour consists of
didactic instruction on such relevant topics
as medical aspects of addiction and relapse
prevention techniques. All nondidactic
groups are co-led by trained staff.
On the third day, a staff member gives Tom All clients who abuse alcohol are encouraged
a prescription for 250 mg daily of disulfiram to take disulfiram throughout the rehabilita-
to fill at the hospital pharmacy. He will self- tion phase. It has been found to be a useful
administer disulfiram at the start of each adjunct for helping all clients who drink—
evening’s group session. He will receive a whatever other drugs they use—to achieve
double dose on Fridays to last through the and maintain abstinence.
weekend.
When told that his initial urine came back The reasons and circumstances for Tom’s
positive for marijuana, Tom acknowledges that use of marijuana—as well as alcohol—will
he smoked a joint with friends last weekend. To be explored in the group. The program has
deter further use of illicit substances, he must a policy of total abstinence from all mood-
now submit observed urine samples frequently altering drugs, and clients are expected to
and randomly. His counselor also informs Tom report any use of prescription or other sub-
that his liver function test results are back stances before they are discovered by urine
and that his levels are elevated. The counselor toxicology studies.
schedules an appointment for Tom to meet with
a physician to discuss the implications of these
results.
After five sessions, Tom’s schedule is tapered
to 4 evenings a week because he seems to be
responding well to the group and is partici-
pating actively. He got through 1 weekend

Services in IOT Programs 51


Case Presentation Commentary
without too much difficulty and reports
sleeping well and attending two AA meet-
ings per week with a buddy from work. At
the end of the second week, Tom reports
that both his wife and daughter are proud of
him—everything seems rosy.
During the third week of treatment, how- Although it is not uncommon for psychiat-
ever, Tom begins feeling depressed—with ric symptoms to emerge within the first few
early morning wakening and loss of appetite. weeks of abstinence, clients may experience
When a score of 25 on the Beck Depression protracted abstinence withdrawal, which
Inventory reveals that he is moderately can cause similar symptoms. This program’s
depressed, Tom’s counselor meets with him policy is to manage mild-to-moderate symp-
and assures him that it is not unusual for toms nonmedically at first and to monitor
people in early recovery to feel depressed the client carefully. Depending on the sever-
and to have trouble sleeping. They dis- ity of the symptoms, an immediate referral
cuss some things Tom can do to manage his for medication management of depression or
depression, such as starting a moderate for an appointment with a psychiatrist could
exercise program. The counselor gives Tom be appropriate.
a relaxation tape that he can use at night to
help him fall asleep easier and encourages
him to report any new symptoms or worsen-
ing of his depression immediately.
Tom also reports having some “really good” Tom’s wife and daughter are encouraged
family times at baseball games over the week- to attend a weekly support group for rela-
ends. He’s pleasantly surprised at what a tives and significant others. This relatives’
nice kid his daughter can be, although he’s support group meets separately for 2 hours,
had a few arguments with her about the TV and then participants join the clients for the
shows she prefers and the boy she has been third hour of didactic substance abuse edu-
dating. Gloria has been coming regularly to cation. No additional charges are incurred
the relatives’ support group and attended an for family members’ attendance at support
Al-Anon meeting last week. groups. Relatives also are encouraged to
attend Al-Anon or Alateen meetings.
Nevertheless, at 5 weeks into treatment Tom During individual sessions, the counselor
reveals to his counselor that he and his wife continues to assess clients’ personal prob-
are increasingly in conflict, but he’s uncom- lems, helping them sort out issues related
fortable discussing his marital problems in to their clients’ (and their families’) early
group. With Tom’s permission, the counselor adjustment to a recovery lifestyle. The coun-
schedules several sessions with Tom and his selor may need to address a client’s issues
wife to discuss these issues and assess the of shame, guilt, sexual functioning, or child-
need for referral for marriage counseling. hood trauma if these issues appear to be
interfering with the client’s recovery.
Tom reports increasing feelings of sadness, The counselor continues to assess and moni-
irritability, and lack of energy. He says he tor other medical or psychiatric conditions
has tried to exercise more, with some suc- that may require more a detailed evaluation,
cess, but often is “too tired.” He has used the counseling, or referral to outside resources.
relaxation tape every night and says that it

52 Chapter 4
Case Presentation Commentary
helps “sometimes” but that he still is having
significant problems sleeping. He has missed
two group sessions in the last 2 weeks and
is participating less in the group sessions he
does attend. Tom’s counselor schedules an
appointment for Tom with the program’s
psychiatrist for further evaluation.
The psychiatrist meets with Tom and decides The program’s consulting psychiatrist is
that Tom’s current level of depression should readily available to meet with Tom and
be managed medically. He prescribes antide- assess his need for medication. The psychia-
pressant medication and discusses with Tom trist meets regularly with Tom to monitor
possible side effects and when he can expect his medication and answer any questions he
to begin feeling the effects of the medication. may have.
The psychiatrist schedules followup appoint-
ments with Tom.

Tom continues to attend group sessions 4


days a week for another 4 weeks. By 3 weeks
after starting the antidepressant he is partici-
pating actively, reports feeling much better,
and is positive about his recovery. He attends
AA three times a week and has a sponsor. He
reports that he has not used marijuana, and
urinalysis supports his self-report.

At this point, program staff members assess


that Tom is progressing well enough to step
down his group treatment to two times per
week and individual counseling to every
other week.

Stage 3: Maintenance
In week 11, while participating in the reha- A 2-week overlap between early recovery
bilitation phase, Tom begins attending a and maintenance groups eases the transi-
2-hour continuing care group that meets tion to the longer term, stepdown treatment
in the same facility once a week in place of phase at the same site. If possible, clients are
one of his rehabilitation phase groups. He is placed in more homogeneous groups whose
assigned to a group of mostly other profes- members have similar interests and values.
sional people. Tom already knows a few of Bonding and trust among group members
the members who transitioned earlier from become important in this phase as partici-
the rehabilitation group; his counselor is a pants give one another constructive feedback
co-leader of the new group. The meeting for- and model techniques of daily living that
mat is familiar, consisting of group therapy prevent relapse.
but no more didactic presentations. The
break between the two parts of the meeting At the point of transition to the maintenance
becomes a time for group members to talk phase, Tom has been abstinent for more

Services in IOT Programs 53


Case Presentation Commentary
frankly and share perspectives about the than 10 weeks, has started a regimen of anti-
therapeutic process. After 2 weeks of over- depressant medications, has attended AA
lap, Tom steps down to attending only the meetings regularly, has learned a great deal
once-per-week maintenance group. At this about alcoholism and substance abuse, and
point, Tom is given his disulfiram prescrip- has begun to identify and understand the
tion to take on his own at home. emotional triggers for his drinking and the
negative influence that a circle of friends at
Tom adjusts well to his continuing care group
work has on him. He is trying to implement
and attends regularly for about 2 months.
several important lifestyle changes and has
When he catches a bad cold, however, he
taken on more responsibility for his own
calls in sick—just before the Christmas
recovery.
holidays. After Tom misses another session
without reporting in—and his wife also stops
coming to the relatives’ support group—
Tom’s counselor telephones him at home.
Tom acknowledges that he has “slipped” and It is not unusual for clients to relapse, at
has been drinking on a daily basis for 7 days. least briefly, after they are comfortable,
He stopped taking disulfiram about a month think they no longer need treatment, and
after he joined the continuing care group, stop believing recovery is a lifelong process.
thinking he could “handle it.” He has drifted This is a predictable event, especially among
away from AA meetings. Now, Tom says, people who are in treatment for the first
he has missed the last 2 days of work and is time. It can be difficult for them to accept
afraid his supervisor suspects the reason. that a substance use disorder is a chronic
Tom promises to return to the program the condition, requiring lifelong care.
next day with his wife to discuss what to do.
After Tom acknowledges that he has “messed The intensity and duration of the response
up” because of overconfidence and the to a slip or relapse—a return or step-up to the
stress of the holidays, he is returned to the rehabilitation phase—depend on a client’s
rehabilitation phase, attending 4 evenings a reactions. Each client must understand how
week and taking disulfiram again at the start and why the relapse occurred and not blame
of each session. He is expected to continue others. Clients should be acknowledged
attending his weekly continuing care group, for interrupting their relapse quickly and
resume attending AA meetings, and recon- returning to treatment voluntarily. This can
nect with his sponsor. mark a turning point in clients’ understand-
ing of their condition and recovery needs.
After Tom attends 11 of the 3-hour reha- The program covers the costs of this more
bilitation sessions over a period of 3 weeks, intensive relapse intervention as part of its
program staff members agree that Tom is regular charges.
“back on track” with an increased apprecia-
tion for the long road of recovery. He returns
to his regular schedule of weekly continuing
care group and AA meetings.

Stage 4: Discharge to Continuing


Community Care
Planning for discharge begins early in the Although treatment may continue at the pro-
continuing care process. After 3 months in gram for as long as 1½ to 2 years, only a

54 Chapter 4
Case Presentation Commentary
the continuing care group, Tom’s primary minority of clients actually stay that long.
counselor refers him to a local psychiatrist Other clients leave earlier—on average, after
for continued medication management. Tom about 25 weeks of continuing care. They
is asked to prepare a plan for maintaining are, however, encouraged to announce their
his recovery following discharge from treat- plans in advance and receive clinician and
ment. He reports the following plans for group member endorsement. The goal is for
ongoing community care to members of his them to leave with a realistic plan for
group for their approval: ongoing recovery.
• Continue to attend AA meetings four to five
times weekly and maintain regular contact
with his sponsor.
• Encourage Gloria to continue attending Al-
Anon meetings.
• Join an AA club’s bowling league team as a
substitute for occasional “nights out” with
rowdy drinking buddies at work who also
smoke pot.
• Continue to attend the church that he and
Gloria have joined and continue to par-
ticipate in a couples group that is part of
their pastoral counseling services—with
the understanding that referral to a private
therapist may be indicated.
• Continue his antidepressant medication
and meet regularly with his psychiatrist for
medication management.
• Consider courses he might take that would
qualify him for a promotion to a supervi-
sory position at work.

After 6 months of continuing care, Tom is dis-


charged from active treatment. He will receive
support calls every 6 months for 3 years.

Services in IOT Programs 55


Appendix 4-B. Induction Protocol for Disulfiram
After detoxification, some IOT clients benefit ciently unpleasant to discourage most clients
from receiving drugs that help them remain from drinking while taking disulfiram.
abstinent and resist relapse. Disulfiram
is appropriate for clients who are alcohol Some physicians recommend waiting 4 to
dependent, including clients whose alcohol 5 days after a client is alcohol free before
dependence is combined with cocaine use and initiating disulfiram treatment (CSAT
methadone clients who have alcohol problems. 1997a). The Physicians’ Desk Reference
(2003) instructs physicians not to adminis-
Disulfiram interferes with the normal ter disulfiram until 12 hours after the last
metabolism of acetaldehyde, an intermedi- drink. The IOT consensus panel finds that
ary product in the oxidation of alcohol, and careful monitoring of clients’ BALs achieves
precipitates an unpleasant physical reaction the same effect—assurance that no alcohol
if alcohol is consumed within 12 hours to exists in the system. Exhibit 4-8 outlines the
7 days (depending on dose) after taking the protocol for ambulatory detoxification and
drug. Within several minutes of a person’s disulfiram induction. Low doses (125 mg)
drinking alcohol, the disulfiram reaction of disulfiram can be administered as soon
begins, with facial flushing followed by as a client’s BAL reaches zero—usually on
throbbing headache, tachycardia, increased the day of admission. The consensus panel
respirations, and sweating. Nausea and vom- recommends that clients who are alcohol
iting usually occur within 30 to 60 minutes, dependent receive disulfiram as soon as they
sometimes accompanied by hypotension, are detoxified rather than jeopardize their
dizziness, fainting, and collapse. The whole abstinence by waiting for a liver function test
reaction can last for 1 to 3 hours and is suffi- to be conducted. If needed, testing for liver

Exhibit 4-8

A Protocol for Ambulatory Detoxification and Disulfiram Induction

First day: Chlordiazepoxide 50 mg hourly until anxiety is relieved—50 mg to 300 mg


When BAL = 0: Disulfiram 125 mg*
First night: Chlordiazepoxide 50 mg at bedtime;† repeat hourly x 2 until asleep (3
doses provided)

Second day: No medication


Second night: Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if not asleep (2
doses provided)
Third night: Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if not asleep (2
doses provided)
*Disulfiram is dispensed only at the clinic.
†All unused chlordiazepoxide doses must be returned to the clinic the following morning.

Source: G. Kolodner, M.D., personal communication, 2003.

56 Chapter 4
impairment can be done during the 2 to 3 scribed for pregnant women or clients who
weeks after starting disulfiram. have had a previous allergic reaction. Women
of childbearing age are warned to use contra-
ception while taking disulfiram because the
Dosage Levels medication might endanger a fetus.
Some experienced clinicians prefer to pre-
scribe low doses of disulfiram (125 mg) for Clients who take phenytoin (Dilantin®),
most clients because at this dose the reaction isoniazid, or warfarin (Coumadin®) should
to drinking is not as potent or potentially be warned that disulfiram might intensify
dangerous as it would be at a higher dose. the effects of those medications, requiring
Other physicians use an initial dose of 250 a reduction in the disulfiram dose. Clients
to 500 mg of disulfiram. Lower doses are taking disulfiram should not take metronida-
appropriate for persons who have some liver zole (Flagyl®). They should avoid inadvertent
impairment, small women, and elderly per- exposure to the alcohol contained in many
sons. Although no studies exist regarding the cough medicines and mouthwashes or emit-
optimal length of disulfiram treatment, some ted by alcohol-based solvents in a closed
clients have taken the drug for as long as 16 area. Consumption of food that contains
years (CSAT 1997a). Compliance beyond the liquor or wine usually does not cause a
active treatment phase, however, is a major problem if the alcohol has been evaporated
problem. during the cooking process. Clients should
report any allergic reaction in the form of an
Episodic use of disulfiram is an effec- itchy rash, which usually can be controlled
tive strategy for clients who want to guard by lowering the dosage or administering an
against drinking in situations that carry a antihistamine.
high risk for alcohol consumption. These
situations might be special events or cel- Monitoring Procedures
ebrations where most people are consuming
alcohol or meetings with friends who are for- Clients taking disulfiram should be moni-
mer drinking buddies. tored a minimum of every 4 months to
ascertain whether any allergic hepatitis
requires immediate discontinuation of
Contraindications and Cautions the drug. Other potentially adverse effects
Disulfiram is contraindicated for clients with include optic neuritis, peripheral neuritis,
acute hepatitis, severe myocardial disease or polyneuritis, and peripheral neuropathy.
coronary occlusion, chronic lung disease or Mild reactions to the initiation of disulfiram,
asthma, psychoses, or sensitivity to disulfi- such as headaches and drowsiness, usually
ram or its derivatives used in pesticides and are transient and dissipate spontaneously
rubber vulcanization. Disulfiram is not pre- within a few weeks.

Services in IOT Programs 57


5 Treatment Entry
and Engagement

Entry into intensive outpatient treatment (IOT) for a substance use


disorder is a complex and critical process for both the client and
In This the program. Clients’ motivations to change range from outright
resistance to eager anticipation. An IOT program’s intake process,
Chapter... from initial contacts through ongoing assessments and treatment
planning, strongly influences whether clients complete admis-
Elements of sion procedures, select appropriate interventions, and engage in
Engaging the Client treatment.
in IOT
Early attrition of clients is a pervasive problem in substance abuse
Collect Screening treatment (Claus and Kindleberger 2002). To address this problem,
Information the consensus panel recommends the following in the admission
Assessing Barriers process:
to Treatment • Assessing a person’s readiness for change and applying appropri-
Crises and ate strategies to motivate the client to enter and participate in
Emergencies treatment
• Establishing a collaborative relationship between the clinician and
Components of client from the start
the IOT Admission • Identifying and overcoming barriers that discourage the client
Process from engaging in treatment
• Matching clients to the least intensive and restrictive treatment set-
Sample Treatment ting that can support recovery effectively
Plans • Developing individualized interventions of variable intensity and
duration that meet each client’s needs, rather than fitting the per-
son into a predefined program

More is being learned about the complicated interrelationships


among substance abuse and many other biopsychosocial factors,
including mental disorders, child abuse and neglect, domestic vio-
lence, issues related to physical and cognitive functioning, history of
trauma, poverty, criminal activities, skill deficiencies, and infectious
diseases. Many screening and assessment instruments are available
to ascertain the presence of these factors.

59
A major challenge of the admission process Create a welcoming
is to balance a rapid and empathic response environment
to a client’s request for treatment with the
need to obtain information about many Programs should do everything possible
aspects of the client’s life that can affect the to make the waiting area welcoming and
treatment response. The need for detailed comfortable. Staff members or others can
assessment infor- provide current magazines and recovery lit-
mation must not erature. A television set can show instructive
Abruptness or impinge on the videos. Toys (games, paper and crayons) can
main admission be provided for small children who accom-
rudeness on the activities: to engage pany potential clients. A bathroom, public
the individual in telephone, and source of water should be
part of staff...can treatment, ame- accessible and clean. A vending machine is
liorate immediate desirable if people spend much time in this
crises, and remove space.
result in no-shows or
barriers to treat- The Americans with Disabilities Act guar-
early dropout. ment. Attention antees equal access to treatment for clients
needs to be given with disabilities. All program staff members
to clinicians’ inter- should anticipate clients’ needs, be mind-
viewing styles and the program’s intake ful of physical barriers that limit access to
procedures, as well as to the content and or use of the program’s facilities, and be
sequence of the screenings or assessments prepared to make accommodations. Stairs,
conducted. cluttered areas, narrow hallways, doorknobs,
and even deep pile carpet may restrict the
movements of clients who use crutches or
Elements of Engaging wheelchairs. Clients with disabilities may
the Client in IOT require assistance in arranging transporta-
tion and may require more time to get from
The acknowledgment that the provider
place to place when they are at the treatment
shares responsibility with the client for
facility.
the client’s motivation to change and
commitment to treatment marks a funda-
mental shift in substance abuse treatment. Ensure availability
Treatment engagement can be fostered by The facility where new clients are admitted
• Providing a positive, welcoming should be accessible by public transporta-
environment tion and be open during hours that are
• Adopting effective initial response convenient for them. Information about the
procedures program should be available by telephone.
• Preparing for and conducting supportive, An answering service can provide an ongoing
productive intake interviews message about the program’s location, access
by public transportation, parking availabil-
ity, hours of operation, and when a staff
Program Surroundings member is available to answer questions.
This information also can be listed on a
The physical layout and ambience of the
program Web site and posted on the clinic’s
IOT program can influence a person’s com-
front door.
mitment to the treatment process (Grosenick
and Hatmaker 2000).

60 Chapter 5
Communicate cultural Ensure a rapid response
competence A review of initial response procedures
Often the first thing potential clients notice should include an examination of how quick-
is whether the program seems receptive to ly potential clients are engaged by program
their ethnic, cultural, or gender identity. staff and how long the intake procedure
Posters and pictures of populations served lasts. Once they have made up their minds
by the program, reading materials in vari- to seek treatment, some potential clients
ous languages, posted announcements of may become apprehensive or afraid if their
workshops and community activities that first steps toward recovery are not met with
address topics of interest, and staff mem- support by the program staff. It is important
bers who can communicate in the potential for staff members to greet walk-in clients
clients’ languages as well as empathize with and those who telephone promptly and to
different cultural attitudes are some accom- respond knowledgeably to their questions.
modations that IOT programs can provide. Individuals who leave messages inquiring
Chapters 9 and 10 discuss other aspects of about treatment should be called back as
serving diverse populations; chapter 4 of TIP soon as possible.
46, Substance Abuse: Administrative Issues in The initial contact should be limited to an
Outpatient Treatment (CSAT 2006f), discuss- hour, with additional time for questions and
es how administrators can prepare programs an introduction to the treatment process.
for cultural diversity; and the forthcom- Detailed assessment usually can be delayed
ing TIP Improving Cultural Competence in until a subsequent session. If intake can-
Substance Abuse Treatment (CSAT forthcom- not be completed during the initial contact,
ing a) addresses this issue as well. preliminary information should be collected
and another appointment should be sched-
Reinforce privacy and uled at the earliest mutually convenient
confidentiality time—preferably within 24 hours.
All staff members need to be mindful of cli-
ents’ privacy. Clients should never be greeted Convey respect
by name in public areas. All interviews need An important aspect of treatment engage-
to be conducted in a private room. To ensure ment is making certain that all program staff
privacy, the intake worker provides the client members greet new clients in a respectful,
with any forms that need to be completed friendly, and supportive manner that reflects
and walks with the individual to a private sensitivity to their situations. If a caller
area where the client can fill out the forms. has to be put on hold, this should be com-
It may be necessary to arrange for an inter- municated in a pleasant voice. Abruptness
preter to translate conversations and forms. or rudeness on the part of staff, no matter
Extensive telephone interviews should be how busy the program or what emergency
conducted from a private or soundproof occurs, can result in no-shows or early drop-
office so that those in the waiting room do out. (See chapter 3 of TIP 46, Substance
not overhear conversations. Abuse: Administrative Issues in Outpatient
Treatment [CSAT 2006f], for a discussion of
training staff in customer service skills.)
Initial Response Procedures
An IOT program should review its initial
response procedures to make sure that it Intake Interviews
receives potential clients in a welcoming way. Intake interviews may require a variety of
approaches to ensure that potential clients
feel connected to the treatment program.

Treatment Entry and Engagement 61


These interviews should be used to collect cussing questions you still may have about
screening information and lay the ground- treatment and this program.”
work for treatment. Intake interviews should
be conducted by counselors or staff members When summarizing findings and beginning
trained in intake procedures. to plan treatment, the counselor needs to
use strategies that are appropriate to the
client’s change stage. For the final portion
Use informal approaches for of the intake, the counselor can focus on the
initial interviews individual’s expectations for treatment.
Potential clients who spend their first hours A less structured interview method uses a
in an IOT program answering a series of genogram for gathering information about
structured questions in a formal interview the individual and his or her familial rela-
are unlikely to reveal their personal prob- tionships (CSAT 2004c). A more detailed
lems or to become engaged in the process explanation of the family genogram, along
(Miller and Rollnick 2002). Research and with a sample, is included in chapter 6 of
anecdotal evidence suggest that other, less this TIP.
formal approaches are important for build-
ing rapport between the counselor and client
and documenting important information. Adjust interviewing styles
One such approach is the sandwich tech- Much attention has been given to the critical
nique, in which a standard screening and role that motivational interviewing plays in
assessment are “sandwiched” between two treatment engagement and retention (CSAT
less formal discussions that focus on finding 1999c). Appropriately solicitous approaches
out the individual’s views, gaining coopera- increase the likelihood that intake interviews
tion, and defusing potential resentments or elicit accurate information from poten-
hostilities. tial clients. Such approaches also foster a
productive working alliance between the
During the first 15 to 30 minutes of the counselor and the potential client that can
interview, a counselor enhance the client’s impetus to change and
• Solicits the client’s perceptions of prob- engage in treatment. Exhibit 5-1 presents
lems that brought him or her to treatment effective interviewing styles based on TIP
• Explores what the client expects from 35, Enhancing Motivation for Change in
treatment Substance Abuse Treatment (CSAT 1999c),
• Supports the client’s commitment to and input from the consensus panel.
change
• Offers hope that change is possible
• Informally assesses the client’s readiness Collect Screening
to change Information
At this point, the counselor switches from During the initial contact, sufficient infor-
a casual and conversational tone to a more mation needs to be collected from the client
directive tone as formal screening and to determine whether to continue the admis-
assessment are conducted. sion process or make an immediate referral
to a more appropriate facility. No one seek-
The counselor can offer an explanation such ing treatment should be turned away from
as, “We started talking rather informally the program without a referral to a specific
about what brought you to treatment. Now, person at another service facility.
we need to shift gears and complete some
forms to gather more detailed information.
When we are finished, we can go back to dis-

62 Chapter 5
Exhibit 5-1

Effective Interviewing Techniques

• Begin with a brief overview of the topics to be covered, the expected duration of the
interview, and confidentiality requirements.
• Ask the least threatening questions first.
• Listen attentively and reflectively. Restate what the individual said to determine the
level of understanding. Provide enough time for the individual to express himself or
herself.
• Support self-efficacy by communicating that the individual can change, make autono-
mous decisions, and act in his or her best interests.
• Affirm the strengths, and compliment the positive values of the client.
• Explain everything that is happening or planned in treatment, and allow time for
questions.
• Ask open-ended questions that cannot be answered with a one-word response to encour-
age the individual to talk, describe feelings, and express opinions.
• Convey empathy through voice tone, facial expression, and body language as well as
with direct expressions of caring.
• Observe the client for nonverbal expressions of feelings that may either be inconsistent
with or confirm what the individual is saying.
• Avoid argument, remain nonjudgmental, and adjust to any resistance.
• Probe gently to clear up discrepancies and inconsistencies.
• Be completely candid and honest.
• Help the client move beyond anger, resentment, frustration, or defensiveness; even
if the individual does not return, this single contact can be a constructive, positive
influence.

Record Basic Information ment. (For information on the importance


of obtaining signed consent agreements
The following information often is docu-
before any reports are made, see The
mented on an intake form:
Confidentiality of Alcohol and Drug Abuse
• Name, age, and gender to establish iden- Patient Records Regulation and the HIPAA
tity and determine whether other special Privacy Rule [CSAT 2004b].)
arrangements or interventions are needed • The individual’s perspective on why treat-
(e.g., if the person is a minor). Some pro- ment is needed and any crises that may
grams require a valid identification such require immediate attention.
as a driver’s license, birth certificate, or • Pertinent medical conditions.
passport. • Any suicidal or other violent thoughts.
• The referral source, if any, and supporting • The person’s usual residence to determine
documentation of the need for treatment. whether the individual lives in a designat-
It is important to note whether treatment ed catchment area, if required, as well as
is sought voluntarily or mandated formally the stability of living arrangements, prox-
by an organization that expects periodic imity to the program, and how this might
reports and whether the potential client affect attendance or transportation.
has consented formally to this arrange-

Treatment Entry and Engagement 63


• The substance use disorder and its sever- a well-accepted, comprehensive diagnostic
ity, including types and amounts of sub- criterion for measuring substance-related
stances consumed, presenting signs and disorders. The study found that only three
symptoms, and potential for withdrawal. instruments had high rates of accuracy,
Appendix 5-A (page 84) has a sample form positive predictive value, and sensitivity,
that can be used to document the current in addition to the capacity to distinguish
substance use pattern and can be complet- between substance abuse and dependence
ed during a subsequent interview. More disorders. These three instruments are
detailed information can be collected later.
• Elapsed time since the most recent sub- • The Center for Substance Abuse
stance abuse treatment episode; what type Treatment’s Simple Screening Instrument
of treatment or level of care was used and (reproduced in TIP 11, Simple Screening
why it ended, especially if there are restric- Instruments for Outreach for Alcohol and
tions on readmission. Other Drug Abuse and Infectious Diseases
• Other information that may be germane to [CSAT 1994f])
treatment, scheduling, and special arrange- • A combination of the Alcohol Dependence
ments such as Scale and the Addiction Severity Index
(ASI)-Drug Use Subscale (see appendix 5-B
– Employment hours and work location for more information)
– Next of kin or person to contact, with • Texas Christian University Drug Screen
advance consent, to locate the client (see appendix 5-B for more information)
– Number and ages of dependent children
living with the client Other widely used simple screening instru-
– Date of the individual’s most recent ments are the CAGE Questionnaire, the
physical examination and name of Short Michigan Alcoholism Screening
the primary care physician who can, Test, the Offender Profile Index, and the
with legal permission, release medical Substance Abuse Screening Instrument. Each
information instrument is in the public domain, and there
– Primary language spoken, understanding is no cost for reproduction and use. TIP 11,
of English, and literacy level Simple Screening Instruments for Outreach
for Alcohol and Other Drug Abuse and
Infectious Diseases (CSAT 1994f), provides
Use Short Screening information on these and other screening
Instruments To Document a instruments. Additional resources for screen-
ing tools include Assessing Alcohol Problems:
Substance Use Disorder A Guide for Clinicians and Researchers (Allen
Several short screening instruments are and Columbus 1995), Assessing Drug Abuse
available and may be used to document the Among Adolescents and Adults: Standardized
presence of a substance use disorder that Instruments (National Institute on Drug
later may be confirmed with a diagnostic Abuse 1994), and Diagnostic Source Book
interview. on Drug Abuse Research and Treatment
(Rounsaville et al. 1993).
Not all screening instruments perform
equally well for specific populations. A
study comparing the effectiveness of eight Assessing Barriers to
frequently used screening instruments
for ascertaining substance use disorders Treatment
used the Structured Clinical Interview for During an initial contact, the counselor
Diagnosis of DSM-IV, Version 2, Substance should be alert to any barriers the individual
Abuse Disorders module (Peters et al. 2000), may face when entering treatment.

64 Chapter 5
Intoxication or Withdrawal site to assess clients and to make these deci-
sions, the IOT program should have access
Although some individuals stop consuming
to immediate medical consultation or emer-
all abused substances a few hours or days
gency treatment. Direct affiliations must be
before coming to the facility, others arrive
in place with other levels of care in the local
at the IOT program shortly after ingesting a
alcohol and drug treatment system and with
“last” dose of a substance. Intake staff must
mental health facilities. If clients are too sick
be able to recognize and know how to handle
or intoxicated to transport themselves, the
persons who are severely intoxicated, are
IOT program must arrange safe transporta-
manifesting signs of withdrawal from physi-
tion home or to another treatment facility.
cal dependence on alcohol or drugs, or are
at risk of developing such symptoms. Staff
members need training and a protocol for Acute or Chronic Medical
determining when the intake process needs
to be suspended until (1) such symptoms can
Conditions
be alleviated or allowed to remit spontane- During intake, all individuals need to be
ously and (2) the individual can cooperate screened for potential medical emergencies.
productively or return safely to the commu- Those with unexplained acute symptoms
nity. A severely intoxicated individual may (e.g., pain, altered consciousness, disori-
be unable to provide accurate responses to entation, delirium) need to be referred for
intake questions, and the person’s symptoms medical evaluation. All applicants need to be
may mask a serious medical condition. asked about diagnosed medical conditions,
onset of serious symptoms, previous head
Staff members should note the potential injury, recent hospitalizations for major
client’s behavioral and physical signs of medical problems, and medications they are
intoxication and evaluate them against the taking.
individual’s report of recent substance use.
If discrepancies exist between the reported
consumption patterns and signs of incoher- Psychiatric Stability
ence, drowsiness, or stupor, staff members Individuals with mental disorders are at high
should consider that a physical symptom risk for self-destructive and violent behav-
could be the result of head injury, infections, iors. Because use of alcohol and drugs can
diabetes, overdose, or some other cause. At be associated with psychiatric symptoms and
a minimum, the program should be able disorders, interrelationships between the
to conduct a brief physical examination, substance use and the psychiatric symptoms
assess vital signs, and document evidence should be considered in the screening pro-
of acute intoxication or potentially serious cess (Brems et al. 2002; Carey and Correia
withdrawal symptoms. Persons whose level 1998; Scott et al. 1998). The IOT clinician
of consciousness is decreasing require urgent needs to be alert to any evidence of bizarre
medical evaluation in a medical setting. or acutely paranoid thinking, threats to
Each IOT program needs guidelines that harm oneself or
indicate whether sick or intoxicated persons others, disorga-
can be observed and assisted at the facility, nized thoughts, During intake, all
should be transferred immediately to a more or delusions and
intensive level of care (e.g., detoxification auditory hallucina- individuals need to be
facility, hospital emergency room), or are tions. Individuals
ready to return home. IOT program medical with such symp- screened for potential
staff members must make the decision about toms should be
asked about any
who can be admitted safely. If medically medical emergencies.
trained staff members are unavailable on history of violent

Treatment Entry and Engagement 65


or suicidal behavior, previous psychiatric Modifications in the treatment regimen or
hospitalization, current treatment of mental environment can help these clients function
disorders, prescribed psychotropic medica- well in treatment.
tions, and whether these medications are
being taken at recommended doses and A brief examination of cognitive functioning
times. is recommended for individuals who appear,
for unexplained reasons, to be disoriented
A simple ABC model that can help intake with respect to time, place, or person or to
personnel detect overt signs of psychiatric have memory problems or language distur-
disorders is shown in exhibit 5-2. bances. Many clinicians use the Mini-Mental
State Examination (MMSE) (Folstein et al.
1975) for this purpose. The MMSE can be
Physical Disabilities or ordered at www.minimental.com. Cognitive
Cognitive Limitations impairment can limit the utility and accu-
The consensus panel recommends that racy of such frequently used assessment
IOT programs conduct early screening for instruments as the ASI. Additional screen-
physical, sensory, and cognitive disabilities ing instruments for use with individuals
because these conditions may affect cli- with physical and cognitive disabilities are
ents’ ability to participate in treatment. identified in TIP 29, Substance Use Disorder

Exhibit 5-2

ABC Model for Psychiatric Screening

• Appearance, Alertness, Affect, and Anxiety

– Appearance: How are general hygiene and dress?


– Alertness: What is the level of consciousness? Confusion?
– Affect: Are there signs of elation, anger, or depression in gestures, facial expression,
and speech?
– Anxiety: Is the person nervous, phobic, or panicky?

• Behavior

– Movements: Is the person hyperactive, hypoactive/subdued, abrupt, agitated, or calm?


– Organization: Is the person coherent and goal oriented?
– Purpose: Is behavior bizarre, dangerous, impulsive, belligerent, or uncooperative?
– Speech: What are the rate, coherence, organization, content, and sound level?
• Cognition

– Orientation: To person, place, time, and condition


– Calculation: Memory and capability to perform simple tasks
– Reasoning: Insight, judgment, and problemsolving abilities
– Coherence: Delusions, hallucinations, and incoherent thoughts

Adapted from CSAT 1994b, p. 16.

66 Chapter 5
Treatment for People With Physical and Suspicions of immediate danger should be
Cognitive Disabilities (CSAT 1998e), and TIP investigated at the initial contact by ask-
31, Screening and Assessing Adolescents for ing questions such as, Do you feel safe at
Substance Use Disorders (CSAT 1999d). home? Do you feel safe in your current rela-
tionship? Is someone threatening you now
or making you feel unsafe? The program
Crises and should have arrangements with appropri-
ate shelters, domestic violence counselors,
Emergencies and experts in forensic evidence who can
Counselors need to be alert to any crises that be consulted about appropriate protection
threaten clients’ safety or the safety of those and safety plans (CSAT 1997b). TIP 25,
around them. Substance Abuse Treatment and Domestic
Violence (CSAT 1997b), provides additional
information.
Potential for Violence or
Suicide
A brief psychiatric evaluation should be Components of the
completed to determine the potential risk of IOT Admission Process
violence or suicide or the presence of psy-
chosis. A full psychiatric evaluation should Admitting a potential client to substance
proceed only after withdrawal and linger- abuse treatment entails
ing withdrawal effects have passed. TIP 43, • Establishing the individual’s eligibility,
Medication-Assisted Treatment for Opioid which involves validating the suitability of
Addiction in Opioid Treatment Programs the program’s services for the individual
(CSAT 2005b), discusses risk factors for vio- and assessing the individual’s readiness to
lence and suicide and recommends measures change
treatment programs can take. • Initiating treatment, which may involve
detoxification, providing an orientation to
Immediate Threats to the the program, and addressing immediate
barriers to treatment
Client’s Safety • Conducting a comprehensive biopsychoso-
IOT program staff members need to be alert cial assessment
to any immediate threats of violence to staff • Conducting a multidimensional
or clients. The close association between assessment
domestic violence and substance abuse • Summarizing assessment findings
has become clearer and better documented • Developing an initial individualized treat-
in recent years (CSAT 1997b). It is now ment plan
recognized that individuals’ unexplained,
evasively acknowledged, or untreated inju- Although treatment entry can be a straight-
ries—especially to the face, head, neck, forward procedure, treatment staff members
abdomen, or breasts—may indicate battering. should be understanding and willing to
Chronic headaches, depression, recurrent adapt the intake procedure for clients who
vaginal infections, abdominal or joint pain, have complicated problems and living situ-
sexual dysfunction, or sleep and eating ations. Treatment evolves with the results
disturbances also may indicate domestic of ongoing assessments that both monitor
violence (Naumann et al. 1999). Reports of the client’s progress and identify new or
child abuse by a spouse or significant other reemerging problems.
should raise concerns about related abuse of
the concerned parent.

Treatment Entry and Engagement 67


Eligibility Admission to either of the Level II IOT
options requires the following:
After screening individuals for substance-
related disorders and problems that could • A diagnosis of a substance-related disorder
affect treatment, IOT staff verifies whether based on the Diagnostic and Statistical
the IOT program offers a suitable treatment Manual of Mental Disorders, Fourth
intensity and environment to meet clients’ Edition (DSM-IV) (American Psychiatric
needs. IOT programs should be prepared to Association 1994), or similar criteria (see
justify the need for the specific services and appendix 5-C)
support at admission and as clients progress • Identification of at least one criterion in
through treatment. ASAM PPC-2R dimensions 4, 5, or 6
• Meeting the requirements of dimensions 2
Apply patient placement and 3 if biomedical, emotional, behavioral,
criteria or cognitive conditions or problems exist

Criteria for matching clients to appropriate The diagnosis of a substance use-related


settings and services for specific problems disorder is based on findings of the compre-
are available. Attempts to specify place- hensive assessment, a physical examination,
ment criteria are designed to individualize and laboratory tests. A diagnosis also may be
substance abuse treatment and ensure its derived from administering specific instru-
effectiveness. ments, such as those described in appendix
5-B (page 85).
The American Society of Addiction Medicine
(ASAM) developed Patient Placement
Criteria for the Treatment of Psychoactive Assess readiness for change
Substance Use Disorders (PPC) (Hoffman et Persons with substance use disorders who
al. 1991). The criteria in this document are are not motivated to change may not benefit
used widely by providers and a few payers, from or participate in intensive treatment
including Medicaid in some States. Research interventions unless their motivation
shows that the criteria described in ASAM improves. These precontemplators (i.e., those
PPC are reliable and have predictive validity who have not yet considered change) and
(Gastfriend 1999). contemplators (i.e., those thinking about a
change in the near future) may require spe-
The most current version, the ASAM PPC- cial preparatory counseling that is directed
2R (Second Edition, Revised) (Mee-Lee et at raising their awareness about the negative
al. 2001), separates IOT into two different consequences of substance use and generat-
degrees of treatment participation. Level ing a commitment to change (Connors et
II.1: Intensive outpatient treatment requires al. 2001a; CSAT 1999c). Dimension 4 of
a minimum of 9 contact hours a week, ASAM PPC-2R assesses individuals’ readi-
whereas Level II.5: Partial hospitalization ness to change. Programs should consider
(daycare) involves at least 20 hours weekly ascertaining individuals’ readiness to change
of structured programming. Exhibit 5-3 pro- before conducting full-scale assessments and
vides an overview of the functional deficits developing comprehensive treatment plans.
and problem severity that indicate a client Several brief instruments are available to
should be placed in Level II.1. The criteria help staff members rapidly determine a
for partial hospitalization are listed in ASAM client’s readiness to change or motivational
PPC-2R. ASAM PPC-2R can be ordered from stage (see exhibit 5-4).
the ASAM Publications Distribution Center
(Box 101, Annapolis Junction, MD 20701-
0101; (800) 844-8948; www.asam.org).

68 Chapter 5
Exhibit 5-3

The Six Dimensions of the ASAM PPC-2R for Level II.1 IOT

Dimension 1: Acute intoxication or withdrawal potential. Clients who are not experi-
encing or at risk of acute withdrawal (e.g., experiencing only sleep disturbances) can be
managed in Level II.1 IOT, provided that their mild intoxication or withdrawal does not
interfere with treatment. To be managed successfully in Level II.1 IOT, clients should be
able to tolerate mild withdrawal, make a commitment to follow treatment recommenda-
tions, and make use of external supports (e.g., family).

Dimension 2: Biomedical conditions or complications. Clients with serious or chronic


medical conditions can be managed in IOT as long as the clients are stable and the prob-
lems do not distract from the substance abuse treatment.

Dimension 3: Emotional, behavioral, or cognitive conditions or complications.


Dimension 3 problems are not a prerequisite for admission to IOT. But if any of these
problems are present, clients need to be treated in an enhanced IOT program that has
staff members who are trained in the assessment and treatment of both substance use
and mental disorders. IOT is appropriate for clients with co-occurring disorders who
abuse family members or significant others, may be a danger to themselves or others, or
are at serious risk of victimization by others. IOT also is indicated if mental disorders
of mild-to-moderate severity have the potential to distract clients from recovery without
ongoing monitoring.
Dimension 4: Readiness to change. The structured milieu of IOT is appropriate for
clients who agree to participate in but are ambivalent about or engaged tenuously in
treatment. These clients may be unable to make or sustain behavioral changes without
repeated motivational reinforcement and support several times a week.

Dimension 5: Relapse, continued use, or continued problem potential. Despite prior


involvement in less intensive care, the client’s substance-related problems are intensifying
and level of functioning deteriorating. Appendix C of ASAM PPC-2R (Mee-Lee et al. 2001)
discusses this dimension in detail and suggests instruments and questions for assessing
four constructs involved in relapse and continuing use potential: (1) chronicity of prob-
lem use or periods of abstinence, (2) positive and negative pharmacological response to
substances, (3) reactivity to external stimuli, including triggers and chronic stress, and
(4) cognitive–behavioral measures of self-efficacy, coping, impulsivity, and assumption of
responsibility or assignment of blame.

Dimension 6: Recovery environment. IOT supervision is needed for clients whose


recovery environment is not supportive and who have limited contacts with non-substance-
abusing peers and family members. These clients have some potential for making new
friends and seeking appropriate help and can cope with a passively negative home envi-
ronment if offered some relief several times a week.

Source: Mee-Lee et al. 2001.

Treatment Entry and Engagement 69


Exhibit 5-4

Brief Screening Instruments That Assess Motivational Stage

• Readiness Ruler is a simple approach that asks respondents to gauge their readiness
and willingness to commit to change on a scale of 1 to 10.*
• University of Rhode Island Change Assessment Scale is a self-administered question-
naire with 32 items that requires about 5 to 10 minutes to complete. Respondents rate
statements about their substance use from “Strongly Disagree” to “Strongly Agree.”
Summed items give scores that correspond to the four stages of change (DiClemente
and Hughes 1990; Willoughby and Edens 1996).*
• The Stages of Change Readiness and Treatment Eagerness Scale is a 40-question, writ-
ten test that requires about 5 minutes to complete and has 5 separately scored scales
of 8 items apiece that are summed to derive the scale score (Miller and Tonigan 1996;
Miller et al. 1990).*
• Readiness to Change Questionnaire—Treatment Version has 30 alcohol-related ques-
tions that can be self-rated on a 5-point Likert scale. A shorter 12-item version address-
es only the precontemplation, contemplation, and action stages for hazardous drinkers
(Heather et al. 1993, 1999).*
• Circumstances, Motivation, Readiness, and Suitability Scales-Revised (CMRS) is a factor-
derived, 18-item instrument that a respondent at a third-grade reading level can self-
administer in 5 to 10 minutes (De Leon and Jainchill 1986; De Leon et al. 1994). The
revised, copyrighted CMRS is applicable to both residential and outpatient modalities.

More information about the psychometric properties, target populations, scoring, utility,
ordering, and other references for these instruments can be found at www.niaaa.nih.gov
by typing “Alcoholism Treatment Assessment Instruments” and clicking on Search.
* Described in detail and reproduced for unrestricted use in appendix B of TIP 35, Enhancing Motivation for
Change in Substance Abuse Treatment (CSAT 1999c).

Beginning Treatment sedative-hypnotics, opioids, or stimulants


can undergo ambulatory detoxification in
Once the individual is determined eligible
a Level II.5: Partial hospitalization or day
for IOT, detoxification is the first priority.
treatment program (see exhibit 5-5). To
When the individual is ready to be admitted
undertake ambulatory detoxification of these
to the IOT program, a staff member explains
clients, IOT programs should offer 20 hours
the treatment program so that the potential
of clinical programming per week and have
client can make an informed decision about
direct access to medical services.
enrollment.
Program staff must determine whether
Provide for detoxification detoxification can be accomplished safely on
an ambulatory basis in an IOT program that
Detoxification, if necessary, should be
offers fewer than 10 hours of client contact
accomplished before a client is admitted into
per week and has limited access to medi-
the full IOT program. Clients experiencing
cal services. In general, referral to a more
symptoms of mild withdrawal from alcohol,

70 Chapter 5
Exhibit 5-5

Mild Withdrawal Symptoms for Four Drug Classes That


Can Be Managed in Level II.5 Ambulatory Detoxification

Alcohol Mild withdrawal without need for treatment with sedative-


hypnotics; no hyperdynamic state; CIWA-Ar score of 8; no signifi-
cant history of morning drinking.

Sedative-hypnotics Mild withdrawal with history of almost daily sedative-hypnotic use;


no hyperdynamic state; no need for treatment with sedative-
hypnotics; no complicating exacerbation of affective disturbance;
no dependence on other substances.

Opioids Mild withdrawal in context of almost daily opioid use but no need
for substitute agonist therapy; withdrawal symptoms respond well
to symptomatic treatment; comfortable by the end of the day’s
monitoring.

Stimulants Mild withdrawal involving lethargy, agitation, or depression; the


client has sufficient impulse control, coping skills, or support to
engage in treatment and to prevent immediate continued use.

Source: Mee-Lee et al. 2001.

intensive level of 24-hour care should be con- • Abuse alcohol, sedatives, barbiturates, and
sidered for clients who have been heavy and anxiolytics in combination
consistent alcohol drinkers or consumers of • Have an unstable, unsupportive, or unsafe
benzodiazepines or sedative-hypnotics or any home environment without supportive
combination of these substances for a period friends or relatives to monitor medication use
of weeks to months and who
Withdrawal from alcohol and sedative-
• Have a slow response (more than 2 hours) hypnotics can be life threatening. ASAM
or allergic reactions to the medications and other professional groups recommend
used for detoxification using the Addiction Research Foundation’s
• Have unstable vital signs, confusion, or Clinical Institute Withdrawal Assessment-
delirium Alcohol, Revised (CIWA-Ar), to assess and
• Have serious and unstabilized medical monitor the severity of alcohol withdrawal.
disorders (e.g., heart, lung, liver disease; The CIWA-Ar uses a scale of 10 quantifi-
seizure disorders; HIV infection) able signs and symptoms; has documented
• Are older adults or adolescents reliability, reproducibility, and validity
• Have a history of serious psychiatric disor- (Sullivan et al. 1989); can be administered
ders and complications in 5 minutes by staff members who have
• Have a history of seizures, delirium, or psy- undergone a 3-hour training; and helps in
chosis during previous withdrawals making the decision whether to hospitalize
• Have a history of drug overdoses the client or treat the client as an outpatient

Treatment Entry and Engagement 71


(Fuller and Gordis 1994). The CIWA-Ar is clients in achieving and maintaining absti-
not copyrighted and is available from the nence, clients also need to know that the
ASAM’s Web site program will help them accomplish other
(www.asam.org) by positive and realistic goals (e.g., getting off
Program staff typing “Addiction probation, regaining child custody, enrolling
Medicine in a vocational school). An orientation also
should work with Essentials” should help clients allay any fears they may
and clicking on have about treatment. Ample time needs
clients to plan a Search. Appendix to be left in orientation sessions to answer
4-B of this TIP pro- questions. Topics for program orientation
treatment schedule vides additional include
resources for the
clinician regarding • The general program philosophy, poli-
around available cies, and services offered. Clients should
ambulatory detoxi-
fication. TIP 45, be informed of the program’s treatment
transportation. philosophy, approach (e.g., individual and
Detoxification and
Substance Abuse group counseling, psychoeducation, treat-
Treatment (CSAT 2006e), provides addition- ment phases), and policies (e.g., family
al information on detoxification. involvement, drug testing, discharge crite-
ria). Clients also need to understand how
the program handles domestic violence,
Conduct informal orientation intoxication and driving, and the reporting
A preliminary, informal orientation con- of child abuse and neglect and infectious
sists of a description of program rules and diseases.
requirements, client’s rights and responsi- • The program’s responsibilities to clients.
bilities, and confidentiality protections. The Confidentiality safeguards, procedures for
staff member answers specific questions issuing warnings to clients, process avail-
about the anticipated duration of treatment, able to clients for appealing termination or
the frequency and length of sessions, and other decisions, client access to staff mem-
the program’s scheduled hours. Many indi- bers, 24-hour crisis assistance, referrals to
viduals at admission are too distracted by outside agencies and services, availability
the process, nervous about the commitment, of childcare services, and assistance with
or focused on their feelings to comprehend transportation should be discussed with
important details. All important points clients. New clients are required to receive
should be communicated again in a more a written summary of Federal alcohol and
formal orientation session or, at a minimum, drug confidentiality regulations. Programs
described in brochures or handouts. subject to Health Insurance Portability
and Accountability Act rules must provide
Conduct formal orientation additional information about client rights
and how to exercise them (CSAT 2004b).
A formal orientation offers an opportunity • Clients’ responsibilities to the program.
for staff members, including the program Clients need to understand their role in
director, to introduce themselves and treatment plans and contracts and appreci-
welcome new clients, reinforce clients’ moti- ate the importance of regular attendance,
vations to remain in treatment, and induct compliance with program and group rules,
clients into appropriate roles. New clients submission of drug-testing specimens,
need to hear—and believe—that they are timely fee payments, participation in sup-
respected as individuals and will be involved port groups or other community activities,
in planning their treatment. Although the and completion of homework assignments.
primary treatment objective is to assist

72 Chapter 5
Address immediate barriers Understand purposes of
to treatment entry assessment
Barriers to treatment entry that clients reveal The comprehensive biopsychosocial assess-
during the intake interviews require the ment is the foundation for treatment
attention of IOT program staff. In addition planning, establishes a baseline for measur-
to the medical and mental health conditions ing a client’s progress during treatment,
discussed above, these barriers may include ascertains the relative severity of a client’s
the lack of childcare assistance, transporta- current problems, and helps set priorities
tion, shelter, or food. for treatment interventions. The comprehen-
sive assessment also identifies the client’s
For some individuals, lack of affordable strengths that can foster recovery. Repeated
childcare assistance and reliable transpor- assessments are important for monitoring
tation are immediate barriers to treatment the client’s progress and adjusting care if
engagement. If the IOT program does not needed.
provide onsite childcare services, it should
maintain a list of community-based child-
care groups to which it can refer clients. Develop assessment methods
Some programs offer vouchers for clients and protocols
who are unable to afford this care, and some IOT clinicians gather evidence about each
provide vouchers for public transportation. client’s problems through
Program staff should work with clients to
plan a treatment schedule around available • Clinical observations
transportation. • Structured and informal interviews
• Standardized tests and instruments
A client who is struggling to meet shelter and • Physical examinations
food needs is unlikely to engage in IOT. The • Laboratory drug tests
IOT counselor, through the program’s col- • Medical records from previous treatment
laborations with community services, needs episodes (with the client’s permission)
to connect the client to appropriate re- • Records and reports from referring sources
sources. After obtaining the client’s consent, (with the client’s permission)
the counselor can arrange with community • Interviews with spouse, family members,
food banks for emergency food allocations, friends, and co-workers (with the client’s
contact emergency shelters or recovery permission)
housing groups, and contact the local
social service agency to start the process of Most aspects of an individual’s functioning
obtaining temporary financial relief. A case can be explored adequately by a few well-
manager is helpful in these circumstances. chosen questions and observations. Brief
screening questionnaires help direct more
detailed assessments. Because this compre-
Comprehensive hensive biopsychosocial assessment serves
Biopsychosocial Assessment a variety of purposes for both the client and
To develop a tailored therapeutic regimen, the program, IOT programs need to con-
the counselor gathers detailed information sider the assessment tools, content, and staff
on substance use patterns and other prob- training required to administer the instru-
lems. This broad investigation of multiple ments competently, as well as the cost of
dimensions of functioning should continue purchasing them. To guide the selection of
throughout treatment. However, the most appropriate assessments each IOT program
detailed assessment occurs during the com- is encouraged to consider
prehensive biopsychosocial assessment.

Treatment Entry and Engagement 73


• The problems most commonly found in sion document. The ASI is a commonly used,
the population being served (e.g., language multidimensional assessment instrument
barriers) and the exigencies of assessing that can serve as a basic assessment docu-
the population. ment. Together, these clinical impressions
• The financial resources that can be devot- and assessment instruments provide the
ed to intake and detailed assessments. foundation for initial treatment plans.
• The availability of qualified staff members
to conduct interviews, administer and Using the Addiction Severity
score standardized instruments, or per-
form physical examinations. Index
• The information needed to identify acute The ASI generates a profile of a respondent’s
problems, enroll a new client, document problem severity in six functional domains:
admission, complete required State or medical status, employment and support
insurance forms, and provide base- status, alcohol and drug use, legal status,
line findings for program performance family and social relationships, and psy-
evaluation. chiatric status. The 161-item ASI is useful
• The scientific accuracy, utility, and psycho- for measuring changes or improvements in
metric properties of selected instruments functional and treatment outcomes. Chapter
and the availability of normative data or 6 of TIP 46, Substance Abuse: Administrative
cutoff scores for the population being Issues in Outpatient Treatment (CSAT 2006f),
served. presents a discussion of how the ASI can be
• The availability of translated materials used for program performance evaluation.
and the ease of use of these materials.
• The willingness of referring sources and At the completion of each section in the ASI,
treatment providers to forward requested the respondent is asked to rate from “Not at
records on a timely basis. The report that All” to “Extremely” the extent to which he
accompanies a referral (e.g., by a private or she is troubled by the problem and feels
physician, an employee assistance pro- a need for counseling or treatment in that
gram, children’s protective services, the area. The interviewer rates the severity of
criminal justice system) may contain criti- each problem area on a 10-point scale and
cal information about how the applicant’s indicates his or her confidence about wheth-
substance use disorder was discovered and er questions were understood and answered
what consequences may ensue if progress truthfully. The instrument has demonstrated
in treatment is not demonstrated. high reliability and concurrent predictive
validity (Leonhard et al. 2000; McLellan et
al. 1992a; Schottenfeld and Pantalon 1999).
Multidimensional Assessment
Appendix 5-D (page 88) lists areas for further
Client records, which are a crucial part of exploration within the six domains of the
multidimensional assessment, may include ASI and discusses ways to explore other top-
notes from the intake interview, toxicology ics that are not included in the six domains
results, reports from the referring agency or of the ASI.
previous treatment providers, findings from
other clinicians, self-administered screen-
ing tests, and specially ordered diagnostic Summary of Assessment
consultations. To round out the assessment, Findings
some IOT programs design intake screening
and comprehensive assessment forms, and The process of compiling the assessment
others use standardized, multidimensional findings into a report and presenting the
assessment instruments as the basic admis- report to the client leads to the development
of an individualized treatment plan.

74 Chapter 5
Compile the summary report health, relationships, and legal and employ-
The summary report includes an overview ment statuses. These reactions direct the
of the clinical findings with references to clinician to the problems the client is most
admission documents, archival reports, interested in solving. They also point out
findings from screening and assessment discrepancies between the client’s values or
instruments, laboratory test results, and the goals and the adverse effects of substance
physical examination. Many IOT programs abuse. These concerns can be highlighted in
format this summary according to the assess- the treatment process to enhance motivation
ment dimensions of ASAM PPC-2R, the six for change.
domains of the ASI, or other special problem
areas (e.g., housing for the homeless, par- The Treatment Plan
enting skills for single parents). Regardless
of the format, the report should facilitate a Formulating a treatment plan is necessary to
quick review of related problems and aid cli- ensure clients’ engagement and initial progress.
nicians and clients in setting priorities.
Prepare the treatment plan
Present assessment findings Once the assessment findings have been
to the client summarized and discussed, the client—and
significant others, if appropriate—col-
The assessment summary is best presented laborates with the clinician in developing
in a straightforward manner in language a comprehensive treatment plan. This plan
that the client understands, with a clear identifies the client’s primary problem, indi-
interpretation of the significance of the vidualized goals, and clinical interventions
findings. It is a good idea to introduce designed to achieve these goals (Connors
information in a motivational style, asking et al. 2001a). The order and manner in
for responses and considering the client’s which problems are addressed is tailored to
verbal or nonverbal reactions without being each client’s needs. It is not appropriate for
judgmental or confrontational. For example, substance abuse treatment programs to con-
the counselor might say, “It seems that this struct one-size-fits-all treatment plans for all
information is distressing you” or “Is this clients, prescribing interventions to achieve
what you expected to hear?” The counselor goals that reflect the program’s philosophy,
should avoid labeling the behavior in a nega- not necessarily the client’s needs. Although
tive way or interjecting opinions. the treatment plan may focus on abstinence
The counselor notes which findings seem in the early stages of treatment, it addresses
most disturbing to the client. The coun- all noted problems, even though some prob-
selor tries to elicit the client’s reactions to lems may not be solved until long after the
the effects of substance abuse on his or her client leaves the IOT program.

An Emphasis on the Client’s Prioritizing Problems


One research study of IOT programs found that longer retention and better treatment out-
comes were associated with an early focus on the problems that clients considered most
important to them (e.g., family relationships, housing, medical conditions). Although these
results could be interpreted as confirming the observation that clients who do well tend to
remain in treatment, they show the importance of addressing problems that clients identify
(Weinstein et al. 1997).

Treatment Entry and Engagement 75


Some variation of three general goals usu- problems addressed or emerging issues
ally is incorporated in individualized plans to be assessed.
for substance abuse treatment (American • A signature line for the client to indicate
Psychiatric Association 1995; Schuckit participation in development of the treat-
1994): ment plan and agreement with its speci-
fications. The client receives a copy as a
• Achieving a substance-free lifestyle reminder of both his or her responsibilities
• Improving life functioning and role as a partner who works with the
• Preventing relapse or reducing the fre- clinician to achieve treatment goals.
quency and severity of relapses

Most treatment plans also incorporate the Plan for continuing


following elements: community care
• A few clearly stated, unambiguous goals Comprehensive planning and ongoing review
that do not compete with one another. of the treatment plan during IOT lay the
These should be realistically attainable by groundwork for ongoing recovery support fol-
the client. lowing a client’s discharge. Beginning early
• Specific actions for addressing each in treatment, the client is encouraged to help
goal. The clinician should ensure that the design the continuing care plan to develop
client understands the actions to be taken a sense of ownership and involvement
and how they will help the client achieve in implementing it. The consensus panel
the goals. believes that allowing the client to choose
• Objective, easily measurable criteria continuing care goals and types of engage-
for monitoring whether actions are ment can increase satisfaction, compliance,
completed and goals are accomplished. and positive outcomes, because the client is
Examples include (1) attending a specified given some authority over the treatment plan.
number of Alcoholics Anonymous (AA) The earlier this process is initiated, the more
meetings each week and (2) maintaining time is available to address concerns, ambiv-
abstinence for 3 months as monitored by alence, or other issues. Chapter 3 provides a
three times per week Breathalyzer™ tests, more detailed discussion of continuing care.
self-reports, and daily ingestion of disulfi-
ram (Antabuse®).
• The sequence in which goals are Sample Treatment Plans
addressed and activities undertaken. The following two case histories illustrate
Acute problems need to be addressed first. different ways problem summaries and
Until the client is stabilized and testing is treatment plans can be developed and docu-
completed, it may not be possible to final- mented. The first case summarizes problems
ize the sequence of treatment services. that often are discovered by using the ASI
• A specified timeline or target date for as the basic assessment instrument, with
goals. The plan identifies goals that are supplemental followup questions by the
likely to be met during IOT, those that will interviewer. The treatment plan indicates
be worked on during continuing care, and goals, objectives, actions to be taken, target
those that need input from other agencies dates for accomplishment, and responsible
or community groups. persons involved. The problems in the sec-
• The resources, responsible persons, or ond case are summarized according to the
activities required. The means for achiev- six dimensions of the ASAM PPC; the treat-
ing each goal are listed in detail. ment plan specifies objectives, interventions,
• Specific dates for reviewing the treat- responsible persons, and dates for comple-
ment plan and modifying it to reflect tion or service delivery.

76 Chapter 5
Sample Case 1 after Alice stole money from her mother’s
purse. Alice has been living with anyone who
Clinical summary will take her in for the last 9 months.
Alice is a 23-year-old, Caucasian, single The immediate events that precipitated
mother of two daughters who are fathered by Alice’s seeking treatment are a pending crim-
the same man, Lewis. Lewis introduced Alice inal charge for shoplifting (she was placed
to alcohol and marijuana while she was in on probation for a previous shoplifting
high school. At age 15, Alice discovered she charge) and the recent removal of her chil-
was pregnant and dropped out of school to dren from her custody and their placement
live with Lewis. She has alternated between in foster care. An anonymous caller to the
staying with him and staying with her moth- child welfare agency complained that Alice
er ever since. Her drinking increased steadily left her children unattended for long periods
over the years. Shortly after the birth of her and that the older daughter was truant from
second daughter 4 years ago, Alice and Lewis school most days.
were introduced to crack cocaine. Alice’s
use of crack rapidly escalated. She also Alice has a history
continued to drink to “come down.” She lost of criminal justice ...allowing the client
several fast-food jobs because of unexplained system involve-
absences. Because of her children she was ment, mostly for to choose continuing
eligible for Temporary Assistance for Needy prostitution. Her
Families and has depended on this assistance. current probation
To support her drug habit, Alice turned to officer has told her
care goals and types
prostitution, theft, and trading sex for crack. if she does not seek
Before admission, she smoked crack almost treatment, she will of engagement can
daily and drank excessively. She also has be violating her
injected a cocaine/heroin mix twice, at probation. Alice increase satisfaction,
Lewis’s urging. has entered treat-
ment twice before compliance, and
Born in a rural community, Alice moved to but dropped out
a large city with her mother and five older both times after positive outcomes...
siblings when she was 10, leaving behind an only a few sessions.
unemployed and abusive father, who was She is now shocked
dependent on alcohol and who died of liver at the loss of her children and terrified
cirrhosis 5 years ago. Alice’s relationship that she could do some long jail time. She
with her mother always has been strained, believes she is ready to change her life and
partly because her mother struggled long appears motivated for treatment. Although
hours as a cleaning woman to support her her mother is angry at Alice and appalled
children and partly because she had numer- at the placement of her grandchildren into
ous boyfriends whom Alice resented. It seems foster care, she has agreed to let Alice move
to the counselor that Alice has spent most of back as long as she gets into and stays in
her life searching for approval and love from treatment. Her mother stresses, however,
anyone who pays attention to her. that this cannot be a long-term living situa-
tion for Alice. The probation officer referred
Lewis has been incarcerated for a drug
Alice to a local IOT program, where she was
charge for the past year; he will be in prison
evaluated and admitted.
for at least the next 5 years and will be
unable to provide support for his children Although she has engaged in many risky sex-
or for Alice. Alice had moved back with her ual behaviors and has injected drugs twice,
mother when Lewis began his incarceration, Alice did not report any medical problems
but her mother threw Alice out of her house

Treatment Entry and Engagement 77


but has not seen a physician since her young- • Possible depression, but never evaluated
er daughter was born. At that time, she had (family history of substance use disorders
no prenatal care, was abstinent briefly, and and suicide)
did not reveal her substance abuse during
the 1-day hospital stay. Alice has never been The IOT program assigns case managers and
tested for HIV or other sexually transmit- counselors to clients who have numerous
ted diseases (STDs) and does not remember problems that require extensive coordina-
the last time she went to a dentist. She has tion with various community agencies. After
never had psychiatric evaluation or treat- conferring with Alice about her priorities
ment, although one of her sisters committed and preferences, treatment staff developed
suicide and several brothers also use sub- the following treatment plan. This client has
stances. Alice reported that she has difficulty multiple pressing needs, and her treatment
sleeping, feels “devastated” about the loss of plan includes more goals than are required
her children, and cries frequently. for clients with fewer challenges.

Alice has never been employed regularly and Short-term goals


has no skills, but she was a good student, is
articulate, and appears to be bright. 1. Address cocaine and alcohol
dependence
Alice stated that she wants to change her life,
Objective: Help client understand the
primarily to regain custody of her children.
importance of abstaining from all psy-
She says she is “done with Lewis” because
choactive drugs
she does not think he will ever change. She
Action: Enroll client in appropriate psy-
realizes that she needs to cease illegal activi-
choeducation and early recovery groups
ties; give up drugs; stop getting drunk; find
in the IOT program; encourage her to
safe, permanent housing; and obtain train-
attend mutual-help groups in the com-
ing and a job. She is optimistic that these
munity (AA and Cocaine Anonymous
goals are achievable, but she has an unreal-
[CA]); regularly monitor urine and
istic view of the difficulties she faces and the
breath drug tests
time it will take to reach her goals. She does
Target date: Immediately
not appear to have any close friends who do
Responsible persons: Client, counselor
not use drugs. Alice does not attend church
and has no recreational interests.
2. Engage client’s mother in treatment
Objective: Increase emotional support
Master problem list for client’s recovery
• Children, ages 8 and 4, removed from cus- Action: Explore mother’s interest in
tody and placed in foster care attending family education group and
• Crack cocaine and alcohol dependence participating in family therapy
• Ongoing illegal activities and a pending Target date: Contact mother immediately,
criminal charge with client’s consent; if mother is willing,
• No permanent residence begin family education immediately
• No apparent job skills or work history Responsible persons: Mother, client, pri-
• Lack of positive support system mary counselor, family counselor
• Strained relationship with mother and
family members 3. Establish communication with child
• No recent physical or dental examination; welfare services and client’s children
at high risk for HIV, STDs, and hepatitis Objective: Begin process of family reuni-
• History of dropping out of substance abuse fication; facilitate reasonable visitation
treatment schedule

78 Chapter 5
Action: Obtain client consent to contact Action: Observe signs of continuing
child welfare representative to ascertain depression after client is stabilized;
conditions for return of child custody refer her for psychological evaluation,
and negotiate an action plan (This plan if indicated
may include regular reports about the Target date: Within 30 days; ongoing
client’s treatment progress, having the Responsible persons: Client, primary
client attend parenting classes, and hav- counselor, clinical supervisor, consult-
ing the client participate in regular, ing psychologist or psychiatrist, medical
observed visits with her children.) director
Target date: Within 2 weeks
Responsible persons: Client, case man- Intermediate goals
ager, child welfare representative
1. Sustain abstinence from cocaine
4. Establish communication with and alcohol
criminal justice system Objective: Reinforce treatment progress;
Objective: Avoid client’s probation assist client in meeting other goals by
violation; seek leniency for client’s sustaining abstinence
shoplifting charge Action: Help client identify cues for
Action: Obtain client consent to drug use; teach client relapse prevention
contact probation officer; get officer’s techniques; monitor drug test results;
perspective on client and what encourage continuing participation in
conditions may be negotiated (e.g., AA or CA groups in the community
regular reports to probation officer Target date: Ongoing
about treatment attendance and Responsible persons: Client, case man-
compliance, community service for ager, medical staff, group counselor
shoplifting conviction)
Target date: Within 2 weeks 2. Obtain transitional housing
Responsible persons: Case manager, Objective: Move client into safe, stable
client, probation officer housing that supports continuing recovery
Action: Obtain client consent to contact
5. Obtain medical and dental evaluation local transitional housing program to
Objective: Assess client’s health; prevent arrange for placement and daily trans-
client’s potential transmission of infec- portation to IOT program
tious diseases Target date: Initiate within 60 days;
Action: Refer client for medical and ongoing
dental evaluations, including testing for Responsible persons: Client, case man-
HIV infection and other drug-related ager, case aide, transitional housing
diseases; enroll client in health educa- admission staff
tion group with counseling about HIV
testing; encourage the client to stop high- 3. Undergo vocational testing; begin
risk behaviors, consent to testing, and working toward a general equivalency
follow through on needed medical care diploma (GED)
Target date: Within 2 weeks Objective: Enhance client’s employabil-
Responsible persons: Client, case manag- ity and self-esteem
er, health care coordinator, medical staff Action: Refer client to an educational
specialist for testing; have client attend
6. Evaluate psychological functioning GED classes
Objective: Evaluate client’s mental
health; assess her suicide risk; treat her
depression if necessary

Treatment Entry and Engagement 79


Target date: Initiate activities within 90 2. Obtain full-time employment
days; ongoing Objective: Help client become economi-
Responsible persons: Client, educational cally self-sufficient
specialist, GED or adult education Action: Support client in job search
coordinator activities; refer client for search assis-
tance if necessary
4. Obtain employment Target date: 1 year
Objective: Help client become economi- Responsible persons: Client, vocational
cally self-sufficient counselor, job club and life skills group
Action: Refer client to a vocational coun- leaders, case manager
selor to test client and determine an
appropriate career goal; ensure atten- 3. Obtain permanent housing
dance in life skills group and job club; Objective: Move client into safe, stable,
encourage participation in volunteer activ- permanent housing
ities that enhance employment-related Action: Assist client in finding housing
skills and enhance the client’s résumé in the community; assist client in negoti-
Target date: Initiate activities within 90 ating lease agreement
days; obtain at least part-time employ- Target date: Within 1 year
ment within 6 months Responsible persons: Client, case manag-
Responsible persons: Client, vocational er, case aide, transitional housing staff
counselor, job club and life skills group
leaders, case manager 4. Regain child custody
Objective: Reunite client with children
5. Cultivate a positive support group; Action: Help client meet the require-
participate in healthy leisure activities ments of the child welfare services for
Objective: Encourage client to develop regaining custody of her children
friendships with those who support a Target date: 2 years
new abstinent way of life; encourage Responsible persons: Client, caseworker,
client to participate in appropriate social worker from child welfare
recreational activities that she and her
children enjoy
Action: Ensure that client continues to
Sample Case 2
attend AA or CA meetings; enroll client
in recreational group and parent train-
Clinical summary
ing classes to meet other mothers; help
client explore other community activities Joe is a 24-year-old, unmarried, African-
Target date: Ongoing American man who lives in a poor
Responsible persons: Client, case manager neighborhood of a large city and works as a
dock loader for a large trucking company.
He has been a heavy drinker and marijuana
Long-term goals smoker since his teens but only recently
started snorting cocaine. Joe lives with an
1. Sustain abstinence from cocaine and aunt and uncle, paying a small monthly rent
alcohol for a basement room, and he hangs out with
Objective: Assist client in meeting life his street buddies most of the time, “boozing
goals by remaining abstinent and drugging” at dance clubs and pool halls.
Action: Encourage ongoing participation
in AA or CA groups in the community Joe never knew his father and was raised by
Target date: Ongoing his grandparents. His alcoholic mother left
Responsible persons: Client Joe and two younger brothers in his

80 Chapter 5
grandparents’ care when she ran off with a worried he is, the more money he spends on
man—only to die in an accident about a year drugs and his son and girlfriend.
later when Joe was 8 years old. His beloved,
very religious grandfather died of complica- When asked, Joe says he wants to clean up his
tions from diabetes when Joe was in high act and become a man like his grandfather.
school. Although his grandmother is alive However, he does not see a way out, especially
still, Joe seldom sees her. None of the family if he is convicted of manslaughter. The thought
members are close. of spending time in prison terrifies him.

Now Joe is in serious trouble: a street brawl Integrated problems list


that he got into after a dance ended with
the shooting death of one of his friends. Joe Withdrawal potential. Although he drinks
is one of those charged, though he swears daily, it does not appear that Joe will have
he was not involved. He was, however, so more than minimal withdrawal symptoms
drunk and high that he does not remember when he stops consuming alcohol. These can
what happened. Because Joe has a his- be managed, if needed, by the IOT program
tory of fighting while drunk and a series of as can any rebound depression he may expe-
previous assault charges, the court has man- rience from quitting cocaine.
dated treatment because of the alcohol and Biomedical condition or complications. Joe
cocaine found in Joe’s urine after his latest definitely needs to see a physician for a thor-
arrest. He feels lucky to have been released ough physical examination. His weight needs
and sent to an IOT program rather than to to be evaluated, along with his eating habits.
jail or a residential facility.
Emotional/behavioral/cognitive status.
Joe is overweight but otherwise reports no phys- Joe’s legal and financial problems are caus-
ical complaints or serious medical problems. ing a great deal of stress. His repeated
The one bright spot in Joe’s life is the 2-year- fighting while under the influence may mask
old son, Charles, he fathered with a “nice” other psychological problems. It is not clear
girl (Brianna) he has known since high whether Joe ever fully has expressed his grief
school. Brianna says that she loves Joe and about losing his mother and grandfather.
would like them to be a family. However, she His isolation from family members and his
is very concerned about Joe’s alcohol and job situation need to be explored.
drug use and is thinking about ending the Readiness to change. Joe does not seem to
relationship. Although Brianna knows that appreciate fully how much his drinking and
Joe thinks Charles is special, she is reluc- drug use have complicated his life, but he
tant to let the father and son go anywhere regrets the fight in which his friend was killed.
together—fearing that Joe is not responsible. He genuinely is conflicted between his love for
Brianna is a stabilizing influence on Joe, his son and admiration of his girlfriend’s val-
with a strong spiritual side that reminds ues and his desire to remain one of the gang.
Joe of his grandfather. However, to impress
Brianna and Charles, Joe has acquired a Relapse or continued use potential. All Joe’s
lot of bills that he sees no way to pay off. buddies, except for his girlfriend, abuse sub-
Creditors are hounding him. Moreover, Joe stances seriously and encourage his continued
knows that his job is in jeopardy if he does drinking and drug use. He has not abstained
not show up for work more regularly. He spontaneously for any period and seems to be
has been skipping work after attending wild using more drugs, more frequently.
parties. As a high school dropout, Joe does
not have many opportunities to increase his Recovery environment. Most family mem-
income and has no aspirations for a better bers show no support for Joe’s recovery. His
job. Also, it seems as though the more mother was addicted to alcohol; there may be

Treatment Entry and Engagement 81


a more extensive history of substance abuse employed clients and a variety of medical, psy-
in the family. It is unclear how far Brianna chological, and case management capabilities.
is willing to encourage Joe’s recovery; it also After reviewing his problem list, Joe and the
is unclear how attached Joe is to his son and intake counselor developed the following plan
how willing he is to be a supportive father. for his initial treatment. It will be reviewed
and revised again after 4 to 6 weeks, when the
Joe has applied for treatment at an IOT need for continuing IOT may have diminished.
program that has an evening schedule for

Initial Treatment Plan

Specific Responsible
Objectives Interventions Persons Timing

Achieve Monitor for potential withdrawal Client, medical 9 hours


2 weeks and needed medication on days staff, primary per week
of con- 1 through 3; enroll in substance counselor, group in evening
tinuous abuse education and early recovery leaders treatment
abstinence groups 3 times per week; screen for program over
drug and alcohol use 2 times per first 4 to 6
week; attend individual counseling weeks
1 time per week

Determine Obtain full medical history, Client, medical As soon as


health physical examination, lab work; staff possible
status and participate in health education
control group 1 time per week
weight
and diet

Relieve Consolidate debts and develop Client, case Begin as


stress repayment plan; enroll in money manager, group soon as
from management skills group after leader, consulta- client is
unpaid completing health education; refer tion with credit stable—2 to 3
debts and client to Debtors Anonymous agency weeks
collectors

Clarify Contact court about trial date, Client, program’s As soon as


legal sta- reporting requirements, potential legal consul- client is
tus and for plea bargain, or alternative tant, client’s stable
explore sentencing lawyer, primary
options counselor, court
representative

(continued)

82 Chapter 5
Initial Treatment Plan (continued)

Specific Responsible
Objectives Interventions Persons Timing

Stabilize Give health excuse for missing Client, medical Ongoing


employment work, if needed, for first 3 days staff, primary
of treatment; monitor pay stubs counselor
to see whether Joe is working
regularly

Strengthen Explore discrepancies between Client, primary Begin


treatment client’s religious values and com- counselor, clini- individual
commitment mitment to son and girlfriend and cal supervisor counseling
and moti- his continuing substance abuse sessions as
vation for and lack of direction soon as cli-
recovery ent is stable

Identify Require attendance at a mutual- Client, primary Begin mutual-


drug-free help group or community counselor help group
support alternative at least 5 times per attendance
network week and participation in struc- immedi-
tured sports or leisure group 1 ately; begin
time per week recreational
activities
within 30 days

Obtain Encourage Brianna to attend fam- Client, girlfriend, Begin family


Brianna’s ily education 1 time per week and primary coun- education
support for couples counseling 1 time per selor, family immedi-
Joe’s recov- week therapist ately; begin
ery and couples
explore their counseling
relationship within 1
month

Explore Observe reactions to group dis- Client, group Defer refer-


grief and cussions of family relationships; leaders, primary ral to next
isolation refer client for grief counseling if counselor, clini- phase
from family needed cal supervisor

Treatment Entry and Engagement 83


84
Appendix 5-A. Substance Use History Form
Client’s Name: Date: Interviewer:
Year Frequency/
of First Date/Time Usual Amount Duration of Observed
Drug Type Street Name Ever Used Use Current Use* Last Use of Daily Use Extended Use Route/Mode Signs†

Alcohol

Cocaine

Methamphetamine

Stimulant

Anxiolytic

Heroin

Methadone

Other Opioid

Sedative-Hypnotic

Hallucinogen

PCP

Cannabis

Inhalant

Nicotine

Other
* Note if just released from controlled environment.

Circle observed signs, if any, of currently used drugs:
Needle track marks Agitation Burns on inside of lips Tremors Smell of alcohol, marijuana, or methamphetamine (production)
Burns or stains on fingers Flushed face Incoherence Nodding Unusual speech pattern (slurred, rapid, incoherent)
Dilated or constricted pupils Scratching Swollen hands or feet Sores/abscesses Unsteady gait

Sources: CSAT 1994a, 1994f.

Chapter 5
Appendix 5-B. Instruments for Determining
Substance-Related and Psychiatric Diagnoses
• Addiction Severity Index—Several ver- Clinician interview and computerized,
sions of the ASI (including Spanish and self-administered versions are available
clinical training versions) are available at and require about 70 minutes to complete.
no cost from www.tresearch.org. This Web Twelve-month and lifetime versions are
site includes a variety of ASI manuals and available in English, Spanish, French, and
related materials, all free of charge. The Dutch. (Visit www.who.int/msa/cidi/index.
ASI Helpline ([800] 238-2433) provides html.)
assistance with research applications and • Diagnostic Interview Schedule, Version
answers training questions. Training mate- 4—This instrument elicits information
rials for the ASI, known as the Technology about the presence of syndromes meeting
Transfer Package, developed by National DSM-IV diagnostic criteria in the past year,
Institute on Drug Abuse, are available the course of these disorders, functional
from the National Technical Information impairment, treatment utilization, per-
Service ([800] 553-6847) for approximately ceived need for treatment, links between
$150. The package includes forms, train- psychiatric and physical causes, and dat-
ing videotapes, a handbook for program ing of most recent symptoms and risk fac-
administrators, a training facilitator’s tors. The latest version requires 90 to 120
manual, and a resource manual. minutes to administer and has explicit
• Alcohol Dependence Scale (ADS)—This instructions for close-ended and precoded
instrument consists of 25 items designed to questions that are scored by a computer.
provide a quantitative measure of alcohol (Order from Department of Psychiatry,
dependence. The test can be administered Washington University School of Medicine,
in 5 minutes and covers alcohol withdraw- St. Louis, MO 63108; [314] 286-2267;
al symptoms, impaired control with respect mccrarysl@epi.wustl.edu.)
to alcohol, awareness of compulsion to • MINI International Neuropsychiatric
drink, increased tolerance to alcohol, Interview (M.I.N.I.)—This instrument is
and drink-seeking behavior. A computer- an abbreviated psychiatric interview tool
ized version of the ADS is available. This that screens for major Axis I psychiatric
instrument is copyrighted; user’s guide disorders using DSM-IV and ICD-10 criteria
and questionnaires must be purchased. (Sheehan et al. 1998). The M.I.N.I. has high
(Order from Marketing Services, Addiction validity and reliability, can be administered
Research Foundation, 33 Russell Street, in approximately 15 minutes, and has been
Toronto, Ontario, Canada M5S 2S1; [800] translated into 20 languages. A computer-
661-1111.) ized version can be self-administered. A
• Composite International Diagnostic more detailed M.I.N.I. Plus also is available
Interview (CIDI)—Core Version 2.1, that addresses all 24 major Axis I diagnos-
Alcohol and Drug Modules (World Health tic categories in the DSM-IV, 1 Axis II disor-
Organization 1997)—This instrument der, and suicidality and requires approxi-
covers the diagnostic criteria for both mately 30 to 45 minutes to administer.
DSM-IV and International Classification (Download various versions of the M.I.N.I.
of Diseases, 10th Edition (ICD-10) (World in English and Spanish from www.medical-
Health Organization 1992), for substance outcomes.com.)
abuse, harmful use, and dependence dis- • Psychiatric Research Interview for
orders as well as onset of some symptoms, Substance and Mental Disorders
withdrawal, and consequences of sub- (PRISM)—This instrument produces reli-
stance use and other psychiatric diagnoses. able DSM-IV diagnoses for substance-

Treatment Entry and Engagement 85


related and primary psychiatric disorders level of dependence and has items that can
(Hasin et al. 1996). PRISM includes pro- yield diagnoses using the ICD-10 classifica-
cedures for differentiating primary dis- tion system. The instrument was designed
orders, substance-induced disorders, and specifically to measure changes in diagnostic
effects of intoxication and withdrawal. severity over time. It measures quantity and
PRISM takes between 1 and 3 hours to frequency of recent drug use and is thereby
administer, depending on the respondent’s sensitive to variation in client clinical sta-
history, and can be useful for focusing tus. The SDSS requires 30 to 45 minutes
treatment. PRISM is not copyrighted, but to administer. Training typically requires 2
interviewer training is required and scor- to 3 days but may take longer if staff mem-
ing is computerized. (Order from New bers have little or no background in clinical
York State Psychiatric Institute, Columbia diagnosis and assessment. Computerized
Presbyterian Medical Center, Department data entry and scoring programs are avail-
of Research, Assessment and Training, able. There are no licensing fees. (Order
[212] 923-8862; www.nyspi.cpmc from New York State Psychiatric Institute,
.columbia.edu.) Columbia Presbyterian Medical Center,
• The Structured Clinical Interview Department of Research, Assessment and
for DSM-IV Axis I Disorders (SCID-I), Training, [212] 960-5508; www.nyspi.cpmc.
Clinical Version—The SCIDI-I uses the columbia.edu.)
comprehensive “gold standard” for psy- • Texas Christian University Drug Screen
chiatric diagnoses of not only substance- (TCUDS)—This instrument consists of 25
related disorders but other psychiatric dis- questions and can be administered and
orders (First et al. 1997). A skilled mental scored in less than 5 minutes. TCUDS
health professional needs 1 hour or more often is used with incarcerated persons
to administer the complete and detailed but is appropriate for the general popula-
version, but because the instrument is tion. TCUDS quickly identifies individuals
modular, only 10 minutes is required for a who report heavy drug use or dependence
substance abuse or dependence diagnosis. (based on the CIDI—see above). TCUDS
• The Substance Dependence Severity is available free of charge. (Order from
Scale (SDSS)—The SDSS is a semistruc- Institute of Behavioral Research, Texas
tured interview that provides current (last Christian University, TCU Box 298740,
30 days) diagnoses of DSM-IV substance Fort Worth, TX 76129; [817] 257-7226;
abuse or dependence (Miele et al. 2000). In visit www.ibr.tcu.edu.)
addition, the SDSS assesses current severity

86 Chapter 5
Appendix 5-C. DSM-IV Criteria for Substance
Dependence and Substance Abuse*
DSM-IV Diagnostic Criteria for Specify:
Substance Dependence • With physiological dependence if evidence
The individual has a maladaptive pattern of either tolerance or withdrawal is present
of substance use with clinically significant or
impairment or distress manifested by three • Without physiological dependence if no evi-
or more of the following criteria, occurring at dence of either tolerance or withdrawal is
any time in the same 12-month period: present.

1. Tolerance is defined by either of the


following: DSM-IV Diagnostic Criteria for
• A need for markedly increased
Substance Abuse
amounts of the substance to achieve A. The individual has a maladaptive pattern
intoxication or the desired effect of substance use with clinically signifi-
• Markedly diminished effect with cant impairment or distress manifested
continued use of the same amount of by one or more of the following criteria,
the substance. occurring within a 12-month period:

2. Withdrawal is manifested by either of the 1. Recurrent substance use resulting


following: in a failure to fulfill major obliga-
tions at work, school, or home
• The characteristic withdrawal 2. Recurrent substance use in situ-
syndrome for the substance ations in which it is physically
• Use of the same (or a closely related) hazardous (e.g., driving an auto-
substance to relieve or avoid mobile, operating a machine when
withdrawal symptoms. impaired by substance use)
3. Recurrent substance-related legal
3. The substance is often taken in larger
problems
amounts or over a longer period than
4. Continued substance use despite
was intended.
having persistent or recurrent
4. There is a persistent desire or there are
social or interpersonal prob-
unsuccessful efforts to cut down or con-
lems caused or exacerbated by
trol substance use.
the effects of the substance (e.g.,
5. A great deal of time is spent in activities
arguments with spouse about the
necessary to obtain, use, or recover from
consequences of intoxication)
the effects of the substance.
6. Important social, occupational, or recre- B. Symptoms have never met the criteria
ational activities are given up or reduced for substance dependence for this class
because of substance use. of substance (i.e., a diagnosis of sub-
7. Use of the substance is continued despite stance dependence preempts a diagnosis
knowledge that a persistent or recurrent of substance abuse).
physical or psychological problem is like-
ly to have been caused or exacerbated by
the substance.
_______________________
*Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Copyright 2000.
American Psychiatric Association (2000).

Treatment Entry and Engagement 87


Appendix 5-D. Supplements to the Six
Assessment Domains in the ASI and Other Topics
Six Assessment Domains • History of job terminations, previous refer-
rals to an employment assistance program,
Medical status and outcomes
• Education, including highest grade com-
Information collected in this area deter-
pleted and educational accomplishments or
mines the level of physician or medical
difficulties
involvement, laboratory tests, and health
• Attitude toward money and ability to man-
education needed. The program may want to
age money
explore
• Client’s current complaints or symptoms of Patterns of alcohol and
physical illness and infectious diseases
• Client’s availability of health insurance
drug use
and a personal physician Patterns of substance use provide informa-
• Client’s medical history including injuries, tion about the severity and duration of the
operations, hospitalizations, chronic dis- client’s current substance use and previous
eases, vaccinations, and allergies treatment episodes. Questions can review
• Client’s current medical treatment and
• Reasons for seeking treatment
prescribed medications
• Quantity, frequency, route of administra-
• Client’s diet, exercise and activity level,
tion, and cost of substances currently used;
and perception of health status
how long the use pattern has persisted;
• Client’s attitude toward traditional
and primary and secondary drugs that are
medical treatment and alternative or folk
causing problems
medicine
• History of periods of abstinence, including
• Screening client for infectious diseases
efforts to control or cut back use
(CSAT 1994e, 1994f, 2000c) and admin-
• Desired effects of current use, context of
istering the Risk Assessment Battery, a
substance use, and usual physical and
self-administered HIV-risk assessment
emotional consequences
instrument
• Experience with substances other than the
ones currently being abused
Employment or support • Triggers and circumstances for relapse
status • Prior treatment, including duration and
dates, types of treatment, voluntary or
Clients’ economic status is an indicator of
coerced entry, response to treatment,
their recovery potential and need for addi-
reason for discharge, and length of time
tional training or vocational counseling.
before and reasons for relapse
Inquiries focus on
• Sources of income, number of dependents, Criminal history and legal
perception of socioeconomic status, and
financial solvency or indebtedness
status
• Eligibility for or receipt of benefits such as A client’s current legal status and history of
Medicaid or Medicare or employer health criminal involvement may have implications
benefits for treatment. Topics to explore in this area
• Work history, marketable skills, access to include
transportation, job qualifications, and sat-
isfaction with job and pay

88 Chapter 5
• History of juvenile offenses or adult arrests Domestic violence. In many States, provid-
or convictions, including types of crimes ers have a duty to inform law enforcement
• Time spent incarcerated and nature of the of evidence of abuse. Providers need to be
crimes familiar with applicable laws in their State.
• Episodes of substance abuse treatment Programs also should be prepared to recom-
while in the criminal justice system mend alternative housing for clients who are
• Status and relevant dates of pending drug living with domestic violence.
court appearances, pretrial release hear-
ings, meetings with probation or parole TIP 25, Substance Abuse Treatment and
officers, or trials Domestic Violence (CSAT 1997b), dis-
• Determination of a criminal justice system cusses the complicated interconnections
mandate for treatment between substance abuse and battering or
• Unresolved legal issues victimization, stressing the importance of
identifying people in destructive, exploit-
ative relationships and helping them openly
Family and social address issues that are otherwise likely
relationships to sabotage recovery. TIP 25 contains the
The client’s relationships and living arrange- Danger Assessment (Campbell 1995) and
ments have a powerful influence on the the Psychological Maltreatment of Women
recovery process. Social networks involving Inventory (available at www-personal.umich.
or encouraging alcohol or drug use have edu/~rtolman/pmwimas.htm) (Tolman
a negative effect on treatment outcome 1989), which are not yet validated as clinical
(Longabaugh et al. 1998). A social network tools but which contain questions that can
supportive of drinking is associated with less be used in interviews or as suggestions for
involvement in AA (Connors et al. 2001b). promoting discussion.
Topics to explore are Childhood history. Childhood history can
• Marital or primary relationship status, have a dramatic, often unrecognized, influ-
duration, and satisfaction; the involvement ence on current functioning. Questions in
of significant others with substances; and this area focus on
their attitudes toward recovery • Perceived closeness of family members
• Current living arrangements, household while growing up and currently
composition, satisfaction level with house- • Primary caregivers during childhood and
hold members, residential stability and memories of their expressed interest, affec-
reasons for any changes in the last year, tion, and disciplinary practices
and contribution to the household • Quality and number of close childhood
• Children (including stepchildren) and their friendships and recollections of childhood
ages, living and custody arrangements, and problems or traumatic events
any charges or reports of neglect or abuse • Significant childhood illnesses, accidents,
and related outcomes or diagnoses and treatment
• Friendships, including the numbers, per- • Childhood experience of emotional, physi-
ceived closeness, and activities undertaken cal, or sexual abuse, including frequency
together and duration of episodes, age at victimiza-
• Living relatives and perceived closeness or tion, and the perpetrator’s identity; family
alienation and relatives’ current and previ- knowledge of or reactions to these events;
ous involvement with substances whether and how social services or chil-
• Conflicts with relatives or friends in dren’s protective services were involved;
the last 30 days and the nature of these and subsequent counseling or treatment
encounters and responses

Treatment Entry and Engagement 89


TIP 36, Substance Abuse Treatment for • Describing children in sexual terms
Persons With Child Abuse and Neglect Issues • Reports of inappropriate punishment of
(CSAT 2000b), includes information about children by oneself or a partner
assessing adults for childhood abuse and • Children’s consistently unkempt appear-
neglect. It includes symptoms and effects, ance, obvious underweight condition or
direct questioning techniques, and screening hunger, or unexplained bruises or other
and assessment instruments. Appropriately injuries
trained and supervised staff members should
screen and assess clients with respect to trau- Psychiatric status
matic events.
Many people with substance-related diagno-
The parent–child relationship. TIP 36, ses have co-occurring psychiatric disorders.
Substance Abuse Treatment for Persons The existence of a psychiatric disorder and
With Child Abuse and Neglect Issues (CSAT the need for a referral to a mental health
2000b), contains information for assess- provider may be indicated if (Schottenfeld
ing the parent–child relationship. These and Pantalon 1999)
tools include the Parental Acceptance and
Rejection Questionnaire and the Parent– • The onset of psychiatric symptoms preced-
Child Relationship Inventory. Requirements ed initial substance use.
for reporting child abuse or neglect and • Symptoms persisted during previous peri-
strategies for working with children’s protec- ods of abstinence.
tive services and child welfare systems are • Symptoms continue 2 to 4 weeks after all
reviewed. substance use ceases.
• A family history of the suspected mental
Current child abuse or neglect. Parents with disorder exists.
substance use disorders are at increased • Symptoms of the suspected mental disor-
risk for abusing or neglecting their children. der are atypical for the substance being
In many States, providers have a duty to used or the dosage being consumed.
inform law enforcement of evidence of child
abuse. Providers need to be familiar with Questions about the mental health status of
applicable State laws. Although caution is clients should determine
advised about potential misinterpretation • Current or unaddressed symptoms of psy-
of socioeconomic and cultural differences chiatric disorders (last 6 months)
in parenting styles, observable signs of • Previous diagnoses of a psychiatric disor-
potential child neglect or abuse by a client der or central nervous system impairment
include, but are not limited to the following: • Current or prior psychiatric treatment and
• Verbal abuse or belittling of children or currently prescribed medications for psy-
wrongly blaming them for the client’s mis- chiatric disorders, dosage, and orders for
takes or frustrations administration
• Taking inadequate safety precautions (e.g.,
leaving young children alone at home or Other Topics
with underage babysitters, letting them
roam by themselves in unsafe places) Sexuality
• Child’s indiscriminate attachment to per-
sons other than the parent or the child’s A person’s feeling about sexuality may affect
flinching or cowering unnecessarily when substance abuse treatment. Although sexual-
the parent is present ity is a sensitive topic, questions can explore
• Expressing unrealistic, age-inappropriate
behavioral expectations

90 Chapter 5
• The client’s sexual orientation and per- any active recreational interests—and has
sonal/familial/social reactions if he or she spent most leisure time in substance-related
identifies as other than heterosexual pursuits—maintaining abstinence may be dif-
• Whether the client is sexually active and, if ficult without assistance in finding appealing
so, the number of partners in the last 6 to alternatives. The counselor can ask the client
12 months about
• Satisfaction with sexual functioning
• Any association of sexual activity with • Recreational activities and whether these
substance use/violence/control, feelings of involved alcohol and drug use
victimization, and any current charges of • Potential leisure time pursuits, including
sexual abuse or rape why these are appealing and how realistic
they are to pursue
Self-concept
Spirituality and personal
The clinician can observe or ask about
values
• Level of positive self-regard, self-efficacy, Spirituality and personal values can sustain
and determination or persistence clients and supplement treatment efforts.
• Coping skills, facility for communication, Acceptance of a higher power is a funda-
and problemsolving abilities mental element of mutual-help groups such
• Personal pride in accomplishments and as AA and Narcotics Anonymous. Other per-
realistic sense of strengths sonal values and affiliations can contribute
to stability and sobriety. The counselor can
Recreation and leisure explore
activities • Religious affiliation and its current and
Non-substance-related recreation and lei- prior importance
sure activities are important components • Racial/ethnic/cultural identity and its rela-
of sustained recovery. They can remove the tive importance, including immigrant sta-
client from social pressures to use alcohol tus and acculturation issues, if applicable
and drugs and provide a healthy outlet for • Community activities, political interests,
new energies. If the client does not have and current involvement

Treatment Entry and Engagement 91


6 Family-Based Services

Substance use disorders exist within several social contexts, one of


which is the family. Family members, whether they are from the fam-
In This ily of origin or family of choice, are important forces in a client’s life.
Each client has a family, a family history, and a family story that
Chapter... play important roles in recovery. Many clients come from substance-
using families and have been raised with alcohol abuse or drug use
Planning as part of their lives. Addressing this legacy is part of their recovery.
for Family In addition, a client’s family members often have significant sub-
Involvement stance use and other psychiatric problems of their own. Intensive
Engaging the outpatient treatment (IOT) programs that take a comprehensive
Family in approach to evaluating the family are likely to identify other indi-
Treatment viduals who would benefit from being admitted to a substance abuse
or mental health treatment program. Some family members may be
Family Services in treatment already. For these reasons, many IOT programs incor-
porate a family systems approach. Family education, family therapy,
Family Clinical and other services are necessary in an IOT program’s process so that
Issues in IOT the contributions and influence of family members support recovery.

A complete discussion of family therapy for substance use disorders


in IOT programs is not within the scope of this TIP. This chapter
introduces features of family involvement in IOT programs and
briefly discusses family therapy as an enhanced service that IOT pro-
grams may offer or, more frequently, to which they may refer clients
and their families. The Center for Substance Abuse Treatment has
developed TIP 39, Substance Abuse Treatment and Family Therapy
(CSAT 2004c), that addresses how a substance use disorder affects
the family, how family therapy works to change the interactions
among family members, and the integration of family therapy into
substance abuse treatment.

Families of people who abuse substances live in a world shaped by


substance use. This world may include inconsistent behaviors and
few or very rigid rules. Family members may have difficulty express-
ing their emotions, achieving intimacy, and solving problems. They
frequently may experience but may not express anger, shame, guilt,

93
sadness, and hopelessness. To function,
families often subscribe to the following:
Planning for Family
don’t trust, don’t feel, and don’t talk. The Involvement
result can be an unhealthy environment in IOT planning for family-based services
which individuals may be isolated, engage in involves defining the client’s family in broad
destructive alliances, be overly involved with and flexible terms, setting essential goals,
other family mem- and determining the desired outcomes.
bers, or develop
...family members... significant medical
and stress-related Defining the Family
are critical to problems. In recent years, the concept and definition
of family have broadened significantly to
the strength and Increasingly, treat-
include people who are important to the cli-
ment professionals
ent. These people can include a spouse, a
duration of the view substance use
boyfriend or girlfriend, a same-sex partner,
disorders from a
parents, siblings, children, extended family
family systems per-
client’s recovery. spective (Crnkovic
members, friends, co-workers, employers,
members of the clergy, and others. The
and DelCampo
term “family of origin” commonly is used to
1998). Research findings document a rela-
describe individuals related by blood, such
tionship between family involvement in
as parents, grandparents, and siblings. The
treatment and positive outcomes and attest
term “family of choice” is used to describe a
to the need for family-based services (Rowe
family created by marriage, partnership, or
and Liddle 2003). Family involvement in
friendships and other associations.
treatment seems to work equally well for
adults and adolescents (Stanton and Shadish When determining the client’s concept of
1997). When the family is ready and able to family, the key is to identify who will be sup-
shift from old, negative behaviors to new, portive of recovery and who might seek to
healthier ones, family members become col- undermine it. The treatment provider can
laborators in the treatment process (Edwards begin this process by creating a genogram (see
and Steinglass 1995). Most IOT programs do appendix 6-A, page 107) to assess the family
not offer couples- or family-based therapies of origin or choice. Similarly, a social network
(Fals-Stewart and Birchler 2001). However, map (see appendix 6-B, page 109) can help
potential benefits of family therapy are such the counselor identify and understand the
that IOT programs should have well- family of origin and family of choice.
established links with organizations that
provide these services. • Creating a family genogram. This tech-
nique renders the client’s family relation-
No matter how alienated family members ships schematically and helps the counsel-
may be, they are critical to the strength and or identify trends or patterns in the family
duration of the client’s recovery. Family history and understand the client’s current
members are the individuals who were part situation. As treatment progresses, the
of the client’s life before treatment and will genogram is revised to reflect new knowl-
be part of his or her life after treatment. edge and changes in the family (CSAT
Family-based services that are part of IOT 2004c).
help ensure that family functioning adjusts • Assessing the client’s social supports
to and positively influences the recovery of with a social network map. A social net-
the client. work map displays the links among indi-
viduals who have a common bond, shared
social status, similar or shared functions,

94 Chapter 6
or geographic or cultural connection. substance use disorders develop or that
Highly flexible, social networks form and patterns of behavior and interaction have
disband on an ad hoc basis depending on developed in response to the substance-
specific need and interest. A social net- related behavior of the family member who
work assessment is used in social service is in treatment. It is valuable for individu-
arenas, including substance abuse treat- als in the family to gain insight into how
ment. When the assessment is used in IOT, they may be maintaining the family’s dys-
individuals are identified who can support function. Counselors should help family
the client or participate in the treatment members address feelings of anger, shame,
process (Barker 1999). and guilt and resolve issues relating to
trust and intimacy.
• Take advantage of family strengths.
Goals and Outcomes of Family Family members who demonstrate positive
Services attitudes and supportive behaviors encour-
One main goal of involving families in age the client’s recovery. It is important to
treatment is to increase family members’ identify and build on strengths to support
understanding of the client’s substance use positive change.
disorder as a chronic disease with related • Encourage family members to obtain
psychosocial components. Edwards (1990) long-term support. As the client begins
states that family-based services can have the to recover, family members need to take
following effects: responsibility for their own emotional,
physical, and spiritual recovery.
• Increase family support for the client’s
recovery. Family sessions can increase a A comprehensive IOT program views the
client’s motivation for recovery, especially client as part of a family system. When the
as the family realizes that the client’s sub- family is involved in treatment, the following
stance use disorder is intertwined with treatment outcomes are possible:
problems in the family. • The client is encouraged to enter
• Identify and support change of fam- treatment.
ily patterns that work against recovery. • The client is motivated to remain in
Relationship patterns among family mem- treatment.
bers can work against recovery by support- • Relapses are minimized.
ing the client’s substance use, family con- • A supportive and healthy environment for
flicts, and inappropriate coalitions. recovery is provided.
• Prepare family members for what to • Other family members who may need treat-
expect in early recovery. Family members ment or other services are identified and
unrealistically may expect all problems to treated.
dissipate quickly, increasing the likelihood • Changes in the family’s longstanding dys-
of disappointment and decreasing the like- functional patterns of communication,
lihood of helpful support for the client’s behavior, and emotional expression may
recovery. protect other family members from abus-
• Educate the family about relapse warn- ing substances.
ing signs. Family members who under-
stand warning signs can help prevent the
client’s relapses. Engaging the Family
• Help family members understand the
causes and effects of substance use dis- in Treatment
orders from a family perspective. Most Difficulties with engaging the family in treat-
family members do not understand how ment often are cited as reasons for not using

Family-Based Services 95
a family systems approach and, in many your recovery?” The client then might be
cases, substantial obstacles exist. Family asked to invite these supportive people to
members may be resistant, or the client come to the initial intake interview. During
may be ambivalent or object to the family’s the intake interview, family members can
involvement in treatment. But given the be asked to complete a brief written family
potential benefits associated with taking a assessment. A more comprehensive fam-
family approach to service delivery, engaging ily systems approach can involve multiple
the family in treatment is worthwhile. private and family interviews. These inter-
views and other early meetings with the
family develop support from a family that
Strategies To Engage the is empowered to address systemic issues.
Family Similarly, the initial meeting helps family
The following approaches have proved help- members learn about substance use disor-
ful in encouraging families to engage in the ders, their influence on a family, and the
treatment of a family member: services the program can offer to the fam-
ily (see exhibit 6-1).
• Include family members in the intake • Use client-initiated engagement efforts.
session. The counselor can involve family The counselor and client collaborate on a
members in the treatment process from plan to engage family members in treat-
the beginning. If a family member makes ment. The client can be given the oppor-
the initial call to the program, the coun- tunity to invite chosen family members to
selor can ask that person to come with the participate in the program. If this effort is
client. If the client calls, the client can be unsuccessful, then, with the client’s written
asked to bring a family member. If the cli- permission, the counselor telephones, vis-
ent is reluctant at this point, the counselor its, or sends a personal note to the identi-
can gently encourage the client to include fied family members. Federal confidential-
family members but should not make it a ity rules require that client permission be
condition of the person’s entry into treat- documented (CSAT 2004b).
ment. In another approach, the counselor • Offer a written invitation. The IOT pro-
can ask, “Who close to you is concerned vider can give the client written invitations,
about your substance use and might be with the clinic’s contact information, to
willing to serve as a support to you during deliver to family members. Giving the client

Exhibit 6-1

Suggestions for Engaging Family Members at Intake

• Emphasize the need to gather information from family members.


• State the program’s policy about family members’ participation in treatment.
• Indicate the program’s desire to hear family members’ concerns about the client’s
substance abuse.
• Acknowledge family members’ influence over the client and their desire to help.
• Make clear that family members’ participation will help the client on the road to recovery.
• Emphasize how the program can help family members maintain a relationship with the
client and manage their own feelings (anger, frustration, depression, and hopelessness).

96 Chapter 6
the invitations allows the provider to deter- who abuse substances to enter treatment
mine whether the client is willing to (Meyers et al. 1998, 2002). Among other
involve family members in treatment and strategies, the CRT approach teaches fam-
which family members the client wants to ily members that substance abuse is not a
involve in the process. The invitation brief- moral failing but a disease and that they
ly describes the treatment program and are not the cause of and cannot be the
identifies activities family members will be cure of their loved one’s substance use
asked to participate in. For example, a disorder. They also learn to identify and
family member may be asked to attend pursue their own interests, communicate
family education sessions, complete an in nonjudgmental ways, encourage drink-
assessment questionnaire, remove all sub- ing of nonalcoholic beverages during social
stances from the home (if applicable), par- occasions, manage dangerous situations,
ticipate in family counseling sessions, or and discuss treatment entry with the fam-
attend a celebration of the completion of a ily member who abuses substances when
treatment phase. the consequences of abuse are severe
• Offer incentives. Incentives may help (Kirby et al. 1999b).
address recruitment problems. Family • Use the resources of the program. To
members can be provided with cou- create a family-friendly environment, IOT
pons (e.g., for pizza, movies) for attend- staff at all program levels need to work
ing sessions or completing assignments. together toward the goal of engaging fami-
Refreshments also help family members lies. For example, flexible program hours
feel welcome. In addition, providers can and large offices or meeting rooms may be
facilitate transportation (e.g., arrange needed to accommodate family schedules
carpools) and childcare services and and large families. Safe toys should be
remove other obstacles to family members’ made available for children so that they
participation. are less likely to disrupt a session. Front
• Plan picnics or dinners for families. office staff should be trained to encourage
Multifamily picnics and dinners are a and reinforce the efforts of family mem-
part of some IOT programs and can be bers who call or come in with the client
scheduled for holidays or weekends. These for the initial visit. Programs can organize
events can be held on the program’s their client record systems and procedures
grounds or in nearby parks or community so that staff members have easier access to
centers and provide a supportive and non- family-related information for each client.
threatening environment where individuals • Provide a safe, welcoming environment.
can have fun and learn about substance Family members may be anxious or reluc-
use disorders, recovery, and the IOT pro- tant to participate in the treatment pro-
gram. The client and family members are cess. A welcoming environment encourages
asked to bring a dish, but all are welcome. them to participate despite their concerns.
Immediately after the meal, a counselor A safe, clean, and cheerful meeting space
conducts an hour-long educational ses- is important. Good lighting, a well-marked
sion covering topics such as recovery sup- and well-maintained exterior, culturally
port groups, family-oriented services, and appropriate décor, comfortable furniture,
characteristics of substance use disorders. and amusements for children convey the
Participants are told of the educational message that family members are welcome,
nature of the sessions when invited. valued by the treatment team, and essential
• Use community reinforcement training to the recovery of the client. Ice-breaking
(CRT) interventions. CRT interventions activities, simple games, and role-play activ-
have improved the retention of family ities can make the group meeting inviting
members in treatment and induced people and encourage family involvement.

Family-Based Services 97
Overcoming Barriers to family services, individual counseling for
Engaging Family Members in other family members, health care, and
financial and legal services to support
Treatment clients’ families.
Not all family members participate in the
treatment process. Sometimes individu-
als are reluctant to become involved with Family Services
treatment, even though they care about the Family members
client. Women are more likely to be involved
in their male partners’ treatment; men are • May need guidance on how to address
less likely to participate in their female part- many issues that can arise during early
ners’ treatment (Laudet et al. 1999). Also, recovery
the client may not want family members to • May have questions or misconceptions
be involved because of threats of domestic about substance use disorders
violence or past abuse by a family member, • May need to find healthy ways to handle
guilt about the substance abuse, fear that their justifiable feelings of anger, frustra-
family secrets may be revealed, concern tion, shame, helplessness, guilt, and sad-
about adding to the family burden, or other ness that stem from attempts to fix the
reasons. All family members who do partici- client’s substance use disorder
pate must feel free to raise pertinent issues, • May need the counselor’s intervention
even if another family member objects. to understand and avoid behaviors that
Because of the risk of domestic abuse that contribute to the client’s continued use of
comes with raising difficult issues, providers alcohol and drugs
must assess carefully the potential for vio-
lence within the family (CSAT 2004c). The types of services described in this section
can support the efforts of family members as
Despite these barriers, the IOT provider is the client moves through the course of treat-
encouraged to take every possible action to ment. Although every family is different, and
engage families of clients in the treatment the pace of recovery varies from family to
process. Better client retention, fewer relapses, family, a sample treatment calendar is pro-
improved family functioning, and family vided in exhibit 6-2. IOT services can assist
healing are all possible outcomes (O’Farrell family members in accomplishing the tasks
and Fals-Stewart 2001). described in the calendar.

Supportive supervision of the counselors pro-


viding these family services Family Education Groups
• Gives staff members confidence that they Family education groups provide information
are providing appropriate levels of service about the nature of a substance use disorder;
while addressing clinical issues that inevi- its effects on the client, the family, and others;
tably arise the nature of relapse and recovery; and family
• Ensures that counselors and staff members dynamics. These groups often motivate fami-
understand their limitations in working lies to become more involved in treatment.
with family members The family education group typically meets
• Guards against counselors and staff mem- weekly for 2 to 3 hours, often in the evening
bers attempting to provide therapy for or on weekends, and includes between 10 and
which they have not been trained 40 individuals. The group is facilitated by a
When working with families, programs counselor and usually covers these topics:
can make use of existing partnerships with
agencies and groups that provide enhanced

98 Chapter 6
Exhibit 6-2

A Treatment Calendar for Family Members

Beginning stage: 1–5 weeks


• Commit to treatment.
• Understand that a substance use disorder is a chronic illness.
• Support abstinence.
• Begin to identify and discontinue behaviors that support substance use.
• Learn about the family support groups:

– Al-Anon (www.al-anon.alateen.org)
– Nar-Anon (www.naranon.com)
– Families Anonymous (www.familiesanonymous.org)

Middle stage: 6–20 weeks


• Assess the relationship with the client.
• Develop a realistic perspective on addiction-related behaviors so the family member
remains involved with the client but establishes some protective personal distance.
• Work to eliminate behaviors that encourage the client’s substance use (i.e., enabling
behaviors).
• Move past behaviors that are primarily a response to the client’s substance use (i.e.,
codependence).
• Seek new ways to enrich the family member’s life.
• Begin practicing new communication methods.

Advanced stage: 21+ weeks


• Work to develop a healthy, balanced lifestyle that supports the client and addresses
personal needs.
• Exercise patience with recovery.
• Evaluate and accept changes, adaptations, and limitations.

Source: Matrix Center 1989.

• Medical aspects of addiction and • Leisure time planning


dependence • Parenting skills
• Relapse and relapse prevention • Community support groups and resources
• Addiction as a family disease
• Subconscious refusal to admit that the cli- Group members listen to lectures, discuss
ent has a substance use disorder (i.e., denial) topics, and engage in exercises that help
• Enabling behaviors them become knowledgeable about substance
• Communication use disorders and their effects on the family.
• Reasons for testing and monitoring of
the client

Family-Based Services 99
Multifamily Groups learning occurs in a relaxed setting. Group
sessions generally are scheduled weekly and
Multifamily groups can be thought of as
last for 2 to 4 hours with group size rang-
microcosms of the larger community. They
ing from 12 to 30 members (6 to 8 families)
offer more opportunities for learning, adap-
(Crnkovic and DelCampo 1998). Clients’
tation, and growth than do groups of one
recovery may be aided by the inclusion of
client and family members. These groups
supportive individuals from outside the fam-
provide family members with a sense of nor-
ily (e.g., sponsors, friends, religious leaders,
malcy and a support network. Individuals
co-workers). The consensus panel recom-
learn that other families face similar difficul-
mends that multifamily groups be co-led
ties. This discovery may reduce the stigma
by two therapists trained in this process.
and shame commonly found among families
Membership may change frequently, and
struggling with substance use disorders.
clients and their families join the group as
Families often exhibit mutually supportive,
others graduate from the treatment program.
spontaneous involvement with one another
and reinforce one another’s problemsolving
approaches. Cross-learning—in which, for Family Therapy Groups
example, a man learns to understand his
wife better by listening to other husbands In 1997, Stanton and Shadish conducted a
and wives—is one of the most powerful meta-analysis that compared the effective-
effects of multifamily therapy. Incorporating ness of family education, family therapy, and
multifamily groups into IOT has been shown other forms of family intervention for people
to increase the length of treatment for with substance use disorders. Their results
female clients, increase completion rates for suggested family therapy is more effective
men, and improve family functioning and than family education groups and other
children’s behavior (Boylin and Doucette family services. However, family therapy can
1997; Meezan and O’Keefe 1998). Treatment be delivered only by specially trained thera-
providers report that having more than one pists. Forty-two States require that people
generation present in the group can help practicing as family therapists be licensed.
institute a family’s commitment to absti- In most States, a family therapist must have
nence and recovery (Conner et al. 1998). a master’s degree to practice independently
(CSAT 2004c). Family therapy addresses the
Multifamily groups typically engage sev- dynamics in the family that may encour-
eral clients and their family members in age substance abuse and offers support for
group exercises changing these dynamics. It emphasizes
that teach them that the family as a dynamic system, not
Cross-learning...is how to develop merely the inclusion of family members in
healthy communi- treatment, is the hallmark of family therapy
one of the most cation techniques, (CSAT 2004c). These sessions may include
avoid enabling individual family, couples, and child-focused
powerful effects of behaviors, reduce therapy. (Family therapy for adolescents
codependence, and is discussed in chapter 9.) Because not
multifamily therapy. get help. Until a all IOT programs provide these types of
multifamily group therapy groups, providers should consider
coalesces, it may establishing referral agreements with other
be helpful for members’ participation to be community service organizations that pro-
structured (e.g., talking only about them- vide family therapy.
selves, not about the person in IOT).

IOT providers should foster an atmosphere


of acceptance and emotional safety so that

100 Chapter 6
Individual family therapy in families with substance use disorders. In
This type of therapy helps family members groups with their children, parents are taught
look at their interactions and identify the parenting and problemsolving skills and
factors in the family that contribute to a are given information about normal child-
substance use disorder. Family members are hood development. Parents recovering from
encouraged to restructure negative patterns substance use disorders have a chance to
of behavior and communication into inter- experience pleasurable recreational activities
actions that are more conducive to recovery with their children (e.g., volleyball, soccer)
for everyone. Through family therapy, adults and learn to interact with them in a struc-
and children express to the client how behav- tured, therapeutic setting. Older children can
ior has affected them and how new coping be educated about substance use and how it
skills now are affecting their lives. The client can affect them and their families.
has the opportunity to use new skills learned
in treatment and to receive constructive Family Retreats
feedback from family members in a safe
environment. During these sessions, families Some IOT providers have found that fam-
may address issues such as irresponsible ily retreats can be effective in helping
behavior, indebtedness, substance use in the families harmed by substance use disorders,
home by other family members, availability although research is unavailable on this
of alcohol on special occasions, and how to topic. Participants can take important steps
reveal treatment and recovery to others. The toward healing damaged relationships. Some
content of these sessions varies significantly, participants have described family retreats
based on the needs and motivations of the as the most important aspect of their experi-
family members. Family therapy may be ence in treatment.
scheduled monthly or more frequently. Most family retreats cover 2 days, usually
over a weekend; participants spend nights
Couples therapy at home. Retreats provide clients and their
Couples counseling is useful in improving family members with the opportunity to
certain aspects of functioning in families work intensively with one another to address
with substance use disorders (O’Farrell and powerful emotions such as shame and
Fals-Stewart 2002). This therapy focuses on guilt and to restore lost intimacy and trust.
improving a couple’s relationship and reduc- Participants take part in education sessions,
ing problems related to substance abuse. exercises, and group activities. Day 1 activi-
The spouse or significant other is taught to ties can include family education on
reinforce abstinence, decrease behaviors • Communication skills
that cue substance use, and avoid protect- • Experiencing and working with feelings
ing the client from the adverse consequences • Developing trusting relationships within
of substance use. Both partners are taught the family
to increase positive exchanges, improve • Creating healthy expectations
communication, and work together to solve • Reestablishing roles
problems. The number of sessions can be
six or more and can include sessions for one Participants receive an assignment the
couple or groups of couples (Fals-Stewart et evening of day 1 to work on at home.
al. 1996). Assignments may focus on developing
relapse contracts, reading from journals, or
Child-focused therapy sharing positive family memories. Day 2 can
focus on a therapeutic event during which
Play and structured recreational activities
for children and parents can reduce conflict

Family-Based Services 101


• Participants discuss the assignments they participants, family members build on the
completed the night before. momentum of their previous experiences in
• Family members are encouraged to tell treatment. Examples of the issues discussed
one another important things, which may include parenting, decisionmaking, conflicts,
never have been said or discussed before. sexual functioning, intimacy, anger manage-
• Family sculpting exercises are conducted; ment, mood swings, reestablishing trust,
this activity dramatically illustrates rela- adjusting roles, learning what is “normal,”
tionships and communication patterns renegotiating relapse prevention contracts,
that need to change. In family sculpting, and substance use by other family members.
each family member takes a turn position-
ing the other family members in relation Community-based 12-Step support groups
to one another, posing them as he or she such as Al-Anon, Nar-Anon, and Alateen are
sees fit, and explaining the choices (CSAT independent from the IOT program. Because
1999a). family members may be reluctant to initiate
contact with such groups, IOT providers can
Programs that conduct retreats find that assist family members by providing informa-
executing a “contract for participation” tion about meetings, such as what happens
with the client helps ensure that the retreats at these meetings, the rituals observed, who
are well attended. Therapists may need to attends, how meetings are conducted, the
assist the client in recruiting family mem- purpose of the meetings, and where to find
bers to attend. Retreats should be staffed by them. Members of mutual-help groups can
therapists who are experienced in managing be invited to give talks to the family mem-
highly emotional events. bers in the IOT program. Providers also
should emphasize that the meetings are
anonymous. By encouraging family mem-
Support Groups for Families bers to attend at least three meetings before
Mutual-help groups provide the continuing deciding whether to continue, the IOT pro-
emotional, educational, and interpersonal vider increases the probability that family
support that family members often need as members have a positive experience and
clients complete their treatment. Attending continue to attend. IOT staff can encourage
support group meetings helps family mem- members of multiple families from the pro-
bers adjust to changes being made by the gram to attend meetings together so that they
recovering member and begin new lives of can reinforce and reassure one another.
their own. Family support groups may be
sponsored on an ongoing basis by the IOT
program or consist of community-based Family Clinical Issues
fellowships such as Al-Anon, Nar-Anon,
Alateen, Adult Children of Alcoholics
in IOT
(www.adultchildren.org), Adult Children Diverse questions, concerns, and behav-
Anonymous (www.12stepforums.net/acoa. iors are presented by family members
html), and Families Anonymous. during IOT sessions. The complexity of
human relationships and interactions is
When a family support group is sponsored revealed in treatment and can challenge
by the IOT program, it usually meets weekly. both participants and counselors to use the
Family members can discuss problems and opportunities and experiences therapeuti-
concerns that arise because of the client’s cally. Long suppressed anger, family secrets,
recovery and reconnection with the fam- shame, and confusion may surface. Family
ily. Such groups offer continuity for family members may harbor feelings and thoughts
members during the difficult treatment and that can affect the client and the family
recovery periods. Surrounded by familiar adversely and that require resolution within
program staff members and other family a therapeutic environment.

102 Chapter 6
Changing Realities: Working With Clients Who Are Estranged
From Their Families
In one IOT program, some clients revealed that they did not participate in family groups,
family nights, and other family-oriented activities because they had no family. The clients
had been ostracized by or estranged from family members for an extended period.

The counselors suggested that clients and staff rename the “family” events so that clients
could feel more comfortable bringing other individuals such as co-workers or friends who
made up their family of choice. Instead of Family Night, the program sponsored Support
Network Night.

The results
• Participation in the events increased. More clients and their supporters attended
treatment activities.
• Clients were encouraged to build an abstinent support network that included friends, co-
workers, neighbors, or others as well as members of their family of origin.

Unrealistic Expectations • Using a variety of formats to provide


About Treatment Outcomes clear, understandable information about
substance use disorders. A family educa-
Family members often have unrealistic tion group is a basic component of IOT
expectations about treatment and the programming that is effective in debunk-
client’s recovery. Family members may not ing many fallacies about substance use
understand the nature of a substance use disorders. For instance, the group can be
disorder or are unable to accept that it is a used to dispel the idea that once a client
chronic, relapsing disease and recovery is a is in treatment, he or she will stop hav-
lifelong process. Some family members, for ing the urge to use; that once use stops,
instance, can be so fatigued and emotionally everything will be “perfect”; or that doctors
depleted from the stress of living with the and counselors will teach how to get well.
person who abuses substances that they have A counselor can obtain or develop written
unrealistic hopes for treatment. Strategies materials (fact sheets, brochures, posters)
and solutions to address unrealistic expecta- at appropriate reading levels and in rel-
tions and common fallacies about treatment evant languages. These materials need to
and recovery include the following: be available at the program facility and
• Informing the family early in treatment distributed to family members at intake
about common but unrealistic expecta- and during treatment. A brief, informative
tions. By gently raising this issue early in video can be played during family sessions,
treatment during individual family sessions, in counselors’ offices, or in the waiting
the IOT counselor can draw attention to and room.
begin to dispel any fallacies. The counselor • Reaching many family members. It is
can probe for related family beliefs, answer important to educate as many family mem-
family members’ specific questions, and bers as possible and to ensure that the
provide real-life examples before unrealistic most influential family members become
expectations lead to an undermining of fam- knowledgeable about substance use disor-
ily and client functioning. This process also ders and then redirect other family mem-
can identify specific educational needs. bers if necessary.

Family-Based Services 103


Family Responses to Relapse assistance. IOT staff members can help
families
Clients can relapse, and family members
may be unwilling or unable to be compas- – Understand that relapse can happen and
sionate or nonjudgmental about episodes of that each family reacts in unique ways.
relapse. Typically, relapse is an unpopular – Accept that their reactions to the relapse
topic with family members. If relapse occurs, crisis do not necessarily indicate that the
counselors need to be prepared for a range of family is in deep trouble.
emotional responses from families, including – Prepare a plan that identifies steps the
anger, panic, blame, depression, spitefulness, family will take if relapse occurs.
and relief. Some families may abandon or – Identify ways that family members can
withdraw from the client; others may attempt support one another.
to engage the client in substance-using activi- – Seek help if the plan fails.
ties; still other families may be caught in
patterns of depression and resignation or • Assist family members in engaging sup-
panic and fear. port services and resources. Community-
based support groups such as Al-Anon,
The following therapeutic options may help Nar-Anon, Alateen, and Alatot (for chil-
counselors in assisting families that may dren of parents who abuse alcohol) are
experience a family member’s relapse: available in most areas and are indispens-
able sources of help for many families.
• Prepare the family members as well as
Family members should be encouraged to
the client for the possibility of relapse.
attend meetings regardless of the client’s
Family members are likely to be the first to
recovery status. In these groups, family
know when a client relapses. IOT programs
members focus on their own needs, accept
focus on strengthening the client’s relapse
what they cannot change, and engage in
prevention skills, but families also need
healthy, satisfying activities. To facilitate

Living the Treatment Process


Anthony’s wife and son were relieved and optimistic when he entered treatment. Soon
they would be able to enjoy the husband and father they had missed during many
years of substance abuse. As the weeks passed, however, Anthony’s family grew more
angry and disappointed. He rarely spent time with them and was always at recovery
meetings. He showed little interest in their lives and was not physically or emotionally
available to them. “I thought treatment would make our lives better, but it’s just not
true,” said his wife.

Counselor’s response
• Validate the feelings of family members.
• Explain that Anthony’s recovery requires his full attention. For a time, he will be
unable to devote much attention to the needs or expectations of others. Only as his
recovery progresses and risk of relapse recedes can he become less self-focused.
• Discuss the warning signs of relapse.
• Emphasize the family members’ need to focus on enhancing their own lives, inde-
pendent of the addicted loved one, including involvement in support groups such as
Al-Anon.

104 Chapter 6
attendance, some IOT programs offer these • Work with family members to create a con-
groups space at their facility. Others spon- tract that specifies how their behavior is to
sor their own family support groups, led by change.
alumni of the programs, that are open to • Monitor progress.
all who wish to attend for as long as they
desire.
• Seek interventions for individual fam- Family Life Without Substance
ily members when their responses to Abuse
relapse are unhealthy. The IOT counselor As recovery begins, some family problems
needs to be alert to the possibility that resolve with abstinence. Issues of trust and
relapse by a client may require additional worries about how the family will be dif-
family interventions and referrals to other ferent are likely to emerge. Here are a few
service professionals. For example, another common questions and some suggested
family member also may be in recovery answers on how IOT counselors can help
and may need additional assistance from families:
a support group. Another family member
may become depressed as a result of the 1. How do we reestablish trust?
client’s relapse, or an adolescent may act
out. The client and other family members • Teach family members that a lack of
may benefit from psychological or psychi- trust is a normal and natural reaction
atric interventions. in early recovery but, at the same time,
the recovering person may sense this
lack of trust and may become angry or
Sabotage by Family Members sad.
A family can sabotage the client’s progress • Indicate that the newly abstinent
when one or more family members behave in member may suffer from a “time
ways that undermine the client’s abstinence warp” in which a week seems more like
or treatment. For example, family members a month. Such different perceptions
may continue to use or leave alcohol or of time can add to conflict around
drugs where the client is likely to see them. the trust issue because the client may
They may state to the client or others that expect the family’s trust after what
the client is likely to fail or may refuse to let is, in reality, only a short period of
the client use the family car to go to a sup- abstinence.
port meeting or treatment session. Examples • Discuss the idea that mistrust
of successful clinical approaches to dis- transforms into trust only as the
courage sabotage and encourage positive client maintains abstinence and
participation are as follows: demonstrates positive changes in
behavior. Ask the client to accept that
• Schedule individual family sessions to dis- family members may not trust him or
cuss the specific behaviors that are sabo- her for a period.
taging recovery efforts. • Suggest that family members agree
• Discuss alternative behaviors that support to extend their trust incrementally to
recovery, and offer support for making the the client. For example, an adolescent
behavioral changes. client may be given permission to
• Determine whether individual therapy use the family car for an outing if
is needed, and support family members the adolescent’s school attendance is
with a referral to a family therapist as satisfactory for a specific period.
appropriate.

Family-Based Services 105


2. How do we have fun again? and have each member sign the
agreement.
• Suggest creating new family rituals • Review the privacy and confidentiality
to replace old ones that involved provisions that govern treatment
substance use. programs with family members to
• Suggest establishing and celebrating remind them that providers will not
“family” abstinence anniversaries. discuss these topics with others and
• Encourage participation in events that family members are in control
sponsored by Al-Anon, Nar-Anon, and of what others know. Use family
other family support groups. support group sessions to discuss this
• Urge participation in multifamily issue so that members learn from the
groups sponsored by the treatment experiences and examples of other
program. families.
• Ask each member to identify a favorite • Have family members “rehearse”
“family fun” activity for the entire situations they are likely to encounter
family to enjoy. to practice appropriate responses.
• Ask members to consider separate
couples and parent–child activities 4. First the bottle, now the meetings. Will
to create new relationships between it ever get better?
family members.
• Ask members to keep a family journal • Acknowledge that the spouse or
that includes ideas, feedback, and significant other is disappointed and
comments from family members on frustrated.
various activities, rituals, and other • Point out that recovery is the first
family events. and most important goal during this
difficult period and that people in
3. What do we say to friends, neighbors, recovery often immerse themselves
and associates about treatment and in recovery activities with the same
recovery? intensity with which they used
substances.
• Assist family members in discussing • Assist the spouse or significant other
and coming to decisions about what in focusing instead on his or her own
information they want to share with recovery and in attending Al-Anon,
others and when. Write down this Nar-Anon, or other support groups.
information, give it to all family
members in the form of an agreement,

106 Chapter 6
Appendix 6-A. Format and Symbols for
Family Genogram*
The genogram is useful for engaging the ent. Marital status is represented by unique
client and significant family members in symbols, such as diagonal lines for separation
a discussion of important family relation- and divorce. Different types of connecting
ships. Squares and circles identify parents, lines reflect the nature of relationships among
siblings, and other household members, and household members. For instance, one solid
an enclosed square or circle identifies the cli- line represents a distant relationship between

Format for Family Genogram


1st generation:

W
Alcohol Heroin
2nd generation:
m (year)

3rd generation:
W Cocaine

4th generation:

Symbols Useful for Genograms


Symbols Relationships

= male
m 1981 Marriage (give year)
= female
s 1990 Marital separation (give year)
= client

= alcohol or drug abuse d 1992 Divorce (give year)


(indicate drug of abuse)
1992 Living together relationship
= mental or physical illness or liaison (give year)
Induced abortion
= alcohol or drug abuse and
mental or physical problems x
X X = deceased
Children: List in birth order with birth year
Adopted or foster children = dotted line
Members of client's household (dotted lines):
Note any changes in custody

d 1980 d 1996 m 2003


1983 1985 1987 1988 1989
1982 1984

Family Interaction Patterns (nature of relationships)

Distant Estranged/cut off Fused and conflictual


(a bond of ongoing conflict
Very close Conflictual
that is mutually satisfying
and/or rewarding)

_______________________
*Source: New Jersey Division of Addiction Services, New Jersey Department of Health and Senior Services.

Family-Based Services 107


Client John G. and His Family
Bailed out his son "Let my son rot
repeatedly in jail"
Grandparents: X

Aunts/Uncles:
Heroin
Jailed for drugs
Parents: Mr. G. Mrs. G many times
m 1978
Lives nearby,
1980 works with work together
mother
Client and 1982 1983 1985
Siblings: Lives 2 hours away The G. Family
(household members)
Cocaine
John
Arrested for
Children selling drugs
(Nephews/Niece):

two individuals; three solid lines represent “insensitive position” regarding John’s sub-
a very close relationship. Other key data, stance use disorder and there was a serious
such as arrest information, are written on the estrangement between her and her daughter.
genogram as appropriate. In discussing the details of the uncle’s crimi-
nal activity (which was a family secret that
This sample genogram depicts a family that
even John and his brothers did not know), it
initially was seen as a close, loving family
emerged that Mrs. G. had for years agonized
unit. The son, John, had come under the
over her mother’s pain. Now, desperately
influence of some “bad friends” and had
afraid of reliving her parents’ experiences,
become involved in abusing and selling sub-
Mrs. G. had stopped talking to her mother.
stances. While expressing their willingness to
John’s brothers felt free to open up and
help, the family denied the seriousness of the
expressed their resentment of their brother
situation and minimized any problems in
for putting the family in this position.
the nuclear or extended family.
Mr. G., who had been most adamant in
When the discussion was extended to one
denying any family problems, now talked
of John’s maternal uncles, Mrs. G. admitted
about the sense of betrayal and failure he
that her brother had been arrested a number
felt because of John’s actions. It was only
of times for heroin possession. Questions
through the leverage of the family’s expe-
about the maternal grandmother’s reac-
rience that the family’s present conflict
tion to John’s “problem” caused the united
became evident.
family front to begin to dissolve. It became
apparent that Mrs. G.’s mother took an

108 Chapter 6
Appendix 6-B. Family Social Network Map*
Designing a social network map is a prac- been important to you? They may have been
tical strategy to survey various aspects of people you saw, talked with, or wrote letters
social support available to clients and their to. This includes people who made you feel
families. Mapping a client’s social network good, people who made you feel bad, and
is a two-stage process. First, the client uses others who just played a part in your life.
a segmented circle to categorize people in They may be people who had an influence on
the network (e.g., friends, neighbors). Then, the way you made decisions during this time.
a grid is used to record a client’s specific
responses about the supportive or non- There is no right or wrong number of people
supportive nature of relationships in the to identify. Right now, just list as many peo-
network (Tracy and Whittaker 1990). This ple as you can think of. Do you want me to
approach allows both clinicians and clients write, or do you want to do the writing? First,
to evaluate (1) existing informal resources, think of people in your household—whom
(2) potential informal resources not currently does that include? Now, going around the
used by the client, (3) barriers to involving circle, what other family members would you
resources in the client’s social network, and include in your network? How about people
(4) whether to incorporate particular infor- from work or school? (Proceed around each
mal resources in the formal treatment plan. segment of the circle.) Finally, list profes-
Mapping also can identify substance-using sional people or people from formal agencies
behaviors of individuals in the client’s social whom you have contact with.
network. The map takes an average of 20 Look over your network. Are these the people
minutes to complete and provides a concise you would consider part of your social net-
but comprehensive picture of a family’s work this past month? (Add or delete names
social network. Practitioners report that the as needed.)
social network map identifies and assesses
stressors, strains, and resources within
a client’s social environment (Tracy and
Whittaker 1990). This interactive, visual tool
Household
allows clients to become actively engaged
and gain new insight into how to find sup-
port within their social networks. Formal Other
Services Family
Instructions
Step one. Explain to the client that you
would like to take a look at who is in the Neighbors Work, School
client’s social network by putting together
a network map. The client can use a first
name or initials for each important per-
son in his or her life; either the clinician or Clubs,
the client can enter the names in the appro- Friends Faith-Based
priate segment of the circle shown at right. Organizations
Sample script. Think back over this past
month, say since [date]. What people have
_______________________
* Source: Tracy and Whittaker 1990, pp. 463–466. Reprinted with permission from Families in Society
(www.familiesinsociety.org), published by the Alliance for Children and Families.

Family-Based Services 109


Step two. Number the sections of the circle The first three questions have to do with the
1 through 7, as shown in the Area of Life types of support people give you. Who would
section of the grid (exhibit 6-3). If there are be available to help you out in concrete
more than 15 names on the circle, the cli- ways? For example, who would give you a
ent selects the top 15 people to enter on the ride if you needed one or pitch in to help you
social network grid. Transfer the 15 names with a big chore or look after your belongings
and the numbers that correspond to the sec- for a while if you were away? Divide your
tions of the map to the social network grid. cards into three piles: those people you can
Names of people in the network also should hardly ever rely on for concrete help, those
be put on individual slips of paper for the you can rely on sometimes, and those you’d
client to use in preparing the network grid. almost always rely on for this type of help.

Step three. After the names from the social Now, who would be available to give you
network map have been added to the left- emotional support? For example, who would
most column of the social network grid, ask comfort you if you were upset or listen to
the client to consider the nine categories in you talk about your feelings? Again, divide
the column headings. The client uses the 15 your cards into three piles. (Proceed through
slips of paper with the names from the social remainder of the questions.)
network map to respond, sorting the slips
into groups corresponding to the numerical
options that accompany each category in the Clinical Application
grid. For example, when considering how Mapping a client’s social network provides
critical of the client each individual in his or a visual and numerical depiction of the cli-
her life is, the client sorts the slips into piles ent’s significant relationships. The following
representing those who (1) hardly ever, (2) aspects of social functioning are highlighted:
sometimes, or (3) almost always criticize. The
name of each person and the appropriate • Network size
number for his or her level of support are • Availability of support
then entered onto the network grid in each • Criticism client faces
life area. The finished grid gives an over- • Closeness
all picture of support in the client’s social • Reciprocity
network. • Direction of help
• Stability
Sample script. Now, I’d like to learn more • Frequency of contact
about the people in your network. I’ve put
their names on this network grid with a num-
ber for the area of life. Now I’m going to ask
a few questions about the ways in which they
help you.

110 Chapter 6
Exhibit 6-3. Social Network Grid Used in Conjunction With Network Map

ID __________ Infor- How


Concrete Emotional mation/ Critical of Direction How Long
Area of Life Support Support Advice Client of Help Closeness Often Seen Known

Family-Based Services
Respondent 1. Household 1. Hardly ever 1. Hardly ever 1. Hardly ever 1. Hardly ever 1. Goes 1. Never 0. Does not see 1. < 1 yr.
both ways very close
2. Other family 2. Sometimes 2. Sometimes 2. Sometimes 2. Sometimes 1. Few times/yr. 2. 1-5 yrs.
_____________ 2. You to them 2. Sort of close
3. Work/School 3. Almost always 3. Almost always 3. Almost always 3. Almost always 2. Monthly 3. > 5 yrs.
3. They to you 3. Very close
4. Organizations 3. Weekly

5. Other friends 4. Daily/twice or


more per week
6. Neighbors

Name # 7. Formal services

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15

111
Appendix 6-C. Resources for
Family-Based Services
Publications and Videos Publishing & Educational Services and
provides resources to help individuals, fami-
A helpful reference is Family Therapy: An
lies, and communities prevent and recover
Overview (Goldenberg and Goldenberg
from substance use and related disorders.
1985). This book presents a comparison of
six theoretical models of family therapy, Johnson Institute (johnsoninstitute.org).
including the psychodynamic, experiential/ This organization offers books, booklets,
humanistic, structural, communication, and and videos that are distributed through the
behavioral models. Meyers and colleagues Hazelden Bookplace Web site. Some family-
(2003) offer an overview of community rein- related videotapes available are Parenting
forcement and family therapy (CRAFT) that Issues for Recovering Families, The Kid and
emphasizes the approach’s empirical sup- Me: Parenting for Prevention, The Enabler,
port. Using concerned family members and Intervention, and Intervention: How to Help
friends, CRAFT works to bring those who Someone Who Doesn’t Want Help.
deny they have a substance use disorder into
treatment. National Families in Action (NFIA) (www.
nationalfamilies.org). NFIA is a national
American Outreach Association (AOA) drug education, prevention, and policy
(www.americanoutreach.org). AOA is a pri- center with the mission of helping families
vate, nonprofit organization that produces prevent substance abuse among children
pamphlets to help families cope with alcohol by promoting science-based policies. NFIA
and substance abuse. The pamphlets can offers books, pamphlets, and afterschool pro-
be downloaded from AOA’s Web site. Topics grams to keep young people substance free.
include strategies on confronting children NFIA has collaborated with other organiza-
who use substances, effective ways for par- tions on several projects, including Allied
ents to communicate with their children, and Systems Strengthening Families Project and
ways to help someone with alcohol and drug the Drug-Free America Foundation.
abuse problems.
NIMCO, Inc. (www.nimcoinc.com). This
Films for the Humanities and Sciences organization offers videos on alcohol,
(www.films.com). This organization offers tobacco, and drug education and prevention
150 educational films on substance abuse, topics. Videos cover such issues as drinking
covering topics such as treatment issues and and driving, steroid use, substance abuse in
the effects of addiction on family members the workplace, and the effects of substance
and including a series on young adults and abuse on the mind and body.
substance abuse.
Pyramid Media (www.pyramidmedia.com).
Gerald T. Rogers Productions (www. This company offers films and videos about
gtrvideo.com). This company produces films substance abuse that are appropriate for
and videos on substance abuse for many training, educational groups, and individual
audiences, from first graders to families with and family viewing.
members who abuse substances.
Substance Abuse and Mental Health
Hazelden Foundation (www. Services Administration’s National
hazeldenbookplace.org). Hazelden Bookplace Clearinghouse for Alcohol and Drug
is an online resource center and marketplace Information (NCADI) (www.ncadi.samhsa.
for products and services from Hazelden gov). NCADI is a national resource center

112 Chapter 6
funded by the Federal Government that who share their experiences, strengths, and
offers a large inventory of publications and hopes. Members believe that alcoholism is
videos for treatment professionals, clients, a family illness and that changed attitudes
families, and the general public, including can aid recovery. The program is based on
Alcoholism Tends To Run in Families. This the 12 Steps and 12 Traditions of Alcoholics
fact sheet presents important information Anonymous.
about the influence of parental alcohol-
ism on children and families. It considers Families Anonymous (FA) (www.
evidence that links alcoholism to dysfunc- familiesanonymous.org). FA is a 12-Step,
tional marital relationships, child abuse, mutual-help, recovery support group for rela-
depression, physical problems, and impaired tives and friends of those who have alcohol,
school performances, among other undesir- drug, or behavioral problems. FA pamphlets,
able effects. booklets, newsletters, and daily inspirational
thought book are written by the members.
Moyers on Addiction: Close to Home (www.
pbs.org/wnet/closetohome). This is the Nar-Anon family groups (www.naranon.
online companion to the PBS show. It com). Similar to Al-Anon, Nar-Anon is a fel-
features real-life stories of struggles with lowship of relatives and friends of people
addiction, information on treatment and who abuse substances and offers a construc-
prevention, and downloadable resources tive program for members to achieve peace
such as family guides, viewer’s guides, teach- of mind and to gain hope for the future.
er’s guides, and health professional’s guides Contact information is available in local tele-
to the PBS series. phone directories.

National Asian Pacific American Families


Family Support Groups Against Substance Abuse (www.napafasa.
org). This nonprofit organization is dedicated
Adult Children of Alcoholics (ACOA) (www. to addressing the alcohol, tobacco, and drug
adultchildren.org). ACOA is a 12-Step, 12- issues of Asian and Pacific Islander (API)
Tradition program that offers support for populations in the continental United States,
grown children of parents with alcohol or Hawaii, and the six Pacific Island jurisdic-
drug addiction. tions, as well as elsewhere. Its nationwide
Al-Anon family groups (www.al-anon.org). network consists of approximately 200 API
Al-Anon is a fellowship of relatives and and human service organizations, and its Web
friends of people who have alcohol problems site lists resources, services for public and pro-
fessional audiences, and current activities.

Family-Based Services 113


7 Clinical Issues,
Challenges, and
Strategies in Intensive
Outpatient Treatment

Once clients are engaged actively in treatment, retention becomes


a priority. Many obstacles may arise during treatment. Lapses
In This may occur. Frequently, clients are unable or unwilling to adhere
to program requirements. Repeated admissions and dropouts can
Chapter... occur. Clients may have conflicting mandates from various service
systems. Concerns about client and staff relationships, including
Client Retention setting appropriate boundaries, can compromise care. Intensive
Relapse and outpatient treatment (IOT) programs need to have clear decision-
Continued making processes and retention strategies to address these and other
Substance Use circumstances.

Substance Use by This chapter discusses common issues that IOT programs face
Family Members and offers practical approaches to retaining clients in treatment.
Experience has taught IOT clinicians that every problem can have
Group Work Issues many solutions and that the input and ideas of colleagues lead to
creative approaches and solutions. The chapter presents specific
Safety and Security scenarios and options from clinical practice and experience for clini-
Client Privacy cians to consider, modify, or implement.

Clients Who Work


Client Retention
Boundary Issues
Reducing client attrition during treatment must be a priority for
IOT providers. Compared with clients who drop out, those who
are retained in outpatient treatment tend to be White, male, and
employed (McCaul et al. 2001). Client attributes associated with
higher dropout rates are labeled “red flags” by White and col-
leagues (1998); these red flags include marginalized status (e.g.,
racial minorities, people who are economically disadvantaged), lack
of a professional skill, recent hospitalization, and family history of
substance abuse. Being aware of these red flags can help clinicians
intervene early to assist clients at increased risk of dropping out.
Veach and colleagues (2000) found that clients who abuse alcohol
were more likely to be retained and those who abuse cocaine were
less likely to be retained in outpatient treatment. Other studies have

115
found that the substance a client abuses is lar business hours. It can be difficult for
not a good predictor of retention (McCaul et clients to fit many hours of treatment into
al. 2001). their week.
• Use the group to engage and reengage
The following strategies improve retention of the client. The counselor should encour-
clients in treatment: age members to talk about their ambiva-
• Form a working relationship with the cli- lence, how they are overcoming it, and
ent. The counselor should foster a respect- their experiences of dropping out of treat-
ful and understanding relationship with ment, as well as the negative consequences
the client. This therapeutic relationship of dropping out. The counselor can supply
reduces resistance and successfully engages all group members with an updated tele-
the client in working toward mutually phone list and encourage them to talk to at
defined treatment goals. least two other members daily. The coun-
• Learn the client’s treatment history. If selor can ask members to call those who
the client has dropped out of treatment are absent to let them know that they were
previously, the counselor should find out missed and are important to the group.
why. If the client has engaged and been It is important to check with clients to be
retained successfully in treatment before, sure that they are receptive to these phone
the counselor should ask what made treat- calls; some may view them as intrusive and
ment appealing. disrespectful.
• Use motivational interviewing. The coun- • Increase the frequency of contact during
selor should help clients work through the early treatment period. Clients often
ambivalence by supporting their efforts to feel vulnerable or ambivalent during the
change and helping them identify discrep- first few weeks of treatment. Counselors
ancies between their goals and values and need to contact each client frequently dur-
their substance use. Involving clients in ing this period to enhance retention. These
activities, such as support groups, also is contacts can be brief and made by tele-
effective. phone, e-mail, or letter. At the same time,
• Provide flexible schedules. IOT provid- counselors should encourage clients to con-
ers need to consider the client populations tact other group members to reinforce the
they serve and schedule groups accord- value of reaching out for support.
ingly. For example, morning groups can be • Use network interventions. Counselors
for clients who work swing and night shifts need to work with individuals in the com-
and for women with school-age children munity who are invested in the client’s
and evening groups for those working regu- recovery to encourage the client to stay
in treatment. These individuals can be

Multiple Retention Challenges


Clinical issue. A man, age 35, single, and an immigrant from El Salvador, has failed to return to
treatment or contact his counselor in the last 3 days.

Approach
• The counselor writes a note to the client in Spanish, encouraging him to return to treatment.
• The counselor arranges for the client to get a ride to the next group session and for public
transportation vouchers for subsequent sessions.
• The counselor schedules an individual counseling session for the client to discuss several reten-
tion problems, which include lack of transportation, language barriers, and shame over lapses
to his previous drinking pattern.

116 Chapter 7
probation officers, ministers, employee
assistance program counselors, friends,
Relapse and Continued
and co-workers. If the program identifies Substance Use
supportive individuals early in treatment Lapses often happen in the difficult early
and obtains a written consent for release of months in treatment. These brief returns to
information from the client, the counselor substance use can be used as a therapeutic
can ask these individuals to encourage the tool; the goal is to keep them from becom-
client to attend sessions or increase his or ing full relapses with a return to substance
her commitment to recovery. use. IOT clients living in the community are
• Deliver additional services through- exposed to pressures to relapse, often while
out the treatment period. Fishman and struggling with cravings and their own resis-
colleagues (1999) found that attrition tance to change. Clients need to use relapse
was lower during the intensive “services- prevention strategies when they are exposed
loaded” phase of IOT and, conversely, that to alcohol and drugs, experience cravings,
attrition increased during the less rigorous are encouraged by others to return to sub-
program phases. stance use, or are exposed to personal relapse
• Never give up. The counselor should triggers (Irvin et al. 1999). (See appendix 7-A,
make continual efforts to follow up with page 135, for descriptions of several instru-
clients who have dropped out. Successful ments for assessing clients’ relapse potential.)
techniques include telephone calls, letters,
and home visits to encourage the client to General relapse prevention strategies are to
return to the program. This level of dedi-
cation can affect the client’s attitude and • Educate clients and their family mem-
willingness to complete treatment. bers about addiction and recovery.

The Difference Between a Lapse and Relapse


Jack’s experience: A lapse.

Jack comes to group distressed because he drank on the weekend. He has been abstinent for 2
months and is concerned that he has jeopardized his employment and the return of his driver’s
license. He discusses the episode with his counselor, and they identify treatment options. The
therapeutic goal is to reinforce Jack’s desire to stay abstinent, and the episode becomes an oppor-
tunity to strengthen his relapse prevention skills.

This is a lapse, that is, a brief return to substance use following a sustained period of abstinence
(a month or more). The client still is committed to his recovery and has not experienced loss of
control. The event is used to help the client identify relapse triggers and increase his understand-
ing and ability to withstand pressures to use substances.

Phil’s experience: A relapse.

Phil is in treatment for methamphetamine use. He has disappeared from treatment again.

When he returns, he is hyperactive, has a positive drug test, and refuses to talk about the test
results or his return to drug use. He then fails again to return to the program. He is seen on the
street obviously intoxicated. The compulsion to use is strong.

This is a relapse, that is, a prolonged episode of substance use during which the client is not
open to therapeutic intervention or learning. Often a relapse can lead to dropout and indicates a
continuing struggle by the client with his or her disease.

Clinical Issues, Challenges, and Strategies in IOT 117


Clients and family members need infor- • Develop a relapse prevention plan imme-
mation about the disease of addiction diately. A relapse prevention plan should
and its stages, cues to relapse, early signs include coping strategies developed by the
of relapse, how addiction affects rela- counselor and client, such as going to sup-
tionships, and how to find resources for port group meetings, avoiding places where
support (e.g., Al-Anon). Counselors need the client used substances in the past,
to enlist the support of family members identifying good things about a substance-
and significant others to keep them from free life, and telephoning the client’s
sabotaging treatment. Family members sponsor regularly. TIP 33 (CSAT 1999e)
need advice on how to support the client contains information and worksheets
in recovery and how to cease enabling to develop a relapse prevention plan.
behaviors. Technical Assistance Publication (TAP)
• Conduct an early assessment of specific 8, Relapse Prevention and the Substance-
relapse triggers. Together with the coun- Abusing Criminal Offender (Gorski et al.
selor, clients can conduct a functional 1993), and TAP 19, Counselor’s Manual
analysis of their substance use, working for Relapse Prevention With Chemically
to identify and understand with whom, Dependent Criminal Offenders (Gorski and
where, when, and why they use substances. Kelley 1996), are helpful in developing a
Functional analysis is a tool that identifies relapse prevention plan.
not only clients’ high-risk circumstances • Provide intensive monitoring and sup-
for substance use but also the ways in port. These activities include random drug
which triggers are linked to the effects that testing (including urine samples that are
substance use produces. TIP 33, Treatment collected under observation of program
for Stimulant Use Disorders (CSAT 1999e), staff to prevent tampering), family counsel-
and TIP 35, Enhancing Motivation for ing or education sessions about supporting
Change in Substance Abuse Treatment the client during and after treatment, and
(CSAT 1999c), explain how to perform a the client’s self-monitoring of exposure and
functional analysis. response to substance use triggers.

A Relapse Prevention Quiz


This quiz can be a tool to support and strengthen a client’s readiness to avoid relapse. Having
senior members in a group answer the questions reinforces their knowledge while they educate
newer members in relapse prevention skills.
• What might you say to co-workers if they ask you to have a drink or get high with them?
• Craving a drink or drug is quite natural for people who are dependent on alcohol or drugs.
What three things can you do to get past the craving?
• What are three common reasons for feeling that you don’t belong in a support group such as
Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)?
• What two things can you do if someone at an AA or NA meeting annoys you?
• Why must recovery from your disease be your highest priority?
• What three qualities should you look for in a sponsor?
• Emotional discomfort takes a variety of forms. What are the three biggest problems for you?
Anger, depression, self-pity, loneliness, boredom, worry, frustration, shame, guilt, or another
emotion?
• What three things can you do to handle each emotional discomfort you identified?
• What are the key elements of an assertive response when offered alcohol or drugs?
• Why is it important to avoid starting romantic relationships during early recovery?

118 Chapter 7
Multiple Dropouts and Readmissions
Some clients relapse or drop out of treatment and return repeatedly to treatment before they
achieve a stable recovery. Providers may be reluctant to keep offering scarce treatment resources
to the same individuals or to readmit individuals who drop out continually. Programs can
respond to multiple dropouts and readmissions strategically by
• Conducting a comprehensive evaluation of each client to determine whether IOT is the appro-
priate level of care. Some clients, for example, may benefit from a brief inpatient placement to
ready them for IOT (see chapter 5).
• Reviewing the client’s cycle of dropouts and admissions. Several cycles may be appropriate for a
client with severe, complex needs and issues. Arbitrary rules regarding the number of permitted
admissions and dropouts may be too rigid to support recovery of a severely impaired individual.
• Establishing an admissions committee to review and recommend action regarding clients who
seek readmission following repeated dropouts. The committee can include staff and alumni
representatives.
• Developing a profile of clients likely to drop out and designing a plan for them.
• Arranging a psychiatric evaluation for the client, which may indicate that psychiatric treatment
and medication are required.

• Evaluate and review all slips and lapses. leagues (1994) recommend using relapse
Despite their negative consequences, lapses prevention interventions that are matched
can be used therapeutically. The counselor to the client’s stage of change. Joe and
and client can learn more about what con- colleagues (1998) and Connors and col-
stitutes high-risk situations for the client. leagues (2001a) argue that for clients
The client needs to consider the slip or who are ambivalent about abstinence, for
lapse a discrete, unique event that does not example, initial interventions might focus
need to be repeated or continued. The cli- on strengthening their resolve by analyz-
ent should remember that abstinence can ing the pros and cons of use, rolling with
be regained and that the client can renew resistance, and never directly confronting
his or her commitment to abstinence. clients. Subsequent interventions support
Clients should be reminded to contact the abstinence by altering stimulus control
counselor, other group members, their and developing skills for negotiating high-
sponsor, or other mutual-help group mem- risk situations. After a client experiences
bers when they sense that they are verging a period of abstinence, emphasis shifts to
on relapse. lifestyle modifications that promote long-
• Use the behavioral contract with clients. term abstinence.
A behavioral contract spells out treatment
expectations and goals, the rewards when
goals are met, and the consequences if the Substance Use by
contract is broken. The counselor should
involve clients in writing the contract,
Family Members
encouraging them to use their own words. A client may have one or more family mem-
The behavioral contract helps bind clients bers who also actively abuse substances. In
to their commitment to abstinence and fact, research shows that individuals with
change. TIP 35 (CSAT 1999c) provides substance use disorders are more likely than
more information on behavioral contracts. others to have family histories of substance
• Introduce the stages of change. Marlatt use disorders (Johnson and Leff 1999). The
and Gordon (1985) and Prochaska and col- client may be in regular contact with

Clinical Issues, Challenges, and Strategies in IOT 119


members of the extended family, a close
friend, spouse, or a boyfriend or girlfriend
Group Work Issues
who uses substances. Active substance use by Group work is a core service of IOT and
someone living in the same place as the client offers many opportunities for educating,
or who is part of the client’s social support supporting, and nurturing clients. Clients’
network clearly threatens a client’s recovery. feelings toward their peers are important
The IOT counselor can consider using these factors in shaping the way clients view the
options: treatment experience. Clients are more likely
to continue with treatment when they feel
• Stay alert for others using substances. accepted, supported, and “normal” and
Construct and update regularly a geno- receive empathy and kindness from others in
gram or social network assessment (see the treatment group.
chapter 6) to identify possible substance
use among family members, significant Many issues can affect group work and
others, and friends who are likely to influ- impede the progress of clients. For example,
ence the client’s recovery. Gather informa- clients may be disruptive or withdrawn,
tion from the family and client about the have poor English or comprehension skills,
nature, extent, and frequency of any sub- and attend sessions sporadically. TIP 41,
stance use. Substance Abuse Treatment: Group Therapy,
• Request that the family and client devel- provides additional information on work-
op an agreement about substance use in ing with clients in therapeutic groups (CSAT
the home. It is important to enlist family 2005f).
members in the treatment process to help
the client and any other family members
who are using substances (see chapter 6).
Developing Group Cohesion
A substance use agreement, signed by fam- Group cohesion can be a central element in
ily members, identifies substances that a client’s recovery process. Frequent changes
will not be kept or consumed in the home in group membership make it difficult to
and the consequences for violating the build group cohesion. Washton (1997) sug-
agreement. Part of the agreement can be gests that frequent shifting of clients among
to report all substance use to IOT program groups can result in higher dropout rates.
staff for discussion during group and indi- This observation argues for limiting changes
vidual sessions. in group composition that sometimes occur
• Assist the client in identifying alternative in a “phased” or “stage-oriented” IOT
housing if needed. Recovery homes, half- program. Adding new clients to groups gen-
way houses, and shelters, among others, erates challenges for the counselor who must
may be necessary temporary alternatives become oriented to new clients. The follow-
for a client who needs alcohol- or drug-free ing approaches help create effective IOT
housing during and after treatment. If the groups and group cohesion:
client’s recovery is undermined continually
• Create group rituals. When new clients
in current housing, the counselor should
join a group or others depart, group rituals
consider such a housing referral.
promote a sense of acceptance, safety, and
• Provide information about treatment
support. Current members should orient
to a family member who needs it. Offer
new members to group rules and speak
information about treatment options
about their group experience. A ritual
or referrals to a family member with a
can mark a client’s graduation from the
substance use disorder in a manner that
program and celebrate his or her success.
ensures the privacy of the individual and
Departure rituals may include a client’s
does not divert attention from the client’s
demonstration of recovery knowledge and
treatment and recovery.

120 Chapter 7
skills, a group discussion of the departing other members to discuss their feelings or
client’s strengths and how group members fears about failure and relapse and their
can be supportive, a review of the client’s own relapse prevention strategies. Because
relapse prevention plan and options if the a client’s perception of his or her ability
plan should fail, and presentation of the to complete the program influences the
program’s emblem (see below). outcome, counselors need to support group
• Institute a program emblem. Staff and members with positive statements about
clients can design a program emblem to their potential to do well in treatment.
build and sustain group cohesion. The • Encourage identification with the pro-
emblem is a visual symbol that represents gram in addition to the group. It can
the essence of the treatment program. For be helpful if clients develop a sense of
example, a coin, badge, or cup might be belonging to the group and the treatment
inscribed with a recovery motto such as program. For instance, IOT staff can share
“Serenity and Strength Day by Day” or information about the overall goals of the
“Hope, Freedom, and Recovery.” A logo program, use guest counselors or supervi-
might feature the rising sun, a stately oak, sors to co-facilitate groups, and encour-
or clasped hands. These emblems can age former clients to return to share their
incorporate and reflect various cultural experiences. Contacts with alumni outside
and ethnic values and designs. Some treatment can be valuable, too.
programs leave space in the emblem to • Maintain effective group size and staff-
inscribe each client’s name and his or her ing. The ideal adult IOT group consists of
program completion date. Programs that 8 to 12 clients, although up to 15 clients
have emblems have found that clients keep may be on the group roster (CSAT 2005f).
them and use them as reminders of their Programs may need to adjust group sizes
commitment to recovery and their success according to staff resources, the availabil-
in remaining abstinent. The emblem and ity of co-therapists, the experience of the
motto should convey a message of support counselors, and the composition of the cli-
while maintaining the confidentiality of ent population (e.g., adult or adolescent,
the client (e.g., by not including the name women or men, people with co-occurring
of the treatment program). mental disorders).
• Explore the group’s feelings about cli-
ents who drop out. When a member At least one therapist should have the
relapses and drops out of the group, the required academic credentials for group ther-
group provides a safe environment for apy; a co-therapist can be an intern or trainee

Example of a Sendoff for a Treatment Program Graduate


As a client leaves treatment, he or she is invited to take a marble from a bowl of marbles. The
group leader then tells the graduate: “Now that you have begun this new stage in your recovery,
keep this marble with you always—perhaps in your pocket or purse. Keep it where you will see it
often to remind you of how hard your addiction was on you and your family. More important,
it will remind you of how firm and resolved you must be in your commitment to stay clean and
work on a healthy recovery program.

“Each time you reach into your pocket or purse and touch that marble, you will be reminded of
the hard times that are behind you and those that may lie ahead. If, after all this, you decide that
you do not care about the hard times and suffering that your addiction has caused and may cause
again, and you decide that you want to sink back down into the mess of your addiction, then take
the marble and toss it as far as you can, because you will have already lost the rest of your marbles!”

Clinical Issues, Challenges, and Strategies in IOT 121


who assists with managing client behaviors lifestyle. The counselor cannot permit the
and observing the dynamics of the group. client to attend group while under the
influence of drugs or alcohol because this
behavior can compromise the progress of
Preparing Clients for Group other members of the group. However, the
IOT programs should orient new clients counselor can address behaviors displayed
about how group therapy is conducted and by uncommitted clients by
how they are to use the group counseling
sessions (see chapter 4). One way to do this • Discussing the behaviors with the client
is with a pregroup interview that allows the individually to identify the issues and dis-
counselor to assess clients’ readiness for cuss options
treatment, learn more about clients’ circum- • Moving the client to a precontemplator or
stances, and help shape clients’ expectations other group or terminating the client from
by answering questions and supplying the program
information (CSAT 2005f). This information • Introducing more structure into the group
should include group norms and expecta- to enhance its therapeutic value for all
tions and be reviewed with clients so that members (e.g., by combining theme-oriented
it is clear from the outset. Programs also information with client discussion and
should consider posting group norms on the concentrating less on process and more on
wall of the meeting room and having clients organized content)
read them aloud at the beginning of each
group session. Working With Clients Who
Have Severe Mental Disorders
Working With Uncommitted, Individuals diagnosed with severe mental
Ambivalent Clients disorders often require a high level of man-
Some clients in group treatment may not be agement by trained medical and substance
committed to their recovery from substance abuse treatment professionals. These clients
use disorders. Clients who have been man- may have difficulty bonding with a group
dated to treatment by the justice system may and may be disruptive or unable to focus for
feel that they do not have a problem but are long periods. To enhance the effectiveness of
only following a judge’s orders. Some clients group for individuals diagnosed with severe
may be late habitually or talk about their mental disorders, IOT providers are encour-
continuing interest in a substance-abusing aged to consider these approaches:

Treating Individuals Who Have Severe Mental Disorders


Sam increasingly was unable to control his outbursts when in group. Although he usually was
able to return to a calm state, the incidents persisted. His counselor was aware that Sam experi-
enced hallucinations and, with input from Sam’s psychiatrist, determined that Sam was receiving
little benefit from being in a group. His treatment plan was revised to increase his individual
counseling sessions in place of group participation.

Marjorie was diagnosed with bipolar disorder and functioned well while taking prescribed medi-
cations. Her counselor noticed behavior changes in group (such as flirting with male members,
hyperactivity) over several days. After Marjorie was referred to her psychiatrist, it was determined
that she had stopped taking her medications. After she resumed taking her medications, her
symptoms disappeared.

122 Chapter 7
• Treatment should be coordinated with the wise offending other group members. Some
client’s psychiatric care provider to deter- strategies to address these disruptions are to
mine how best to respond to crises that
may arise during group. • Ensure that all clients know the group
• Group treatment should be guided by cli- rules; provide them in writing, if possible.
ents’ readiness for and ability to engage in • Consistently point out group rules about
group work (Substance Abuse and Mental disruptive behaviors and the consequences
Health Services Administration 2002). for engaging in them.
• Group treatment staff members should be • Reassess the client’s level of readiness to
educated and trained about mental dis- change, and assign the client to another
orders so that they are familiar with the group if appropriate.
signs and symptoms of psychoses and crisis • Hold individual counseling sessions to
intervention techniques. discuss specific disruptive behaviors, how
they are disruptive, and why they are not
For more information about treating this pop- allowed; then explore and identify factors
ulation, see chapter 9 of this volume or TIP that may underlie the behaviors.
42, Substance Abuse Treatment for Persons • Refer the client to a mental health profes-
With Co-Occurring Disorders (CSAT 2005e). sional if needed.

Working With Disruptive Working With Quiet,


Clients Withdrawn Clients
Clients in group express a wide range of feel- Clients may be reluctant to participate in
ings, thoughts, and behaviors. Some members group therapy for many reasons. They may
may disrupt the work of the group by chal- be fearful or ashamed of revealing to strang-
lenging or interrupting others, demonstrating ers the extent of their substance use and
their impatience and restlessness, or other- related behaviors. Cultural values may inhib-
it the sharing of personal problems with

The Angry Client in Group


Problem behaviors Key concepts for counselors

• Yelling • Be in control.
• Foul language • Avoid a power struggle.
• Interrupting • Address the behavior, not the content.
• Being mean or insulting to others • Don’t raise your voice.

What to do

Listen reflectively to validate the client’s feelings and to deescalate the situation. If the client
remains angry, use these approaches:
• State that you are there to protect and safeguard the members of the group.
• Identify specific behaviors that are inappropriate.
• State that these behaviors are not allowed.
• Identify the consequences if the behaviors continue (e.g., being removed from the group, not
being permitted to participate in discussion for the remainder of the group session).
• Follow through with the stated consequences if the behaviors are repeated.
• Transfer the client to a different group or clinical service.

Clinical Issues, Challenges, and Strategies in IOT 123


those outside the family. Language and com- • Provide individual mentoring to ensure
prehension barriers may make it difficult to that treatment information is conveyed
follow or participate in the conversation. and understood.
• Create a “buddy system,” pairing clients
Clients may refuse to take part in group to encourage a sense of acceptance and
discussions beyond the level of perfunc- belonging among the members of the
tory comments because they resent being in group.
treatment, are depressed or have some other • Contract with the client to increase partici-
mental disorder, find the group boring, or pation in the group incrementally.
are uncomfortable in a group. Some clients • Refer the client for psychiatric evaluation,
resist treatment because they believe that if needed.
they do not have a disease or do not belong • Adjust the client’s treatment plan to
in treatment. include individual rather than group coun-
Some strategies to assist withdrawn clients seling if that seems to be in the client’s
are to best interest.

• Ask clients individually why they are


quiet; then explore options based on the Responding to Intermittent
feedback. Attendance
• Assess and diagnose language and compre- It takes time for a group to become a cohe-
hension skills, and assign clients to a group sive unit, and clients who do not attend
that functions at an appropriate pace and sessions regularly can impede the group
level. process. The client who misses sessions may

Helping the Client “Speak”


A counselor noted that, time after time, a client sat quietly in group and spoke only a few words,
usually when she was called on. Despite gentle, persistent encouragement from the members of
the group and the counselor, the client was quiet and watchful.

After a week, the counselor suggested this reticent client write out whatever she might want to
communicate. The client was instructed to take an open-ended approach to the writing, similar to
writing in a journal.

The counselor also asked the client to complete the following statements:
• My health concerns are
• The most stress this week came from
• This week I’d rate my stress level as ____, with 1 being low and 10 being high.
• The best thing that happened this week was
• I’m working on my treatment goals by
• How I’m feeling about group is
• My most likely relapse trigger is
• I get support for the healthy changes I’m making from
• I participated in the following substance-free activities this week

After several days, the client returned with a sheet containing her thoughts and comments about
daily events, her concerns for her children, and the statements completed. The counselor used
the information to begin developing a relationship with the client that helped her feel more com-
fortable in the program and ultimately with the group.

124 Chapter 7
feel left out of discussions and may jeopar- unauthorized persons on the premises. One
dize the development of trust among group or more trained staff members promptly and
members that is at the heart of forthright firmly should ask individuals not in treat-
communication. Counselors may find that ment or not participating as family members
such clients are strongly ambivalent about to leave. Police assistance should be request-
being in treatment, have practical barriers ed if there is any resistance to the request or
that prevent them from attending regularly, if unauthorized individuals return.
or feel uncomfortable in the group.
In some cases, a client may encourage the
Some strategies to assist these clients are to presence of drug dealers or gang members.
Criminal justice-mandated clients and
• Assess their readiness to change, and individuals who are ambivalent about treat-
assign them to a precontemplator or other ment, for example, may be susceptible to the
group whose members are at a similar influence of individuals who use substances
stage of readiness. and are part of their social networks. If the
• Identify and address any barriers such as counselor finds this to be true, the coun-
lack of reliable transportation, conflicting selor should inform the client that program
work hours, lack of child care, protests by rules prohibit such activity and explain
the spouse or significant others to treat- the consequences of the client’s continued
ment, and fear of violence from a domestic involvement with drug dealers or gang
partner. members. A client may need the encourage-
• Assign these clients to a group whose mem- ment of the counselor and the support of
bers share a similar cultural orientation, program rules and policies to end harmful
age range, gender, substance used, or level associations.
of psychological functioning.
• Provide refreshments on days when atten-
dance is high to reward desired behavior. Stalking, Domestic Violence,
• Monitor attendance and seek guidance and Threats Against Clients
from the supervising clinician.
IOT programs must take appropriate steps to
ensure the safety of clients and staff members
Safety and Security during treatment. Safety may be threatened
by stalkers, violent domestic partners, former
Clients, family members, and staff members spouses and significant others, drug-related
must feel comfortable and safe when com- associates, or gang members. Counselors
ing to the IOT program. IOT programs that should consider following these steps:
treat high-risk clients need to monitor these
clients carefully, anticipate problems, and • Privately and in a nonjudgmental way, ask
plan appropriate interventions. Common the client about restraining orders, threats,
safety and security issues that IOT programs or violent incidents that have occurred or
face are identified by examples in exhibit 7-1 that may occur. Knowing about possible
along with the counselor responses. problems helps staff members and the cli-
ent take needed precautions. They can be
alert for evidence of any immediate danger
Presence of Drug Dealers or and attempt to prevent it. Treatment staff
Gang Members at the Facility have a duty to warn if the danger is clear
Every IOT program should post prominent and imminent, provided that confidential-
signs (in multiple languages where appro- ity regulations are met (CSAT 2004b).
priate) inside and outside its facility that • Intervene early to deescalate any situation
prohibit loitering, drug-related activity, or that potentially could become violent.

Clinical Issues, Challenges, and Strategies in IOT 125


Exhibit 7-1

Examples of Immediate Safety Concerns and Counselor Responses

Threat of violence against another. While in group, a male client expressed strong feel-
ings of anger toward another man involved with the client’s ex-wife. The client stated that
he had a gun and wanted to kill the other man.

Counselor response. The counselor removed the client from the group and engaged
him in a discussion about his feelings and remarks. The counselor expressed concern
about the client’s well-being and assessed whether he understood the seriousness of his
statements. The client’s anger began to subside, and the counselor had him sign a “no
violence” contract.

For several days thereafter, the counselor telephoned or spoke in person with the client to
assess his feelings and thoughts. The client stated he would “never do anything like that”
and had regretted his outburst.

Threat of suicide. A female client telephoned her counselor and said she was tired of
struggling with her addictions and other problems and was thinking about killing herself.

Counselor response. The counselor assessed the immediacy of the threat by reviewing
the case record to determine whether there had been any previous attempts at suicide
and asking the client whether she had a specific plan and the means to carry out the
plan. If the counselor were still concerned, he or she would have consulted immediately
with the supervisor or program director to develop and document a plan to inform the
police, relatives, and the client’s doctor and scheduled an immediate one-on-one ses-
sion. Because these criteria were not met, the counselor, with the agreement of the client,
scheduled an individual therapy session. During the session the counselor and client
negotiated a “no suicide” contract that included a commitment by the client to see a psy-
chiatrist for evaluation as soon as possible.

The counselor recorded the incident in the case record and discussed it further with the
supervisor.

• Place violence-related information, such as • Assist the client in obtaining a civil protec-
occurrences of stalking, in the client’s case tion order that prohibits harassment, con-
record. Help the client create a detailed, tact, communication, or physical proximity
personal safety plan, and include it in the by a batterer, stalker, or other threatening
case record. (See TIP 25, Substance Abuse individual.
Treatment and Domestic Violence [CSAT • Connect the client to community services
1997b], for a sample plan.) that address domestic violence, such as
• Require the client to sign a no-contact advocates, counselors, emergency housing,
agreement that prohibits contact with a and financial assistance.
batterer during the course of treatment,
with clearly delineated consequences for
violations.

126 Chapter 7
Treating Violent Clients IOT provider notify the justice agency.
Response to other violations may fall with-
Occasionally, a client may display violent
in the discretion of the treatment program.
behaviors while in treatment, such as bran-
(See TIP 44, Substance Abuse Treatment
dishing a weapon or threatening others. IOT
for Adults in the Criminal Justice System
staff can take these steps:
[CSAT 2005d].)
• Have all newly admitted clients sign a • Notify supervisors about threats.
client code of conduct that states that
threats of violence or acts of violence result
in immediate termination of treatment
Clients Arriving Under the
and possible criminal prosecution. Give Influence of Drugs or Alcohol
examples. Clients in IOT programs are expected to
• Notify a law enforcement agency if a threat attend sessions drug and alcohol free.
to safety exists or an assault or other crime Arriving under the influence interferes with
occurs on the program premises; report the clients’ participation, their ability to recall
incident and client’s name, address, and material covered, and the ability of other
treatment status, as permitted by Federal group members to benefit from therapy. It
regulations. also indicates that a client’s substance use
• If the client is mandated into treatment disorder is active and that an alternative
from the justice system, follow the steps treatment plan is indicated, at least for that
prescribed in the program’s agreement day. Strategies to respond to such occurrences
with the justice agency. Certain rule viola- are as follows:
tions, for instance, may require that the

Under the Influence in Group


George arrives at group intoxicated. His speech is slurred, he staggers somewhat, and he laughs
loudly and inappropriately.

Counselor response.
• Inserts an educational video, and instructs the group to continue on its own for the next 15
minutes. Alternatively, asks another staff member to sit in temporarily with the group.
• Escorts George from the group.
• Obtains a urine sample and conducts a Breathalyzer™ test to determine the substances
consumed.
• Asks George in a one-on-one session how he will return home. Because George drove to the
facility, the counselor tells him that he cannot drive home and that the counselor will contact
police if George tries to drive. The counselor reviews with George the names of family members
who can provide a ride home. The counselor follows applicable Federal, State, and local laws
regarding contacts with authorities (CSAT 2004b).
• Allows George to use the phone to call his wife to pick him up. Note: Some programs pay for a
cab.
• Expresses concern about the substance use and encourages George to return to the next session
where the episode will be discussed therapeutically.

Key point. The counselor did not engage George in a discussion about his substance use, such as
why it occurred and the circumstances. Instead, the counselor immediately focused on confirm-
ing George’s substance use, ensuring his safety, encouraging him to return to treatment when
sober, and preserving group time for the benefit of the other clients.

Clinical Issues, Challenges, and Strategies in IOT 127


• Develop clear program rules regarding Inquiries About Clients
use of drugs during treatment. If a client Federal confidentiality regulations do not
arrives under the influence, a therapeu- permit providers to reveal, even indirectly,
tic response is called for. The counselor that someone is a client unless a signed
takes the client aside, reviews the rules, release has been obtained from the cli-
and helps the client arrange alternative ent and is on file. IOT staff members must
transportation if the client drove to the consult a list of client-approved individuals
program. The client is instructed to return before they (CSAT 2004b)
when abstinent and is informed that the
substance use will be discussed in the • Acknowledge that a client is a participant
next session. The counselor also can write in the program.
a note to or call the client to emphasize • Share any information.
that the client is expected to return to the • Transfer a telephone call to the client.
group—actions that are intended to nor- • Take a message for a client.
malize the event and reduce any feelings of
failure and shame.
• Assess the client’s health status. When a Unsolicited Information
client arrives under the influence of drugs About Clients
or alcohol, the counselor should assess
Clients’ spouses, domestic partners, or
the client’s need for acute care or detoxi-
other acquaintances may leave messages
fication. If it is indicated, the counselor
with information about clients’ continued
should refer the client to detoxification.
substance abuse or other activities and his-
In a life-threatening overdose situation,
tory while they are in treatment. Sometimes
no signed release is required to arrange
these individuals share their identities but
for emergency medical care. If indicated,
do not want them revealed to clients because
emergency personnel can be called. If
they fear for their safety. The counselor can
acute care is refused, the counselor should
respond to unsolicited information by (1)
contact a family member or significant
raising the general topic with the client dur-
other to escort the client home. (Unless
ing individual counseling and revising the
the situation is life threatening, the sig-
treatment plan accordingly and (2) increas-
nificant other can be contacted only if the
ing the frequency of drug testing if substance
client has signed a release specifying such
use has been reported.
contact is permitted.) The counselor also
should provide the family member with
emergency care numbers. Knowledge of HIV Status
Withheld From Partner
Client Privacy Substance abuse, particularly the injection
of drugs, increases risk of HIV infection
Treatment programs often receive inquiries
(Pickens et al. 1993). During treatment the
about clients or unsolicited information
IOT counselor may learn that a client has
about clients. Some clients in treatment may
not informed a partner of his or her HIV-
be HIV positive but indicate they have not
positive status, exposing the partner to
reported their status to their partners or a
potential infection. The following approach-
well-known leader or celebrity may enter the
es help reduce this risk while maintaining
program. Each situation presents client pri-
client confidentiality:
vacy and ethical issues for IOT providers.
• Ensure that the client is informed fully
about the connections among drug use,

128 Chapter 7
The Informant
Maria calls the IOT counselor to say that her husband Juan (an IOT client) is drinking almost
every night and gets really drunk every weekend. She insists that the program “has to do some-
thing about it—treatment isn’t working.”

Counselor response. Because Juan has signed a release that permits the counselor to speak
with Maria, the counselor asks for her permission to confront Juan with this information. Maria
refuses permission because she is afraid Juan will be angry with her. The counselor schedules a
session with the couple to discuss problems at home.

The counselor tells Maria that, without her permission, the information will not be conveyed
directly; rather, it will be used in the most therapeutic manner possible. That is, the counselor
will pay increased attention to Juan’s behavior and communications and will perform breath
tests more frequently to obtain evidence of alcohol use.

Key points.
• The counselor avoids being drawn into keeping the wife’s secrets; a couples session is scheduled
to discuss openly the relationship and the husband’s drinking.
• IOT staff members must have a written release to discuss Juan’s behavior with anyone.
• Spouses and others who provide information about clients need to be protected from possible harm.
• Information obtained “anonymously” can be therapeutically useful.
• Clients may continue in the program, even though they may be surreptitiously using substances,
if all other program criteria are met.

unprotected sex, and the transmission of Entry of a Well-Known


HIV/AIDS. Individual Into Treatment
• Acknowledge and discuss with the client
any fears, feelings of embarrassment, and Recovery from substance use disorders is the
guilt about revealing his or her HIV status focus of treatment for all clients, regardless
to a partner. of their position or visibility in the commu-
• Include information about HIV transmis- nity. When a well-known person, such as a
sion in educational materials and presen- political leader, sports personality, artist,
tations made to family members. member of the clergy, or media representa-
• Assist the client in finding ways to talk tive, enters an IOT program, a variety of
about the issue with the partner, offer issues may surface. Examples include
assistance in informing the partner if the
• Increased risk to maintaining privacy
client consents, and refer the client to an
and confidentiality. Interest in the client
HIV/AIDS counselor for assistance.
may result in inquiries by media represen-
• Encourage the client to participate in a
tatives, curious callers, or program visitors.
support group for HIV-positive individuals,
Remind all staff, including administrative
and provide a specific program referral.
and support personnel, as well as clients,
• Discuss possible referrals to community-
to adhere to the program’s confidentiality
based providers if notifying the partner
procedures that protect the privacy of every
results in a need for services.
client.
(See TIP 37, Substance Abuse Treatment for • Feelings of privilege. Well-known clients
Persons With HIV/AIDS [CSAT 2000c].) may enter treatment with a belief that they
do not need to follow all the program’s
procedures or meet each requirement.

Clinical Issues, Challenges, and Strategies in IOT 129


Counselors must assist these clients in considered a successful alumnus and eli-
assimilating as quickly as possible into gible to support the program in these ways.
the treatment milieu by (1) relating to the
private and not the public individual, (2)
communicating treatment procedures and Clients Who Work
requirements, and (3) securing a signed Many clients have employment-related chal-
behavioral contract. Individuals who are lenges, which can include schedule conflicts,
well known in the community may be associating with co-workers who use sub-
concerned about protecting their privacy. stances, and unrealistic employer requests.
The IOT counselor can assist these clients
by (1) acknowledging their concerns while
assuring them that others in similar cir- Conflicting Work and
cumstances have completed treatment and Treatment Schedules
are recovering successfully, (2) evaluating
the feasibility of their being treated out Individuals who enter IOT may face conflicts
of town, (3) reviewing and discussing the between work responsibilities and attend-
program’s confidentiality regulations and ing IOT group sessions. Some clients may
policies, and (4) encouraging clients to rotate shifts or be asked to work overtime
attend support group meetings, which have or work on weekends. Work schedules may
a strong tradition of protecting the identity interfere with treatment sessions. This situa-
of participants. tion most likely occurs when the employer is
• Effect on the treatment milieu. The pres- unaware that the employee is in treatment.
ence of high-profile clients or relatives and The following approaches may be helpful,
friends of such clients may mean that the depending on the client’s situation:
treatment environment is tense or unset- • Encourage clients to make treatment and
tled because of media attention; group recovery their first priority; help clients
cohesion based on trust may be slow to understand that by doing so they are better
develop. The IOT counselor might consider able to meet their work obligations.
these approaches: (1) discuss interpersonal • Support clients in making treatment a high
issues that a client may have with other cli- priority by being flexible with treatment
ents in individual counseling sessions, (2) schedules.
use the group process to discuss confidenti- • Encourage clients to inform their employ-
ality, trust, or other concerns, and (3) place ers that they have a health condition and
any clients who express a concern about to ask the employers to cooperate with
being in a group with a high-profile client efforts to address the health condition.
in different groups.
• Dual relationships. High-profile clients
may offer to help the counselor or pro- Working and Socializing
gram financially, through a personal With Co-Workers Who Use
appearance, or through their influence.
Acceptance of such an offer from a client Substances
introduces a “dual relationship,” which Clients may have used substances with
is unethical. Programs should not accept co-workers and may find it difficult to rene-
gifts or favors from clients beyond the gotiate their relationships with co-workers
published fee schedules. Only after a client and to avoid circumstances that can lead to
has been out of treatment for an extended relapse. Options for addressing these issues
period (which many programs consider to include
be 1 year or longer) should the person be
• Assisting the client in identifying specific
work-related circumstances that may be

130 Chapter 7
uncomfortable or increase the risk of • IOT providers can refer the employer to
relapse resources such as professional associations
• Encouraging the client to distance him- and the drug-free workplace information
self or herself from co-workers who use available on the Internet from the Center
substances for Substance Abuse Prevention Workplace
• Using role plays and other counselor– Resource Center (workplace.samhsa.gov).
client interactions so the client can prac- • IOT providers can negotiate with the
tice responding to questions about treat- employer for an additional period of con-
ment and invitations to use substances in tinuing care for the employee; this period
ways that preclude uncomfortable discus- reinforces treatment gains and reduces the
sions and limit risk-oriented situations risk of relapse.
• Encouraging the client to transfer to anoth-
er work environment that is more support- Millions of private-sector workers in the
ive of recovery, if possible aviation, maritime, railroad, mass tran-
sit, pipeline, and motor carrier industries
are governed by Federal legislation (the
Employer Requests Omnibus Transportation Employee Testing
If the employer referred the client to treat- Act of 1991) that makes workplace drug
ment, the employer may expect information testing mandatory. If an employee of one of
from the IOT provider about whether the these industries fails a workplace drug test
client can assume his or her job responsi- and is mandated to treatment, the treatment
bilities. Many large employers have policies program is required to inform the employer
that address this question, specifying when in writing of assessment results and treat-
an employee can resume driving a bus or ment recommendations (Macdonald and
carrying a gun and mandating regular drug Kaplan 2003).
testing for a specified period. Key points con-
cerning this issue include that Helping Clients Achieve
• IOT providers do not have the expertise to Balance
determine whether a client can perform his Once in treatment, clients sometimes try to
or her job duties. Only the employer can make up for past harmful behavior during
determine this. periods of substance abuse. Feeling guilty
• IOT providers can inform an employer and remorseful, clients may take on addi-
(with the client’s consent) about the client’s tional work, extend their workdays, and try
progress in treatment and the drug test to become perfect employees. IOT providers
results. should caution clients about the risk of

Conflicting Schedules
Emily decided to seek treatment for her substance use disorder. She was employed at a firm that
depended on her to work on key projects. During treatment entry, the IOT counselor learned that
Emily’s supervisor sometimes expected her to work beyond regular hours. On these occasions she
would be unable to attend IOT group sessions consistently.

Counselor response. After exploring this issue, the counselor concluded that Emily was unable
to resolve her schedule conflicts with her employer without jeopardizing her position. The coun-
selor then arranged for Emily to attend a Saturday group session and to increase the number of
individual counseling sessions to compensate for the reduced number of group sessions. Emily
was able to complete treatment successfully.

Clinical Issues, Challenges, and Strategies in IOT 131


Co-Workers Who Use Substances
John and several co-workers went out together every Friday evening after work and drank heavily.
They drank on Saturday and continued drinking during the Sunday football games they watched
together. After making a decision to stop drinking and enter treatment, John wondered what he
could say to his co-workers.

Counselor response. The counselor suggested that John follow these steps:
• Maintain distance from friends and co-workers who use substances.
• Avoid explaining or defending his decision to enter treatment.
• Avoid giving detailed explanations for refusing invitations to activities where substances are used.
• Practice using concrete statements to avoid situations in which substances are used, such as “I
need to attend to personal problems in the family”; “Thanks, but no.” Practice these statements
in group sessions; role play the responses in individual counseling sessions.

The counselor also worked with John to develop a new social network and find recreational activ-
ities that would support his recovery.

compromising their recovery efforts by tak- ine concern and caring for one another. The
ing on too much responsibility too quickly. intensity and environment of an IOT pro-
The following responses may assist a client gram can lead to behaviors and issues that
who tries to overcompensate: challenge the boundaries between staff mem-
bers and clients. The following are examples
• Remind the client that recovery is the first of these challenges and suggested responses.
priority.
• Encourage the client to maintain bal-
ance and perspective with respect to the Clients Giving Gifts to Staff
type and intensity of activities that are Gift giving is relatively common and may
undertaken. have meanings and consequences that
• Assist the client in understanding that require careful consideration by counselors.
there will be time to address past mistakes For example, the customs and traditions of
once recovery is solidly underway. some cultures encourage gift giving to show
respect for someone who offers a valuable
service. Recent immigrants from these cul-
Boundary Issues tures may continue this practice and bring
Clients in treatment and IOT program staff a small gift or food item to the IOT coun-
members interact with one another on many selor or other program staff members. In
levels—intellectual, emotional, and spiritual. some cases, failure to accept the gift may be
The IOT experience is intense for all partici- viewed as a lack of courtesy and result in the
pants. Forming a therapeutic relationship client’s dropping out of treatment.
with the client helps the counselor focus
on the client’s recovery and influence the Other gifts given by clients to IOT staff mem-
client’s behavior. At the same time, clients bers may be inappropriate and should be
work together in group sessions over weeks refused politely and tactfully. Most program
and months on issues of profound signifi- rules prohibit staff members from accepting
cance to them. Furthermore, group members gifts if they
may attend community-based support
• Exceed a certain value (e.g., more than $20)
groups together during and after IOT. In the
process, they often develop trust and genu-

132 Chapter 7
The Meaning of Gifts: A Cultural Perspective
A gift has meaning both to the individual who gives it and to the one who receives it.
Understanding and appropriately acknowledging the true meaning of a gift always require an
awareness of the giver’s cultural background.

For example, many cultures place significant value on relationships rather than on individual pri-
orities or achievement. The giving of a gift recognizes and reflects the value of the relationship and
signals respect and caring. Gifts are given frequently and generally are not connected to an expec-
tation of favor or privilege. By accepting modest and especially handmade gifts from these clients,
IOT staff members acknowledge the respect, cultural values, and practices of these individuals.

• Are not the result of a religious or cultural Client Relationships Involving


tradition Substance Use
• Are offered in anticipation of some
response or benefit (e.g., special treatment Sometimes clients meet in an IOT program
or favor) and decide to use drugs or alcohol together.
• Are obviously personal in nature Others may be acquainted before enter-
• Are likely to cause discomfort, questions, ing treatment and continue a relationship
or confusion for others about the relation- that includes substance use. Options for the
ship between counselor and client counselor include the following:

Other programs permit only such gifts as • Reassess the readiness of clients for treat-
flowers, candy, cookies, or plants that can be ment and recovery.
shared by all staff members and clients rath- • Develop a written contract for abstinence,
er than given to an individual staff member. and have clients sign it.
• Refer clients to separate treatment
IOT providers should develop program programs.
rules that discourage gift giving and discuss • Provide individual therapy for one client
these rules with clients. However, the rules until the other client graduates from the
should permit some flexibility for individual program.
circumstances. It is recommended that pro-
grams require staff members to report all
gifts to supervisory personnel and in the case Socializing Between Staff
record. Counselors should be familiar with and Clients
the program’s policies on these issues. The therapeutic relationship between an
IOT counselor and a client is built on caring,
Socializing Among Clients trust, and genuine interest in the recovery
of the client. These three elements form a
IOT programs differ in the degree of social- basic building block of the treatment alli-
izing expected outside group sessions. Some ance. To safeguard the therapeutic dyad and
programs encourage clients to attend mutual- maintain the quality of the treatment envi-
help meetings together and support one ronment, IOT programs typically prohibit
another in other aspects of their lives. Other staff–client activities such as socializing and
programs discourage contact between clients doing favors. Program consequences for vio-
except within the program. Most IOTs have lations of these rules of professional conduct
rules regarding dating, sexual involvement, should be clear and applied consistently to
or other pairing of clients that could under- all program staff, from administrators to
mine treatment. support personnel. Consequences may vary,

Clinical Issues, Challenges, and Strategies in IOT 133


Counselor Observes the Client Using Substances
in the Community
Residents in a small, rural community occasionally enjoy dancing at the local nightspot. One eve-
ning an IOT counselor observes a client drinking at the bar.

Counselor response. The counselor leaves the establishment as soon as possible and does not
acknowledge the client. Subsequently, in the treatment setting, the counselor meets with the
client one on one. The counselor states the facts of the incident, expresses concern about the pos-
sible relapse, reminds the client of the agreement not to use substances, and, using motivational
interviewing techniques, asks the client to determine how to handle the return to drinking.

based on the circumstances, and can include program client by chance at a mutual-help
supervisory reprimand and counseling, oral meeting, particularly in a small community.
or written warnings, probation, and dismiss- Counselors should avoid attending meetings
al. In some cases, the counselor who violates that current or former clients attend. When
prohibitions must be reported to his or her this is not possible, an IOT counselor should
licensing or certification board. avoid sharing his or her personal issues at
that meeting. If a counselor in this situation
needs to talk, he or she should take someone
Counselors With Dual Roles aside after the meeting or call his or her
Many IOT counselors are also members of sponsor. Some cities have “counselor only”
mutual-help programs and must maintain meetings that are not listed in directories.
appropriate boundaries between these two The mutual-help program’s intergroup office
roles. For example, it would not be appropri- or other counselors are good resources for
ate for an IOT counselor to become a client’s locating such meetings.
sponsor. A counselor also might meet an IOT

The Client Is My Neighbor


The IOT counselor recognizes a new client in the waiting room as her neighbor. The neighbor is
surprised to see the counselor.

Counselor response. The counselor asks to speak privately to the neighbor in her office. The
counselor acknowledges the social relationship that exists between them and states that she will
not be involved in any way with the neighbor’s treatment. The counselor also explains confiden-
tiality regulations and indicates that the neighbor is in charge of how they relate to each other
outside the treatment setting. The counselor also discloses the relationship to his or her supervi-
sor to ensure that the counselor is not involved, even tangentially, in the client’s case.

134 Chapter 7
Appendix 7-A. Instruments for
Assessing Relapse Potential
Clinicians have access to several instruments Alcohol Effects
that help clients identify situations that pose Questionnaire (AEQ)
high risks of relapse and understand their
personal relapse triggers. Most instruments AEQ assesses the positive and negative
are not under copyright and can be used effects that clients expect alcohol to have.
free of charge. More information about these Based on their beliefs about alcohol, clients
tools, including information on obtaining respond “agree” or “disagree” to 40 state-
copies and links to downloadable versions, ments. AEQ yields scores in eight different
can be found at the National Institute on categories that describe the expected effects
Alcohol Abuse and Alcoholism’s Web site of alcohol: general positive feelings, social
(www.niaaa.nih.gov) by entering “Alcoholism and physical pleasure, sexual enhancement,
Treatment Assessment Instruments” into the power and aggression, social expressiveness,
site’s search engine. relaxation and tension reduction, cognitive
and physical impairment, and unconcern.
Administration and scoring of the pencil-
Alcohol Abstinence Self- and-paper AEQ take 10 minutes, and no
Efficacy Scale (AASE) special training is required. Although AEQ
has been used largely as a research instru-
AASE evaluates a client’s confidence in the ment, it can be used therapeutically to
ability to abstain from drinking in 20 situ- assess the effects a client desires to achieve
ations that present common drinking cues. by drinking and to initiate discussions
The instrument comprises 40 items that about alternative methods of attaining those
gauge a client’s risk of relapse on four scales: effects. The AEQ has proved especially help-
when the client is experiencing ful with college students who use alcohol.
• Negative emotions (e.g., depression,
frustration) Alcohol-Specific Role
• Feelings of well-being (e.g., celebrating, on
vacation) Play Test (ASRPT)
• Physical pain (e.g., headache, fatigue) ASRPT uses role playing to gauge client
• Cravings (e.g., testing willpower, experi- responses to 10 different situations that pose
menting with one drink) a threat of relapse. Clients listen to taped
prompts and then act out their responses,
AASE is a paper-and-pencil instrument which are videotaped for scoring purposes.
that can be administered and scored in 20 Five of the situations involve clients playing
minutes. No training is required to use it. out an interaction with another person (e.g.,
It can be used to evaluate clients admitted a scenario in which a business contact asks
to an IOT program, to guide treatment, or the person in recovery to complete a deal
to design individualized relapse prevention over drinks at a local bar); five require cli-
strategies. A user-friendly version of AASE ents to act out their responses to an internal
can be found at adai.washington.edu/ conflict (e.g., a scenario in which the person
instruments/pdf/AASE.pdf. in recovery has been working in the yard all
day and suddenly thinks that a cold beer
sounds good). The ASRPT can be admin-
istered in 20 minutes; male and female
role-play partners and a videotape technician

Clinical Issues, Challenges, and Strategies in IOT 135


are necessary. Training is required to give confident”) how they feel about their ability
the test, and trained judges must score it. to resist the urge to drink. SCQ is available
in paper-and-pencil and computerized ver-
sions and can be self-administered in 8
Situational Confidence minutes. (Scoring for the paper-and-pencil
Questionnaire (SCQ) version takes 5 minutes; the computerized
SCQ assesses a client’s confidence in the version is scored as soon as the question-
ability to cope with eight types of high-risk naire is completed.) Required minimal
drinking situations. For each of the SCQ’s training is available from a user’s guide that
39 items, clients indicate on a 6-point scale can be purchased with SCQ.
(ranging from “not at all confident” to “very

136 Chapter 7
8 Intensive Outpatient
Treatment Approaches

Intensive outpatient treatment (IOT) programs use a variety of


theoretical approaches to treatment. No definitive research has
In This established a best approach to treatment, and many factors (such as
client characteristics and duration of treatment) influence research
Chapter... outcomes. However, studies have found positive associations between
several treatment approaches and client outcomes.
12-Step Facilitation
Approach Providers should be aware of the most commonly used approaches
and their effectiveness so that they can make informed choices. This
Cognitive– chapter contains descriptions of six commonly used and studied
Behavioral treatment approaches that form the core of treatment for many IOT
Approach programs:
Motivational • 12-Step facilitation
Approaches • Cognitive–behavioral
Therapeutic • Motivational
Community • Therapeutic community
Approach • Matrix model
• Community reinforcement and contingency management
The Matrix Model
The chapter highlights each approach’s distinguishing character-
Community istics, theoretical orientation, research support, and other critical
Reinforcement elements such as staffing requirements or funding considerations.
and Contingency Exhibits summarize the strengths and challenges of each approach.
Management
Approaches These descriptions give readers only a basic overview; they are not
recipes for implementing the approaches in an IOT program. Clients
often have complex psychosocial needs that demand creativity on the
part of providers. These approaches are a means for shaping clinical
interventions, but none should be considered complete treatment on
its own. Excellent information, books, and treatment manuals are
available from the Hazelden Foundation (www.hazelden.org), the
National Institute on Drug Abuse (NIDA) (www.nida.nih.gov), the
National Institute on Alcohol Abuse and Alcoholism (NIAAA) (www.
niaaa.nih.gov), and the Substance Abuse and Mental Health Services

137
Administration’s National Clearinghouse for Counselors, originally all in recovery them-
Alcohol and Drug Information (www.ncadi. selves and often with little training, became
samhsa.gov) and Center for Substance Abuse more professional as training and creden-
Treatment (CSAT) (www.csat.samhsa.gov). tialing standards were implemented (M.M.
Miller 1998). Programs also were adapted
Although this chapter describes these six to a variety of settings, including IOT.
approaches as distinct, in reality IOT coun- However, the basic principles and methods
selors increasingly use multiple approaches, of the 12-Step treatment approach programs
modifying and blending them to address remained intact.
clients’ specific needs. This type of tailoring
is a hallmark of effective treatment, but com- IOT programs that use a 12-Step approach
bining approaches calls for the provider to focus on helping clients understand AA prin-
recognize and adjust for conflicts that may ciples, start working through the 12 Steps,
undermine each approach’s effectiveness. achieve abstinence, and become involved in
community-based 12-Step groups, such as
AA, Narcotics Anonymous (NA), or Cocaine
12-Step Facilitation Anonymous (CA). In these programs, edu-
cational efforts present alcoholism as a
Approach disease characterized by denial and loss of
control. Homework assignments entail read-
The Basics ing 12-Step literature, keeping a journal, and
The treatment approach of many IOT pro- undertaking recovery tasks that personalize
grams evolved from the Minnesota Model the 12 Steps. Much of the group work focuses
of treatment, so called because it was first on accepting the disease, assuming responsi-
conceptualized at Hazelden Foundation bility for the recovery process and one’s own
and Willmar State Hospital in Minnesota in actions, renewing hope, establishing trust,
the late 1940s (White 1998). The Minnesota changing behavior, practicing self-disclosure,
Model (also known as 12-Step facilitation) developing insights into one’s behavior,
is based on the concepts of 12-Step fellow- and making amends. Problems often are
ships, such as Alcoholics Anonymous (AA). addressed in the context of step work. Clients
These programs’ efforts were guided by the are encouraged strongly to accept their
philosophical belief that alcoholism was a addiction, develop or adopt spiritual values,
primary, progressive disease, with biological, and develop a sense of fellowship with others
psychological, and spiritual features. in recovery. IOT programs using a 12-Step
approach usually invite AA, NA, CA, or other
The Minnesota Model used treatment teams 12-Step groups to hold onsite meetings.
of physicians, nurses, alcoholism counselors, Clients are encouraged strongly to attend
family counselors, vocational rehabilita- meetings in the community and to find a
tion counselors, and AA members in the sponsor and home group for ongoing peer
treatment process. Basic to the process was support following completion of the formal
a thorough introduction of clients to the treatment program. Ideally, 12-Step-oriented
principles of AA fellowship and the 12 Steps, IOT programs are in touch with a network
education about the disease of alcoholism, of persons in recovery who can accompany
and participation in AA groups inside and ambivalent or reluctant clients to meetings
outside the hospital (M.M. Miller 1998). in the community and help them find com-
patible groups.
Over time, the 12-Step approach evolved
for use with people who use drugs and Exhibit 8-1 summarizes the strengths and
those with other compulsive disorders (such challenges of 12-Step facilitation.
as eating disorders) (M.M. Miller 1998).

138 Chapter 8
Exhibit 8-1

Strengths and Challenges of 12-Step Approaches

Strengths Challenges

• 12-Step meetings are a free, widely • It can be difficult to monitor accurately


available, ongoing source of support. clients’ compliance with assigned step
Metropolitan areas in particular offer tasks, including meeting attendance.
many meetings with a specialized focus • 12-Step groups’ emphasis on a higher
(e.g., meetings for young people, women, power may be unacceptable to some
newcomers to treatment, lesbians, gay clients.
men, Spanish-language speakers). • Some communities may not be large
• The 12-Step approach emphasizes an enough to sustain 12-Step meetings or
array of recovery tasks in cognitive, spiri- appropriate meetings for people with sig-
tual, and health realms. nificant psychiatric disorders.
• The 12-Step approach is effective
with clients from diverse backgrounds
(Tonigan 2003).

Other Important Aspects Step groups clearly serve a widely diverse


group of people.
Staff
Staff members who are not in recovery them- Research Outcomes and
selves should read AA, NA, and CA literature
and consider regularly attending open
Findings
meetings to ensure that they understand The NIAAA-funded Project MATCH com-
the beliefs, values, and mores of 12-Step fel- pared treatment outcomes for persons
lowships. Likewise, staff members should dependent on alcohol who were exposed to
familiarize themselves with local meetings one of three different treatment approaches:
and with the level of acceptance of clients 12-Step facilitation (a 12-Step approach that
with special needs (e.g., those with mental followed a manual), cognitive–behavioral
disorders). Familiarity with 12-Step culture coping skills therapy, and motivational
and with local meetings help staff members enhancement therapy (MET). All three
orient departing clients to 12-Step recovery approaches resulted in positive outcomes
and to the available options. regarding drinking behavior from baseline to
1 year following treatment. The study found
little difference in outcomes by type of treat-
Clients
ment, although 12-Step facilitation showed a
Research has attempted to identify the slight advantage over the 3 years following
individual characteristics that seem most treatment (Project MATCH 1998).
predictive of affiliation with 12-Step pro-
grams, particularly AA, but results often Brown and colleagues (2002) investigated
have been contradictory for some variables matching client attributes to two types of
(McCrady 1998). The 12-Step approach may aftercare: structured relapse prevention and
not be appropriate for every client, but 12- 12-Step facilitation. Overall, the 12-Step

Intensive Outpatient Treatment Approaches 139


facilitation approach provided more favor- normal environments, which are filled
able outcomes for most people who abuse with relapse triggers. These situations pro-
substances. In particular, the study found vide material for problemsolving exercises,
that clients reporting high psychological dis- homework, and role plays during group
tress, women, and clients reporting multiple or individual counseling and offer clients
substance use at baseline maintained absti- opportunities to use new coping strategies,
nence for longer periods following treatment cognitive skills, and behaviors.
with 12-Step facilitation than with structured
relapse prevention. The number, duration, and focus of treat-
ment sessions vary widely in CBT-oriented
programs. The CBT and 12-Step approaches
Cognitive–Behavioral are compatible, and many CBT-oriented
programs encourage participation in 12-Step
Approach meetings.

Exhibit 8-2 summarizes the strengths and


The Basics
challenges of CBT.
Cognitive–behavioral therapy (CBT) is based
on the theory that most emotional and
behavioral reactions are learned and that Other Important Aspects
new ways of reacting and behaving can be
learned. Staff
The CBT approach focuses on teaching Counselors must be familiar with the theory
clients skills that help them recognize and and practice of CBT and have basic coun-
reduce relapse risks, maintain abstinence, seling skills. It is sometimes helpful to have
and enhance self-efficacy. Clients learn to co-therapists lead cognitive–behavioral
identify personal “cues” or “triggers”—the groups, particularly those involving role
people, situations, or feelings that may lead plays and other interactive exercises.
to drinking or drug use. Such triggers may
be internal (such as physiological craving Clients
or stress reactions) or external (such as see- CBT has been effective with a broad range of
ing friends with whom the client has used clients. However, clients with low literacy or
drugs). Clients then are taught new coping intellectual skills or those for whom English
and problemsolving skills and strategies for is a second language may struggle with
effectively counteracting urges to drink or homework or group exercises that require
use drugs. reading or writing. Also, people with sig-
By analyzing their triggers, deciding on nificant psychiatric disorders that have not
recovery-oriented responses and strategies, been stabilized may be unable to participate
and role playing high-risk situations and sufficiently.
responses, clients gain confidence that they
can resist triggered urges to use substances. Research Outcomes and
CBT approaches also are applied to other
challenges in recovery, such as interpersonal Findings
relations, depression, anxiety, and anger CBT models have been evaluated exten-
management. sively, and randomized clinical trials found
CBT-based relapse prevention treatment
IOT programs are ideal for implementing to be superior to minimal or no treatment
cognitive–behavioral interventions. Clients (Carroll 1996b). When CBT was compared
usually continue to live and work in their with other active therapeutic interventions,

140 Chapter 8
Exhibit 8-2

Strengths and Challenges of Cognitive–Behavioral Approaches

Strengths Challenges

• CBT actively engages clients in therapy • Clients with poor reading or cognitive
and experiential learning. skills may need alternatives to written
• Numerous manuals on CBT are assignments.
available. • The approach requires counselor train-
• CBT is suitable for clients from diverse ing in CBT principles and techniques.
backgrounds and with varying histories • Client motivation is critical because of
of alcohol and drug use. the extent of homework assignments.
• CBT provides structured methods for • CBT was developed as an individual, not
understanding relapse triggers and pre- group, counseling approach.
paring for relapse situations.

results were mixed. Project MATCH found MI techniques developed by Miller and
CBT to be comparable with MET and 12- Rollnick (2002) were derived from a variety
Step facilitation for decreasing alcohol use of theoretical approaches to how people
and alcohol-related problems. All three ther- recover in progressive stages from addiction
apies resulted in positive improvements in and other problem behaviors (Prochaska
participants’ outcomes that persisted for up and DiClemente 1984, 1986). MI is a client-
to 3 years (Project MATCH 1998). Farabee centered, empathic, but directive counseling
and colleagues (2002) found that clients strategy designed to explore and reduce a
who received CBT reported more frequent person’s ambivalence toward treatment. This
engagement in substance-use avoidance approach frequently includes other prob-
activities 1 year after treatment than did lemsolving or solution-focused strategies that
clients who received treatment with contin- build on clients’ past successes. Motivational
gency management. approaches acknowledge that drugs of abuse
have rewarding properties that can disguise,
at least temporarily, their hazards and nega-
Motivational tive long-term effects. Through empathic
listening and skillful interviewing, the coun-
Approaches selor encourages the client to

The Basics • Identify discrepancies between significant


life goals and the consequences of sub-
In practice, motivational approaches include
stance abuse.
both motivational interviewing (MI) and
• Believe in his or her capabilities for
MET. These motivational approaches can
change.
be incorporated into every stage of treat-
• Choose among available strategies and
ment (see TIP 35, Enhancing Motivation
options.
for Change in Substance Abuse Treatment
• Take responsibility for initiating and sus-
[CSAT 1999c], pages 31–32, for specific
taining healthy personal behavior.
suggestions).

Intensive Outpatient Treatment Approaches 141


MI requires the counselor to relate to clients effective practitioners, counselors need
in a nonjudgmental, collaborative manner. special training as well as ongoing supervi-
Counselors pose questions to clients in a way sion to become proficient. Counselors also
that solicits information while strengthening need to be flexible and have a high level of
clients’ motivation and commitment to posi- therapeutic empathy. Counselors are seen as
tive change. The counselor acts as a coach collaborators or consultants rather than as
or consultant rather than as an authority experts.
figure. Counselors using MI follow four basic
principles (CSAT 1999c): Clients
• Express empathy. The counselor commu- MET was developed for, and has been effec-
nicates that the client always is responsible tive with, clients exhibiting varying severities
for change and respects the client’s deci- of alcohol-related problems. Court-mandated
sion on this issue. clients appear to benefit as much from MET
• Identify discrepancies. The counselor as do self-referred clients.
encourages the client to focus on how cur-
rent behavior differs from his or her ideals
and goals. Research Outcomes and
• Roll with resistance and avoid arguing. Findings
The counselor uses strategies to reduce A four-session version of MET was one of
resistance. three 12-week approaches tested in Project
• Support self-efficacy. The counselor recog- MATCH. MET was found to be as effective
nizes client strengths and encourages him as the other, more intensive interventions
or her to believe that change is possible. (CBT and 12-Step facilitation). Clients who
MET uses structured instruments for rated high in anger fared better with MET,
assessing dimensions of substance use having more abstinent days (Project MATCH
(e.g., consumption, biomedical and social 1998).
consequences, family history, readiness for Miller and Sanchez (1994) report that
change, risk factors). (Several of these instru- studies conducted in at least 14 countries
ments are reproduced in appendix B of TIP indicate that relatively brief motivational
35, Enhancing Motivation for Change in interventions can have lasting, positive
Substance Abuse Treatment [CSAT 1999c].) effects on drinking behavior that are compa-
Counselors provide feedback about assess- rable with the effects obtained with longer
ment results in relation to societal norms term treatment interventions.
and discuss clients’ responses to this
feedback.

Exhibit 8-3 summarizes the strengths and Therapeutic


challenges of MI and MET. Community Approach
Other Important Aspects The Basics
Therapeutic communities (TCs) have pro-
Staff vided residential substance abuse treatment
Staff members’ educational levels are since the 1960s. Some programs have devel-
not critical to a motivational approach. oped a modified, community-based IOT
Successful counselors may have graduate component either to provide treatment on
degrees and professional certification or an outpatient basis or to help graduates
be recovering peers. However, to become successfully transition from residential treat-
ment into the community. Some traditional,

142 Chapter 8
Exhibit 8-3

Strengths and Challenges of Motivational Approaches

Strengths Challenges

• MI and MET are client centered and rel- • MI and MET rely heavily on clients’
evant to clients’ personal interests. capabilities and level of self-awareness.
• MI and MET focus on realistic, attain- • Commonly used problem-oriented assess-
able goals. ment instruments are incompatible with
• MI and MET encourage client self-efficacy a motivational approach.
and self-sufficiency. • Although MET provides some guidance
• MI and MET emphasize positive, about effective interpersonal strate-
empathic support that does not under- gies for treating ambivalent clients,
mine or elicit anger from clients. the approach does not specify session
content.
• Motivational approaches require signifi-
cant staff training, reorientation, and
ongoing supervision.
• Motivational approaches may be dif-
ficult to combine with disease- or thera-
peutic community-oriented approaches
that expect adherence to program-
imposed goals.
• MI and MET were developed as indi-
vidual approaches; their effectiveness for
use with groups is unproved.

community-based IOT programs serve clients patterns. The TC approach assumes that
who participated in TCs while the clients recovery is a developmental process entailing
were incarcerated. IOT providers should mutual help and social learning. The beliefs
understand the TC process to ensure conti- and values that are essential to a client’s
nuity for clients. recovery include (De Leon 2000)

TCs use an approach known as “community • Demonstrating truth and honesty in all
as method” (De Leon 2000). This approach situations
sees the community as a whole—its social • Remaining in the “here and now”
organization, its staff and clients, and its • Assuming personal responsibility for one’s
daily activities—as the therapeutic agent. behavior and future
• Demonstrating concern for others
The TC model considers a substance use • Developing a work ethic and understand-
disorder as a disorder of the whole person. ing that rewards must be earned
TC program staff members assess each • Understanding the distinction between
participant’s problems along dimensions of external behavior and inner self
psychological dysfunction and social deficits • Accepting that change is the only certainty
(e.g., problems with authority, poor impulse • Valuing the learning process
control, dishonesty) as well as substance use

Intensive Outpatient Treatment Approaches 143


• Developing economic self-reliance encounter session is the main therapeutic
• Becoming involved in one’s community group and heightens clients’ awareness
• Developing good citizenship of specific attitudes or behavioral pat-
terns that need to change. Other groups
Because many clients served by TCs have focus on helping clients identify feelings
histories of severe substance use disorders and express them appropriately and
and criminal behavior, TCs typically strive constructively.
to habilitate, rather than rehabilitate, cli-
ents. TCs focus on all aspects of the client’s TCs feature a structured day that includes
life, and all activities in the TC promote ordered, routine activities to counter the
recovery and habilitation. TCs follow highly characteristically disordered lives of clients
structured schedules, centering daily activi- and distract them from negative thinking
ties on group sessions and hierarchical job and boredom. The treatment protocol is
functions that teach participants specific organized into phases and stages. When a
behaviors and skills. In general, participants client masters the objectives in one phase, he
move from job to job in the community or she moves to the next phase. The length
for different learning experiences. Peers of treatment depends on the client’s needs
confront negative behaviors and erroneous and progress in recovery. Continuing services
thinking in one another within a supportive are part of the TC approach. Clients benefit
milieu. from a peer network that assists them with
ongoing community-based services to sustain
TCs include the following components (De recovery.
Leon 1995):
De Leon (2000) describes the basic stages of
• A sense of community. Community is a TC program as
created partly by a separation from other
agency or institutional programs and, • Admission evaluation (a preprogram stage)
more important, from the drug-using envi- • Induction (an orientation stage)
ronment. A TC facility contains communal • Primary treatment
space for promoting a sense of commonal- • Reentry (into the outside community)
ity during collective activities. Treatment
or educational services (except individual Exhibit 8-4 summarizes the strengths and
counseling) must be delivered within the challenges of the TC approach.
peer community.
• Peers and staff members as role mod- Other Important Aspects
els. TC members and staff members serve
as positive role models by demonstrating Staff
expected behaviors and reflecting the val-
ues and teachings of the community. The TC staff members are generally a mix of
strength of the community for social learn- trained clinicians (certified counselors,
ing rests on the number and quality of its nurses, physicians, and case managers) and
positive role models. TC graduates who have had at least some
• Work as therapy and education. additional training (many become certified).
Consistent with the TC’s self-help approach, All staff members are part of the community
all clients are responsible for the daily and serve as role models. Staff members
management of the facility, and work roles typically receive considerable training in TC
are designed to bring about essential educa- philosophy and methods. Management staff
tional and therapeutic effects. in particular must be well trained to work
• Peer encounter groups, awareness train- effectively in a TC.
ing, and emotional growth training. The

144 Chapter 8
Exhibit 8-4

Strengths and Challenges of the Therapeutic Community Approach

Strengths Challenges

• The TC approach is effective for people • The approach may be too confrontation-
with long histories of substance depen- al for some clients.
dence and antisocial behavior. • Effective TC treatment requires exten-
• The TC approach is particularly effective sive staff training.
in teaching clients how to plan, set, and • Treating clients with mental disorders
achieve goals and to be accountable. can pose difficulties.
• The TC approach is effective in reduc- • Finding an effective mix of professional
ing recidivism among clients who have clinicians and recovering staff (who may
served time in prison. not be trained in assessment, treatment
planning, and counseling) can take time.

Clients Special considerations


Clients appropriate for TC treatment typi- For clients in an outpatient TC, it is impor-
cally have educational and employment tant to arrange for drug-free housing.
deficits and histories of poverty, relationship
problems, criminal behavior experiences or
criminal associations, housing instability, Research Outcomes and
psychiatric disorders, or antisocial or other Findings
dysfunctional behavior. Many have had pre- NIDA has funded treatment outcome studies
vious treatment episodes. that have found that TC treatment is associ-
TC approaches should be modified for ated with positive outcomes. For example,
women, adolescents, and those with co- the Drug Abuse Treatment Outcome Study,
occurring mental disorders because the a long-term study of treatment outcomes,
confrontational nature and strict hierarchi- found that clients who completed TC treat-
cal structure of a standard TC may not be as ment had lower levels of cocaine, heroin,
effective with these groups. and alcohol use; criminal behavior; unem-
ployment; and depression than they had
before treatment (National Institute on Drug
Training Manuals Abuse 2002).
CSAT has developed the Therapeutic
Community Curriculum (CSAT 2006g, Clinical trials of TC day treatment have
CSAT 2006h) to help supervisors provide found that client outcomes for residential
TC staff members with an understanding of TC and for day TC treatment are not signifi-
the essential components and methods of the cantly different (Guydish et al. 1999).
TC and an appreciation that they are part of A study of the effectiveness of extending the
a long tradition of community as a method of TC model from prisons to community-based
treatment. The curriculum provides detailed settings showed that inmates who participated
session-by-session instructions for trainers in an institutional TC followed by a TC-
and exercises for participants. oriented outpatient work-release program

Intensive Outpatient Treatment Approaches 145


had lower rates of drug use and recidivism • Encouraging clients to participate in
than offenders who participated only in the community-based mutual-help groups
institutional program (Inciardi 1996). • Conducting random urinalyses or breath
tests to assess treatment effectiveness

The Matrix Model Several variations of the Matrix model have


been developed. The original 12-month
version began with 6 months of intensive
The Basics
treatment that included 56 individual coun-
The Matrix model was developed during the seling sessions (including conjoint sessions
1980s as an effective way to treat the increas- with the client and family members); clients
ing number of people dependent on stimulant attended treatment sessions 3 or 4 times a
drugs, particularly cocaine. Developers week. The individual sessions were supple-
designed the Matrix model as a more inten- mented by several types of educational,
sive intervention than the then-standard relapse prevention, family, and social sup-
weekly outpatient counseling or 28-day inpa- port groups (Obert et al. 2000). The original
tient treatment. The Matrix model is a good cocaine-specific treatment protocol was
fit for clients who require comprehensive followed by versions for people who used
care. alcohol or opioids primarily. Because of cost
constraints, a 16-week version of the Matrix
The Matrix model, originally known as neu-
model was developed that cut the number of
robehavioral treatment, integrated several
individual sessions to three and emphasized
research-based techniques (including cognitive–
group work.
behavioral, 12 Step, and motivational
enhancement) to target clients’ behavioral, In all versions of Matrix model treatment,
emotional, cognitive, and relationship issues. a primary therapist coordinates the client’s
More research is needed to determine opti- treatment experience. The relationship
mal combinations of treatment approaches; between the primary therapist and the client
the Matrix model is one of many programs (and his or her family) is critical to treatment
that combine various approaches. The progress (Obert et al. 2000).
Matrix model has been selected for discus-
sion because its approach is comprehensive Individual sessions focus on treatment
and manual based and assessment data are planning and evaluating progress and may
available. include members of the client’s family for at
least part of the session. In addition to the
The Matrix approach is predicated on individual sessions, the treatment protocol
for the 16-week program includes specific
• Establishing a strong therapeutic relation-
structured groups (Obert et al. 2000):
ship between the client and counselor
• Teaching clients how to structure time and • Early recovery groups. These groups are
initiate an orderly and healthy lifestyle for those in the first month of treatment
• Imparting accurate, comprehensible infor- and are small to maximize the attention
mation about acute and subacute with- each client receives. Early recovery groups
drawal effects and cravings for substances focus on teaching clients cognitive tools for
• Providing opportunities to learn and managing cravings and emphasize time
practice relapse prevention and coping management. Clients create a daily sched-
techniques ule and monitor their activities with group
• Involving family and significant others in input and support. Early recovery groups
the therapeutic and educational processes assist clients in connecting with commu-
to gain their support for—and prevent their nity support services.
sabotaging of—treatment

146 Chapter 8
• Family education sessions. Family educa- meetings. Clients are encouraged strongly to
tion is presented as a 12-week series and attend additional meetings in the commu-
includes both clients and family members. nity and to find a 12-Step sponsor.
These sessions include slide presentations,
videos, panel presentations, and group Exhibit 8-5 summarizes the strengths and
discussions on topics such as the biology challenges of the Matrix model.
of addiction, medical effects of substances,
conditioning and addiction, and effects of Other Important Aspects
addiction on the family.
• Relapse prevention groups. These groups Staff
are the primary component of treatment.
Group sessions are highly structured and Trained therapists are crucial to Matrix
focus on cognitive and behavioral change model treatment. They are expected to cre-
and on connecting clients to mutual-help ate nurturing, nonjudgmental relationships;
programs. The group protocol includes 32 maintain a supportive attitude in the face
specific topics. of a client’s relapse; foster each client’s self-
• Social support groups. These groups esteem and dignity; and function as teachers
begin in the last month of treatment and or coaches without being either parental or
focus on helping clients pursue drug-free confrontational. Clients with established
activities and develop friendships with long-term abstinence sometimes co-lead
people who do not use substances. They groups, serving as role models who put a
are less structured than the other groups, human face on the recovery process.
and the content is determined by the needs
of the group members. Clients
Matrix programs orient clients to 12-Step The Matrix model has been used in many
programs and often schedule onsite 12-Step different settings (including prisons,

Exhibit 8-5

Strengths and Challenges of Matrix Model Treatment

Strengths Challenges

• The model integrates a cognitive– • Some materials may need to be modified


behavioral approach with family involve- for clients whose cognitive functioning is
ment, psychosocial education, 12-Step impaired.
support, and urine testing. • The program requires special staff train-
• The model follows a manual, provid- ing and supervision.
ing therapists with specific instructions • The highly structured content may not
and practical exercises. A version of the appeal to all clients.
Matrix materials is available free from • The tight structure and schedule may
NCADI (CSAT 2006c, 2006d). not leave time for identification and
• The model has been used extensively stabilization of other non-drug-specific
with people dependent on stimulants problems.
and has been shown to be effective.

Intensive Outpatient Treatment Approaches 147


substance abuse treatment centers, and with their pretreatment levels. In addition,
hospitals) and with a varied client popula- a substantial number of the former clients
tion across the United States and in Mexico, were employed and were not in the criminal
Thailand, and the Middle East (Rawson justice system.
2003).
Shoptaw and colleagues (1998) developed a
48-session variation of Matrix treatment for
Treatment manuals gay and bisexual men who abuse metham-
The Matrix model treatment materi- phetamine. The model was found to be an
als contain instructions for therapists on important tool for preventing HIV infection
conducting individual, group, and family because clients reduced their risky sexual
education sessions (visit www.matrixinstitute. behaviors concurrently with reductions
org). Handouts for clients and family mem- in their stimulant use—without any spe-
bers cover therapeutic session topics. Some cific focus on HIV/AIDS during treatment
materials have been translated into Spanish, (Shoptaw et al. 1997, 1998).
Arabic, Thai, and other languages. CSAT has
adapted the Matrix treatment manuals and
made them available as a package called Community
Matrix Intensive Outpatient Treatment for
People With Stimulant Use Disorders (CSAT
Reinforcement
2006c, 2006d). and Contingency
Management
Research Outcomes and Approaches
Findings
Studies support the utility of Matrix model The Basics
treatment. In a 1985 pilot study, individuals Community reinforcement (CR) and con-
who selected Matrix treatment over a 28-day tingency management (CM) are treatment
inpatient hospital program or participa- approaches based on operant conditioning
tion in 12-Step groups reported significantly theory. This theory maintains that future
lower rates of cocaine use 8 months after behavior is based on the positive or negative
treatment than those in either of the other consequences of past behavior. For example,
groups (Rawson et al. 1986). drug use is maintained by the positively
A controlled trial of the model found that reinforcing effects of the drug itself or by
people from lower income groups who smoke the negative reinforcement of relieving the
crack are more difficult to retain in Matrix pain of withdrawal. Abstinence, in and of
treatment than those who used cocaine intra- itself, may not be sufficiently reinforcing to
nasally and had more social stability and maintain a person’s motivation to stop using
resources (Obert et al. 2000). drugs, particularly in early abstinence. Other
rewards must be found that reinforce ongo-
Researchers conducting a CSAT-supported ing abstinence and lifestyle change.
outcome study of Matrix model treatment
(Rawson et al. 2002) interviewed a nonran- CM is an approach in its own right, but its
domized sample of clients who had used operant interventions are also the main
methamphetamine and received Matrix treatment tool used in CR. In CR, the
model treatment. They found that 2 to 5 positive and negative reinforcers that char-
years after completing treatment these cli- acterize CM are understood to be socially
ents had reduced their methamphetamine mediated. CR uses aspects of the client’s
and other drug use substantially compared life—relationships with family and friends,

148 Chapter 8
job, hobbies, social events—to provide the avoidance skills and relapse prevention
positive reinforcement that motivates the cli- techniques are taught along with social and
ent to stop using substances. CR is successful recreational counseling, relationship coun-
when the client chooses the rewarding rela- seling, and social and other skills training.
tionship and activities over substance use. Clients earn points for each urine screen that
(See Chapter 6 for a discussion of how CR is negative for cocaine. For each consecutive
can be used to motivate family members to negative urine screen, the number of points
support the client.) CR and CM approaches is increased. If a client submits a urine speci-
motivate clients’ behavioral change and rein- men that is positive for cocaine, the point
force abstinence by systematically rewarding value returns to baseline. The client can
desirable behaviors and ignoring or punish- earn back the points lost by submitting five
ing others. Reinforcers are typically positive, consecutive negative urine specimens. The
pleasurable, and rewarding events or objects, client can “redeem” points for a variety of
but some negative reinforcers also are effec- retail items that
tive. Removing a fine or restriction after a are purchased
client has complied with a specified regimen by program staff Abstinence...may
is an example of negative reinforcement. (clients are never
given cash). Staff not be sufficiently
A challenge in this treatment model is to members have veto
identify a reward for a desired behavior that power over clients’ reinforcing to
is both practical and sufficiently powerful— requests. In gen-
over time—to replace or substitute for the eral, staff members maintain a person’s
potent, pleasurable, or pain-reducing effects approve only items
of the drug. The reward must be available that are consistent
without too much cost or expenditure of staff
motivation to stop
with a client’s
energy. The rewards and punishments must treatment goals
be tailored carefully to clients’ responses, as using drugs…
and encourage
well as program capabilities. For example, drug-free activities.
vouchers worth $5 may be motivators for Examples of items purchased for the pro-
some clients but not others or at a particular gram’s clients include socks, toaster ovens,
point in treatment but not later. Most of the baby clothes, camera equipment, ski lift
financial or voucher-based CM interven- tickets, bicycle equipment, and continuing
tions use an escalating series of rewards for education materials.
achievement of the target behavior, such as
drug-free urine specimens. The escalating Effective CR and CM programs select a target-
rewards provide a greater incentive for sus- ed behavior that is attainable in a reasonable
taining the desired behavior. On the other amount of time and has a direct effect on
hand, Kirby and colleagues (1998) found the desired outcome. For example, expecting
greater reductions in cocaine use when a clients who have never submitted a drug-free
larger reward was given at the beginning of urine sample to achieve immediate absti-
treatment, coupled with increased require- nence may be optimistic. Abstinence from a
ments for earning vouchers as treatment specific substance might precede abstinence
progressed. from all substances. Targeting small changes
is an effective strategy. More frequent rein-
An example of this approach is described forcers, even if small, have a greater effect
in a NIDA treatment manual, A Community than larger, more remote rewards or punish-
Reinforcement Plus Vouchers Approach: ments. It is also important that the desired
Treating Cocaine Addiction (Budney and behavior contribute to the treatment goals. A
Higgins 1998). In this approach, abstinence person’s merely attending counseling sessions
is reinforced by awarding vouchers. Drug may not affect his or her drug use. Of course,

Intensive Outpatient Treatment Approaches 149


all rewards must be delivered as promised Other Important Aspects
for the treatment to remain credible (Crowley
1999; Morral et al. 1999). Staff
Specialized assessment and treatment Designing CR and CM treatment programs
planning instruments are not required for requires specialized training and knowledge
successful implementation of a CM interven- of operant learning principles. In practical
tion. However, CM interventions depend terms, however, operant learning principles
on detailed and precise measurements of can be applied by staff members who have
the targeted behavior. Because of the short proper training and supervision. Some coun-
half-life of alcohol, using CM procedures to selors may feel that the theories of operant
monitor alcohol abuse can be difficult. Self- conditioning or behavioral learning are
reported drug use status is not adequate for inconsistent with the disease concept of sub-
awarding vouchers. Rather, drug use status stance use disorders (Bigelow and Silverman
must be determined by frequent testing of 1999) and are incompatible with their train-
observed urine specimens (Crowley 1999). ing and practice because behaviorists view
Similarly, if work activity is the target behav- addiction as a learned behavior rather than
ior, it is not enough to ask clients about an illness with biological, psychological, and
their attendance or productivity. Objective, spiritual roots.
verifiable measures that demonstrate accom-
plishments must be used. Clients
Activity schedules used in CR and CM pro- Intensive CM interventions have been used
grams can vary dramatically. As an example, with treatment-resistant clients and with
the activity schedule of an intensive clients who have severe problems related to
reinforcement-based day hospital program employment or housing or who have psy-
provided abstinence-contingent partial chological and medical conditions and have
support of housing and food and access to been unsuccessful in achieving abstinence
recreational activities, social skills train- through traditional counseling methods.
ing, and job-finding groups (Gruber et al. Behavioral interventions have been effec-
2000). The program required clients recently tive with people who use cocaine (Higgins
detoxified from heroin and cocaine to attend 1999), persons who are homeless (Milby et
treatment for 6 hours a day on weekdays and al. 1996), pregnant women (Higgins 1999),
3 to 4 hours a day on weekends for the first and individuals on methadone who need to
2 weeks, then 1-hour individual counseling discontinue other drug abuse (Higgins 1999).
sessions three times per week for the next 6
weeks, and then two sessions per week for Funding
another 4 weeks. Abstinence-based contin-
The cost-effectiveness of CR and CM is
gencies were in effect for the first month
affected by the expense of incentives, addi-
of the program. By contrast, the schedule
tional urine screens, and the additional
for a 6-month CR-plus-vouchers treatment
time demands placed on staff members.
entailed 60-minute individual counseling
In some research projects incentives cost
sessions two times a week and urine moni-
$1,200 or more per client. This expense
toring three times a week during the first 12
has limited application of CM techniques
weeks. This was followed by weekly counsel-
to research studies or small-scale project
ing and twice weekly urine testing in weeks
demonstrations. However, alternative low-
13 to 24 (Budney and Higgins 1998).
cost incentives can be used to bolster the
Exhibit 8-6 summarizes the strengths and effect of traditional treatment interventions;
challenges of CR and CM. donated goods and services can reduce the
costs of CR and CM (Amass and Kamien

150 Chapter 8
Exhibit 8-6

Strengths and Challenges of Community Reinforcement and


Contingency Management Approaches

Strengths Challenges

• CR and CM have been shown to reduce • Clients may return to baseline drug use
drug use significantly when incentives rates when incentives are terminated.
are used. • CM approaches can be labor intensive,
• CR and CM can be combined readily require specialized staff or training for
with other psychosocial interventions implementation, and entail frequent cli-
and pharmacotherapies. ent attendance.
• CR and CM can be implemented with • For maximal effectiveness, rewards
a variety of low-cost incentives such as must be sufficiently large—and increase
donated goods or services. in value—to have continuing appeal to
• CR and CM have proved effective for clients.
reducing drug use and increasing treat- • Many research studies demonstrating CR
ment compliance among clients with and CM effectiveness have used small
severe problems who are chronically sub- samples and incurred large costs for
stance dependent. incentives.
• CR and CM have extensive and robust • Resources required for implementing CR
scientific support in both laboratory and and CM (e.g., onsite urine-testing capa-
clinical studies. bilities or alternatives to costly incen-
tives) may be unavailable.
• Lack of emphasis on long-term supports
is a potential drawback.

2004). Anniversary celebrations, special Morral et al. 1999). Generally, these studies
books, reductions in clinic fees, and letters have been conducted in outpatient settings
of support to employers and protective ser- in which delivery of incentives is coupled
vice workers are among the incentives that with traditional individual or group counsel-
can be used. Some programs have raised ing and education services. More recently,
funds to support incentives or solicited local the CM approach has been applied in inten-
merchants for donations of goods or services sive outpatient and day treatment settings.
(Kirby et al. 1999a).
The NIDA treatment manual on community
reinforcement (Budney and Higgins 1998)
Research Outcomes has provided an impetus for using empiri-
and Findings cally established CM techniques for treating
cocaine abuse. The manual presents findings
Studies show that the CM approach to treat- from five controlled clinical trials that sup-
ing substance use disorders has proved ported the superiority of CR plus vouchers
effective in motivating clients to achieve and over standard care. In one study, 75 percent
sustain abstinence as well as increase their of the clients participating in CR plus vouch-
compliance with other treatment objectives ers completed the program, compared with
(Bigelow and Silverman 1999; Higgins 1999;

Intensive Outpatient Treatment Approaches 151


only 11 percent of standard care clients. Another landmark CM study examined the
Two subsequent studies showed that add- effectiveness of housing incentives for reduc-
ing redeemable vouchers was more effective ing crack cocaine use among people who are
than CR as a standalone treatment (Higgins homeless (Milby et al. 1996). Incentives for
et al. 1995). A literature review of similar CR drug-free housing and vouchers for social
approaches found positive effects on cocaine and recreational activities were more effec-
dependence in 11 of 13 studies (Higgins tive than 12-Step-oriented treatment alone
1996). Higgins and colleagues (2000) found for reducing alcohol and cocaine use as well
that incentives delivered contingent on as homelessness. At the 12-month followup,
cocaine-free urinalysis results significantly however, cocaine use in both groups had
increased abstinence during treatment and returned to baseline levels, suggesting the
at 1-year followup. need for more intensive aftercare in this
difficult-to-treat population.

152 Chapter 8
9 Adapting Intensive
Outpatient
Treatment
for Specific
Populations

Many assumptions and approaches used in intensive outpatient


treatment (IOT) programming were developed for and validated with
In This middle-class, employed, adult men. This chapter presents informa-
tion about how IOT can be adapted to meet the needs of specific
Chapter... populations: the justice system population, women, people with
co-occurring mental disorders, and adolescents and young adults.
Justice System Chapter 10 presents information on treatment approaches for other
Population special groups, including minority populations.
Women

Populations With Justice System Population


Co-Occurring The number of people in the justice system with a history of sub-
Psychiatric stance use disorders has increased dramatically over the last 20
Disorders years because of increased drug-related crime, Federal and State leg-
islation, and mandatory sentencing guidelines; many of these people
Adolescents
are caught in a cycle of repeated incarcerations.
Young Adults
Between 1990 and 1999, the number of inmates sentenced to
Federal prison for drug offenses rose more than 60 percent (Beck
and Harrison 2001). About three-quarters of all prisoners reported
some type of involvement with alcohol or drug abuse before their
offenses, and an estimated 33 percent of State prisoners and 22 per-
cent of Federal prisoners say that they had committed their current
offenses while under the influence of drugs, with marijuana/hashish
and cocaine/crack used most often (Mumola 1999).

Description of the Population


Justice system populations are younger than the general population,
are overwhelmingly male, and are challenged with many psychoso-
cial, medical, and financial problems (Brochu et al. 1999).

153
Psychosocial issues ted their crimes while under the influence
People involved with the justice system of drugs or alcohol (Greenfeld and Snell
typically have many problems related to 1999). Female offenders with substance use
employment and financial support, housing, disorders experienced more health, educa-
education, transportation, and unresolved tional, and employment problems; had lower
legal issues. Many inmates have not com- incomes; reported more depression, suicidal
pleted high school or earned a general behavior, and sexual and physical abuse;
equivalence diploma. Only about 55 percent and had more mental and physical health
were employed full time before their incar- problems than did male offenders with sub-
ceration (Bureau of Justice Statistics 2000). stance use disorders (Langan and Pelissier
2001). More than half the female inmates in
prisons had at least one child younger than
Medical and psychiatric 18 (Mumola 2000). The National Institute of
problems Corrections’ Gender-Responsive Strategies:
Offenders with a substance use disorder Research, Practice, and Guiding Principles
may have co-occurring psychiatric disorders. for Women Offenders (Bloom et al. 2003)
Approximately 16 percent of State inmates, 7 provides more information about female
percent of Federal offenders.
inmates, and 16
A major challenge to percent of jail Double stigma
inmates and pro- Offenders often are affected by the stigma
IOT providers is to bationers reported associated with involvement in the justice
having mental ill- system, as well as the stigma associated
integrate substance nesses, and nearly with substance abuse. These two factors can
60 percent of these impede an offender’s ability to obtain appro-
abuse treatment offenders reported priate employment or housing.
that they were
with justice under the influ-
ence of alcohol or Implications for IOT
drugs at the time
system processes. In response to the increase in drug-related
of their offenses judicial cases, several approaches for treat-
(Ditton 1999). ing offenders who have a substance use
People in prison have a high incidence of disorder have been developed. IOT providers
HIV/AIDS (Maruschak 2002), tuberculosis, become involved in treating offenders when
sexually transmitted diseases, and hepatitis the offender is (1) referred to treatment in
C (National Institute of Justice 1999). lieu of incarceration, (2) incarcerated, or (3)
released.
Female offenders
Coercion frequently is used to compel
Between 1990 and 2000, the number of offenders to participate in treatment.
women involved with the justice system Coercion may be a sentence mandating treat-
(incarcerated, on probation, or paroled) ment or a prison policy mandating treatment
increased by 81 percent (Bloom et al. 2003). for inmates discovered to have a substance
Women accounted for 15 percent of the total use disorder while incarcerated for a non-
correctional population in 1998; 90 percent drug-related crime. For nonincarcerated
were under community supervision (Glaze offenders, a sanction for refusing to par-
2003; Harrison and Beck 2003). Seventy-two ticipate in treatment often is incarceration.
percent of the women in Federal prisons Research indicates that treatment adherence
were convicted of drug offenses or commit- and outcomes of clients legally referred to

154 Chapter 9
treatment were the same as or better than the community. IOT providers, work-
those of clients entering treatment of their ing closely with justice staff before indi-
own volition (Farabee et al. 1998; Marlowe et viduals are released, engage offenders in
al. 1996, 2003). treatment and support their continuing
recovery through flexible, individualized
approaches. TIP 30, Continuity of Offender
Working With the Judicial Treatment for Substance Use Disorders
System From Institution to Community (CSAT
IOT programs provide treatment for the fol- 1998b), provides more information on
lowing justice system clients: transition of prisoners to the community.
• Offenders who participate in treatment
• Offenders referred to treatment in lieu while incarcerated. IOT can be modi-
of incarceration. IOT providers have fied for use in prisons and jails, although
developed effective partnerships with drug this stretches the concept of outpatient
courts and Treatment Accountability for treatment. Institutions that can segregate
Safer Communities (TASC) programs to offenders in IOT from the rest of the incar-
provide treatment (Farabee et al. 1998). cerated population provide a more effec-
Drug courts, begun in 1989, divert nonvio- tive and supportive structure (U.S. House
lent offenders with substance use disorders Committee on the Judiciary 2000).
into treatment instead of incarceration.
Drug courts oversee the offender’s treat-
ment, coordinate justice and treatment Forging a Working
systems procedures, and monitor prog- Partnership
ress. TASC, formerly known as Treatment A major challenge to IOT providers is to
Alternatives to Street Crime, identifies integrate substance abuse treatment with
and assesses offenders involved with drugs justice system processes. Partnerships are
and refers them to community treatment being forged effectively as justice agencies
services. and treatment providers recognize that,
• Offenders discharged from residential although they have different perspectives,
substance abuse treatment who need they can work together. Both parties need to
continuing community-based treatment. be flexible and interact with clients on a case-
IOT programs provide stepdown, but struc- by-case basis (Farabee et al. 1998). Justice
tured, services and transitional services officials and IOT providers need to agree on
and links to other services for offend- which clients are appropriate for treatment
ers who are discharged from residential and establish clear screening and admission
treatment. criteria.
• Offenders who need treatment and are
placed under community supervision
(pretrial, probation, or parole). Many jus- Rules for Offenders in
tice programs have been developed to sup- Treatment
port this type of treatment for people who
are under the supervision of the justice Most justice system and IOT program part-
system but are allowed to remain in the ners agree that offenders in treatment must
community. not commit another offense, must abstain
• Offenders reentering the community from drug use, and must comply with treat-
after incarceration. Reentry manage- ment requirements. However, disagreements
ment programs funded by various Federal about additional rules may emerge. As a
agencies facilitate the transition and result, some policies and sanctions may
reintegration of prisoners released into work against the recovery they are designed
to achieve. IOT program staff members can

Adapting IOT for Specific Populations 155


help prevent or resolve such conflicts by dis- behavior meriting immediate discharge are
cussing these matters with judges and other needed.
criminal justice officials. Staff members • Uses of drug-testing results. The justice
who are familiar with research on treatment system regards drug-screening test results
outcomes are best suited to convey to others as an objective measure of progress or non-
a realistic, convincing argument for treat- adherence to treatment and can impose
ment and to foster cooperation that leads severe consequences for positive drug tests.
to client recovery. Developing and agreeing Many IOT programs use drug test results
on a process for resolving conflicts early in therapeutically, to inform treatment plans
the collaboration may reconcile discordant and to deter clients from using substances.
opinions. For the collaboration to function Both systems need to discuss how drug test
smoothly, IOT program staff needs the dis- results will be used.
cretion to make decisions about treatment,
such as whether the offender needs a dif-
ferent level of care. The justice system staff Communication Between
needs to be confident that it will be informed Systems
of treatment progress or if sanctions are Clear communication between the two sys-
justified. The partners must agree on the tems is essential. For all referrals from the
following: justice system (pretrial services, probation,
• Consequences for lapses in abstinence and parole), an IOT program should desig-
and continued drug use. When a client nate point-of-contact personnel. To ensure
admits to a single episode of drug use in a clients’ privacy rights, programs need to have
treatment session, the counselor may view confidentiality release forms that specify the
this as a positive development; this admis- information to be shared and the length of
sion of use may indicate that the client time the forms are in effect; all clients must
has gone beyond denial and begun to work sign these forms. These forms permit the two
on treatment issues. Justice system staff, agencies to communicate information about
however, may disagree and consider any the offender for monitoring purposes.
drug use grounds for incarceration. IOT IOT providers are advised to discuss and
staff members may agree to sanctions only agree on the following communication issues
when continued episodes of drug use indi- with their justice system partners:
cate that the offender is not committed to
treatment. • The form and timing of updates on treat-
• Consequences for use of alcohol. The ment progress from the treatment program
justice system considers alcohol a legal to the justice agency
substance and is concerned only with • Reportings of critical incidents, such as
illegal activity resulting from its use. when an offender threatens to commit a
Consequently, the justice agency may not crime or fails to appear for treatment
apply sanctions for continued alcohol use. • Reportings from the criminal justice agen-
In contrast, treatment providers consider cy, such as when an offender is rearrested
alcohol an addictive substance and usually or incarcerated
enforce no-use-of-alcohol rules. The topic
warrants extended conversation between
partners to develop reasonable responses Memorandum of
to alcohol use. Understanding
• Discharge criteria. Agreed-on discharge Once justice system and IOT program part-
criteria that define treatment goals, condi- ners agree on rules, consequences, and
tions indicating therapeutic discharge, and elements of communication, the agreement

156 Chapter 9
needs to be formalized in a written memo- Staff Training
randum of understanding (MOU). The
Treatment is impeded when counselors have
suggested elements of an MOU include
a negative attitude toward clients, believe
• Parameters of treatment, including the that clients have a poor prognosis for recov-
kinds of services ery, or are reluctant to serve offenders in
• Each partner’s responsibilities (e.g., the general. These issues should be included in
criminal justice agency refers and monitors staff training and cross-training.
clients; the treatment program assesses
To provide effective substance abuse treat-
and treats clients)
ment to criminal justice system clients, staffs
• The consequences for noncompliant
in both systems need cross-training (Farabee
behavior, recognizing that not every contin-
et al. 1999). Topics include the philosophy,
gency can be foreseen
approach, goals, objectives, and boundar-
• Identification of which agency deter-
ies of both systems. Treatment providers
mines the consequences of noncompliant
need information
behavior
about the responsi-
• The types, content, and timetable of com- For all referrals from
bilities, structure,
munications and reportings required
operations, and
between the partners the justice system...an
goals of the justice
• Definitions of critical incidents that
system; public
require the treatment program to notify
safety and security IOT program should
the justice agency
concerns; and how
involvement with designate point-of-
Clinical Issues and Services the justice system
affects offenders. contact personnel.
Although working with clients involved with Criminal justice
the criminal justice system is challenging, system person-
it can be rewarding. For example, approxi- nel need information about the dynamics
mately 60 percent of people involved with of substance use disorders, components
drug courts remained in treatment for at of treatment, how treatment can reduce
least a year, with a minimum 48-percent recidivism, confidentiality, and co-occurring
graduation rate (Belenko 1999). Clients psychiatric disorders.
involved with the justice system have unique
stressors, including, but not limited to, their
precarious legal situation. Clients may need
help with transportation, educational ser-
Women
vices, family issues, financial issues such In recent years, heightened awareness and
as obtaining welfare and Medicaid benefits new funding have encouraged the develop-
and arranging restitution payments, hous- ment of specialized programs to address the
ing such as arranging temporary shelter treatment needs of women. The number of
and permanent housing, and job skills and treatment facilities offering programs for
employment counseling. Case management pregnant and postpartum women rose from
can coordinate services for justice system 1,890 in 1995 to 2,761 in 2000, and more
clients. than 5,000 facilities offered special programs
for women (Substance Abuse and Mental
TIP 44, Substance Abuse Treatment for Health Services Administration 2002). The
Adults in the Criminal Justice System (CSAT forthcoming TIP Substance Abuse Treatment:
2005d), provides more information about Addressing the Specific Needs of Women
treating this population. (CSAT forthcoming b), TIP 25, Substance
Abuse Treatment and Domestic Violence

Adapting IOT for Specific Populations 157


(CSAT 1997b), and TIP 36, Substance Abuse affordable child care. They may fear losing
Treatment for Persons With Child Abuse and custody of their children because of their
Neglect Issues (CSAT 2000b), provide more substance use, and this fear may deter them
information. from entering treatment. At the same time,
women (and men) who abuse substances are
more likely to abuse or neglect their children
Description of the Population (National Clearinghouse on Child Abuse and
Even though women and men who have sub- Neglect Information 2003).
stance use disorders have many similarities,
they differ in some important ways. Women Welfare issues
typically begin using substances later and
enter treatment earlier in the course of their Some States require that individuals receiv-
illnesses than do men (Brady and Randall ing welfare benefits be screened and treated
1999). Other differences with therapeutic for substance use disorders; failure to enroll
implications are briefly surveyed below. in or dropping out of treatment may jeop-
Discussions of strategies for addressing ardize benefits (Legal Action Center 1999).
women-specific treatment issues follow. Such requirements can help retain a client in
an IOT program, and a case manager should
coordinate treatment with welfare staff.
Violence
Women with substance use disorders are Pregnancy
more likely than men with substance use
disorders to have been physically or sexually Substance use during pregnancy can mean
abused as children (Bartholomew et al. 2002; poor prenatal care, unregistered delivery,
Simpson and Miller 2002). In addition, and low-weight and premature babies
women who have a substance use disorder (Howell et al. 1999). Heavy or binge alcohol
are more likely to be victims of domestic vio- or drug use during pregnancy can result in
lence (Chermack et al. 2001), with reported negative consequences for the child such as
rates of women in treatment who have been neurological damage, including fetal alcohol
victims of physical and sexual violence rang- syndrome (American Academy of Pediatrics
ing from 75 percent (Oumiette et al. 2000) to 2000).
88 percent (B.A. Miller 1998).
Relationships
Mental disorders A woman’s substance use disorder is often
Compared with men, women with sub- influenced by her partner. Women with male
stance use disorders have nearly double the partners who use substances are retained
occurrence (30.3 percent vs. 15.7 percent) in treatment for a shorter time than women
of serious mental illness and past year sub- with substance-free partners (Tuten and
stance use disorders (Epstein et al. 2004). Jones 2003). Conversely, a woman’s partner
These higher rates of psychiatric comorbidity can have a positive influence on treat-
are particularly evident in mood and anxiety ment through support and participation in
disorders (Zilberman et al. 2003). treatment.

Parenting issues Implications for IOT


Women in treatment often bear the sole Effective treatment for women cannot occur
caretaking responsibility for their children, in isolation from the social, health, legal,
and this role can be a substantial obstacle to and other challenges facing female clients.
seeking and remaining in treatment. Women Some studies suggest that gender-specific
may have difficulty finding reliable and treatment may be advantageous for female

158 Chapter 9
clients (Grella et al. 1999), producing higher Using a comprehensive assessment, staff
success rates in women-only groups or pro- members can identify the client’s strengths
grams. However, research to date on the best and weaknesses and work with her to devel-
treatment for women is inconclusive (Blume op specific treatment goals and a treatment
1998). plan. Because
of the likelihood
of victimization A woman entering
Barriers to treatment entry
and presence of
and retention co-occurring psy- treatment needs
Once a woman decides to seek help, she may chiatric disorders,
face a long wait because of the lack of appro- female clients need to feel that the
priate treatment. In addition, she faces careful assessments
gender-specific barriers and issues that may for psychiatric environment is safe
affect entry and retention in treatment such as disorders and his-
tory of childhood and supportive.
• Concerns about fulfilling her responsibili- trauma and adult
ties as a mother, wife, or partner victimization.
• Fears of retribution from an abusive Chapter 5 discusses intake forms that can
spouse or partner be used or modified to gather these data.
• Gender and cultural insensitivity of some Victimization experiences may be hidden
treatment programs beneath shame and guilt but, as trust devel-
• Threat of legal sanction, such as loss of ops, the client can discuss these events.
child custody
• Lack of affordable or reliable child care
• The disproportionate societal intolerance Clinical Issues and Strategies
and stigma associated with substance Some women-specific programs are based
abuse in women compared with men on the philosophy that supporting and
• Ineligibility for treatment medications if empowering women improve treatment
she is pregnant or may become pregnant success. Some programs advocate using
• Having few other women in treatment predominantly female staff in professional
with her and support positions. Providing enhanced
services that respond to the social service
Entry and assessment needs of women is important for effective
A woman entering treatment needs to feel substance abuse treatment for women with
that the environment is safe and support- children (Marsh et al. 2000; Volpicelli et al.
ive. IOT program staff members who are 2000).
understanding, respectful, optimistic, and
nurturing can build a positive, therapeu- Treatment components
tic relationship. It may help if the intake specific to women
counselor is a woman. The client may be
fearful, confused, in withdrawal, or in Exhibit 9-1 identifies core clinical needs and
denial, and staff members need to be patient service elements that should be addressed in
and supportive, understanding that it is IOT for women (CSAT 1994d).
empowering for the client to choose when It is important to identify issues that the cli-
to provide information and what informa- ent is uncomfortable discussing in a group
tion to provide. Additional ways to facilitate setting. As a woman feels more comfortable,
entry include providing help with child care she may be able to discuss them. Relapse
and extending program hours for working prevention techniques may need to be modi-
women. fied for women. There is some evidence that

Adapting IOT for Specific Populations 159


Exhibit 9-1

Core Treatment Needs and Service Elements for Women

Core Treatment Needs Service Elements

Relationships with family and significant Provide family or couples counseling


others

Feelings of low self-esteem and self-efficacy Address in group and individual


counseling

Identify and build on the client’s strengths

History of physical, sexual, and emotional Avoid using harsh confrontational tech-
abuse niques that could retraumatize the client

Hold individual and group therapy ses-


sions or refer for treatment

Psychiatric disorders Refer for or provide evaluation and treat-


ment of psychiatric disorders, medication
management, and therapy

Parenting, child care, and child custody Hold parenting classes

Develop substance abuse prevention ser-


vices for children

Provide or arrange for licensed child care,


including a nursery for infants and young
children and afterschool programs for
older children

Assist with Head Start enrollment

Medical problems Refer for medical care, including repro-


ductive health, pregnancy testing, and
testing for or treating of infectious diseases

Gender discrimination and harassment Ensure that the program has policies
against harassment and that they are
enforced

women’s relapses are related to negative 1996). Also, women may do better in women-
mood, more so than men’s (Rubin et al. only counseling groups (Hodgins et al. 1997).

160 Chapter 9
Therapeutic styles Treatment for pregnant
Women who abuse substances may benefit women
more from supportive therapies than from Because of the possible harm to fetuses,
other approaches and need a treatment envi- it is important to provide comprehensive
ronment that is safe and nurturing (Cohen treatment services to pregnant women who
2000). Safety includes appropriate boundar- abuse substances. IOT has produced positive
ies between counselor and client, physical results for pregnant women, and retention in
and emotional safety, and a therapeutic treatment is facilitated by provision of sup-
relationship of respect, empathy, and com- port services such as child care, parenting
passion (Covington 2002). classes, and vocational training (Howell et
For women with low self-esteem and a al. 1999). Elements of one model program
history of abuse, harsh confrontational for pregnant women include (CSAT 1993a;
approaches may further diminish their Howell et al. 1999)
self-image and retraumatize them. Less • A family-centered approach with pregnan-
aggressive approaches based on understand- cy and parenting education and mother–
ing and trust are more likely to effect change child play groups
(Miller and Rollnick 2002). The confron- • Interdisciplinary staff
tational approach of “breaking down” a • Counselor continuity
person in treatment and rebuilding her as a • Physical and mental health services
recovering person may be overly harsh and • Child care and transportation services
not conducive to treating women (Covington • Housing services that address homeless-
1999). ness or unstable and unsafe housing
Woman clients can be referred to mutual- conditions
help groups such as Women for Sobriety Other programs have found that being
and 12-Step groups that are sensitive to the flexible and responsive to clients’ needs
needs of women. Some areas have women- and using nonconfrontational approaches
only Alcoholics Anonymous (AA) and improve the health of the women and new-
Narcotics Anonymous meetings, and some borns (Whiteside-Mansell et al. 1999).
groups provide onsite child care. A Woman’s
Way Through the Twelve Steps (Covington
1994) and its companion workbook can Staffing and Training
help women adapt the 12 Steps for their use Making a treatment program gender sensi-
(Covington 2000). tive requires changes in staffing, training,
and treatment approaches. Female program
Considerations for domestic staff and advisory board members may be
violence survivors more sensitive to the needs of female clients.
However, male clinicians can work effective-
IOT providers need to consider the safety ly with female clients.
of the client, develop and implement a per-
sonal safety plan for her, and notify the Training on issues and resources specific
proper authorities if she is in danger. TIP for women is necessary. Both female and
25, Substance Abuse Treatment and Domestic male staff members should be trained about
Violence (CSAT 1997b), provides additional the ramifications for treatment of sexual,
information. physical, and emotional abuse and partner
violence. Training should overcome the ten-
dency to blame the victim. Other training
needs may include assessment techniques
for violence or abuse, appropriate referrals

Adapting IOT for Specific Populations 161


to mental health professionals, coordinat- likely than people admitted with only sub-
ing services with other agencies, and food stance use disorders to be in the labor force.
programs that serve women and children. To They were more likely to be women, abuse
prevent sexual harassment of female clients, alcohol, and be referred through alcohol or
program rules should be explicit and strictly drug abuse treatment providers and other
enforced. Providers need to become familiar health care providers than people admitted
with the duty-to-warn requirement as it per- for substance abuse only (who were more
tains to reporting child abuse and neglect likely to be have been referred by the crimi-
and partner violence. nal justice system) (Office of Applied Studies
2003a).

Populations With Group characteristics


Co-Occurring When a client has co-occurring disorders,
Psychiatric Disorders both the client and IOT counselor are pre-
sented with many challenges, such as
In the field of substance abuse treatment,
people with both psychiatric and substance • Interacting symptoms that complicate
use disorders are said to have co-occurring treatment
mental disorders. • Increased biopsychosocial disruptions
such as increased family problems, violent
victimization, financial instability, home-
Description of the Population lessness, incarceration, suicidal ideation or
Many clients with co-occurring disorders are attempts, and medical problems
in IOT. The Drug Abuse Treatment Outcome
Study found that 39 percent of admissions Barriers to accessing
to substance abuse treatment met Diagnostic
and Statistical treatment
Manual of Most people with co-occurring mental and
Most people with Mental Disorders, substance use disorders are not receiving
Third Edition, appropriate care (Watkins et al. 2001). Two
co-occurring mental Revised (DSM- of the numerous barriers to treatment are
III-R) (American limited access to treatment and poor coordi-
and substance use Psychiatric nation between treatment systems.
Association 1987)
disorders are diagnostic criteria In addition, historically, substance abuse
for an antisocial and psychiatric treatments were provided in
personality disor- separate settings, and it was believed that
not receiving one disorder must be stabilized before the
der, 11.7 percent
met criteria for a other disorder could be treated, resulting
appropriate care. in fragmented services. Clients were caught
major depressive
episode, and 3.7 between two systems (Drake et al. 2001). The
percent met criteria for a general anxiety different treatment approaches led to mis-
disorder (Flynn et al. 1996). Other studies understandings between mental health and
support these findings (Compton et al. 2000; substance abuse treatment providers. Mental
Merikangas et al. 1998). health providers may use more motivational
and supportive techniques and profession-
According to the Treatment Episode Data ally trained staff, whereas substance abuse
Set, people admitted to treatment who had treatment programs use more confronta-
a co-occurring psychiatric disorder were less tional approaches, which may be distressing

162 Chapter 9
for clients with co-occurring disorders, and involvement with both professional- and
often combine peer support with profes- peer-led groups.
sionally trained counselors (Minkoff 1994). • Modify standard substance abuse treat-
Some substance abuse treatment providers ment by simplifying interventions, accom-
and recovering peers still may harbor anti- modating cognitive limitations if necessary,
medication attitudes and not understand the adapting step or group work, and using
benefit of psychotropic medications. mutual-help groups for people with co-
occurring psychiatric disorders.
• Develop interventions specific to each
Implications for IOT phase of treatment.
Although clients with co-occurring psychiatric • Provide comprehensive services that cover
disorders may be challenging, they benefit treatment of both disorders.
from treatment (Dixon et al. 1998). Treatment
has produced marked reductions in suicide In a review of the literature on treating
attempts, mental health visits, and reports of substance use disorders and co-occurring
depression (Karageorge 2002). Clients with schizophrenia, Drake and colleagues (1998b)
less serious mental disorders appear to do found that integrated treatment, especially
well in traditional substance abuse treatment when delivered for 18 months or longer,
settings (Sloan and Rowe 1998), and outpa- resulted in significant reduction in sub-
tient treatment can be an effective setting stance abuse and, in some cases, in
for treating substance use disorder in clients substantial rates of remission, reductions in
with less serious mental disorders (Flynn et hospitalizations, and improvements in other
al. 1996). Long-term approaches seem more outcomes. Many IOT programs do not treat
effective than short-term acute care (Bixler clients with serious mental disorders such as
and Emery 2000). Clients with psychotic con- schizophrenia on a regular basis and do not
ditions, however, might pose insurmountable have the advantages of the programs cited in
challenges for most IOT programs. Drake and colleagues’ review (e.g., intensive
case management, 18-month treatment win-
dow). Charney and colleagues had similar
Theoretical Background success treating clients with co-occurring
depression over a 6-month period (2001).
Integrated treatment Treatment retention and outcome improved
For the past two decades, integrated treat- when psychiatric services were provided at
ment has been proposed as an effective the substance abuse treatment facility.
treatment approach. Minkoff (1994) pres- Integrated treatment coordinates substance
ents a theoretical framework that considers use and mental disorder interventions to
both disorders chronic, primary, biologi- treat the whole client and
cally based mental illnesses that are likely
to be lifelong, but he suggests that conjoint • Recognizes the importance of ensuring
treatment could reduce symptoms of both that entry into one system provides access
disorders effectively and promote recovery. to all needed systems
His general treatment principles follow: • Emphasizes the association between the
treatment models for mental disorders and
• Recognize that the basic elements and pro- addiction
cesses of addiction treatment are the same • Advocates the concomitant treatment of
for clients who have a psychiatric disorder both disorders
as for those without one. • Follows a staged approach
• Include education, empathic confrontation
of denial, relapse prevention, and

Adapting IOT for Specific Populations 163


• Uses treatment strategies from both the more severe disorder—either mental or sub-
mental health and substance abuse treat- stance use disorder—often leaving them with
ment fields little or no care for the other disorder. These
clients may be referred to IOT programs, and
Conceptual framework care requires collaboration between mental
health and IOT providers. Clients in category
The National Association of State Mental IV generally need comprehensive, integrated
Health Program Directors and the National treatment (Substance Abuse and Mental
Association of State Alcohol and Drug Abuse Health Services Administration 2002).
Directors, with support from the Substance
Abuse and Mental Health Services
Administration (SAMHSA), developed a Clinical Issues and Strategies
conceptual framework of four quadrants to Modifications to clinical approaches and
classify service coordination and help pro- service elements to assist clients with men-
viders categorize treatment according to the tal disorders are essential. When financial
severity of symptoms of both disorders (see or other limitations require the provision
exhibit 9-2) (Substance Abuse and Mental of care in separate settings, treatment ser-
Health Services Administration 2002). vices need to be coordinated assertively and
Clients in category I often are identified in efficiently.
primary care, educational, or community set-
tings and may need consultation services for Core treatment needs and
prevention and early intervention services. service elements
Clients in categories II and III generally pres-
ent or are referred for treatment for their Screening. All clients need to be screened
for co-occurring psychiatric disorders to

Exhibit 9-2

SAMHSA’s Service Coordination Framework for Co-Occurring Disorders

high
severity
Category III Category IV

Mental disorders less severe Mental disorders more severe


Substance use disorders more severe Substance use disorders more severe
Substance Use

Locus of care Locus of care


Substance use system State hospitals, jails/prisons, emergency
rooms, etc.

Category I Category II

Mental disorders less severe Mental disorders more severe


Substance use disorders less severe Substance use disorders less severe
Locus of care Locus of care
Primary health care setting Mental health system
low high
severity severity
Mental Disorder

164 Chapter 9
determine whether they have signs and barriers when possible. Similarly, denial of
symptoms warranting a comprehensive access to evaluation or treatment for a sub-
psychological assessment. These signs and stance use disorder because an individual is
symptoms may be subtle, and clients may taking a prescribed psychotropic medication
minimize or deny symptoms because of fear is inappropriate. Clients should continue
of stigma. taking medication for a serious mental disor-
der while being treated for their substance
Assessment. A thorough assessment should use disorders (Minkoff 2002).
be performed either by a clinician trained in
both areas or by clinicians from each field. Treatment engagement. Some clients with
On occasion, symptoms of acute or chronic co-occurring psychiatric disorders, especially
alcohol and drug toxicity or withdrawal can severe disorders, may have difficulty commit-
mimic those of psychiatric disorders. The cli- ting to and staying in treatment. Providing
ent should be observed closely for worsening continuous support and outreach, assisting
conditions that warrant transfer to a more with immediate problems (such as housing),
appropriate facility or to determine whether monitoring individual needs, and helping
treatment for withdrawal symptoms is need- clients access services help develop a thera-
ed. Conversely, substance abuse can mask peutic treatment relationship. In the absence
psychiatric symptoms, which may appear of such support, clients with co-occurring
during the initial stages of abstinence. psychiatric disorders may be at high risk for
Programs should be organized around the dropping out (Drake and Mueser 2000).
premise that co-occurring disorders are com-
mon; assessment should proceed as soon as Treatment planning. Factors to consider
it is possible to distinguish the substance- when developing a treatment plan for these
induced symptoms from other independent clients include the client’s psychiatric status,
conditions. Particular attention should be housing, social support, income, medication
paid to the following: adherence, and symptom management. By
understanding the client’s strengths and
• Psychiatric history of the client and family goals, IOT program staff can develop a treat-
including diagnoses, previous treatment, ment plan that is consistent with the client’s
and hospitalizations needs. Regular reassessments monitor the
• Current symptoms and mental status client’s progress in both conditions and are
• Medications and medication adherence the basis for adjustments to the treatment
• Safety issues such as thoughts of suicide, plan. Increased individual sessions and
self-harm, or harming others smaller group sizes also are indicated.
• Severe psychiatric symptoms that result
in the inability to function, communicate Referral. Clients with psychiatric dis-
effectively, or care for oneself turbances that require secure inpatient
treatment setting, 24-hour medical monitor-
This information can be augmented by ing, or detoxification (such as clients who
objective measurement with assessment are actively suicidal or hallucinating) should
tools such as those described in the TIP 42, be referred to a facility equipped to provide
Substance Abuse Treatment for Persons With appropriate care. The American Society of
Co-Occurring Disorders (CSAT 2005e). Addiction Medicine provides placement cri-
teria for clients with co-occurring psychiatric
Many programs have rigid guidelines for the disorders (Mee-Lee et al. 2001).
initial mental health assessment and evalua-
tion, including the initial psychopharmacology
evaluation, such as requiring a certain Mental health care
length of abstinence. Programs should be Any IOT program that serves a significant
flexible about assessment, removing these number of clients with co-occurring psychiatric

Adapting IOT for Specific Populations 165


disorders should include mental health spe- • Use peers or peer groups to monitor medi-
cialists and psychiatric consultants on the cation and to support the client’s proper
treatment team. use of medication.
• Monitor side effects.
Prescribing psychiatrist. It is ideal to have
a psychiatrist with substance abuse treat- A helpful resource is Psychotherapeutic
ment expertise on site to provide assessment Medications 2003: What Every Counselor
and treatment services, on a full-time, part- Should Know (Mid-America Addiction
time, or consultant basis (Charney et al. Technology Transfer Center 2000).
2001). This approach overcomes problems
with offsite referral such as the client’s lack Collaboration with mental
of transportation and the difficulty of work-
ing with another agency. However, when health care agencies
funding or other constraints prohibit pro- If circumstances prevent the provision of
viding mental health care services on site, mental health care services in the IOT pro-
other options are (1) employing a master’s- gram, a collaborative relationship with a
level clinical specialist who can treat clients, mental health agency can be established.
consult with other staff members on mental One way to form this relationship is through
disorders, and function as the liaison with an MOU that ensures that psychiatric ser-
psychiatric consultants or (2) establishing a vices are adequate and comprehensive. The
working relationship with a mental health MOU specifies referral procedures, respon-
care agency to provide onsite care. sibilities of both parties, communication
channels, payment requirements, emergency
Medication provision and monitoring. contacts, and other necessary procedures.
Appropriate psychotropic medications are TIP 46, Substance Abuse: Administrative
essential. Pharmacological advances over Issues in Outpatient Treatment (CSAT 2006f),
the past decade have resulted in medications provides more information about setting up
with improved effectiveness and fewer side formal mechanisms for working with other
effects. Psychotropic medications stabilize agencies.
clients, control their symptoms, and improve
their functioning. The IOT program coun- Case management services provide assis-
selor can tance with service coordination when clients
with co-occurring disorders require treat-
• Refer the client to a psychiatrist or other ment in two or more systems of care. TIP
mental health care provider for treatment 27, Comprehensive Case Management for
evaluation. Substance Abuse Treatment (CSAT 1998a),
• Help arrange appointments with the men- provides extensive details about case
tal health care provider and encourage the management.
client to keep them.
• Become familiar with common psycho-
tropic medications, their indications, and Modified program structure
their side effects. Treating clients with co-occurring psychiatric
• Instruct the client on the importance of disorders in an IOT program often neces-
complying with the medication regimen. sitates modifying the program structure or
• Report symptoms and behavior to the approach.
prescribing psychiatrist and other staff
members to assist in the determination of Separate treatment tracks in IOT. Separate
medication needs. tracks for clients with both disorders allow
clients to be grouped together to address
issues pertinent to them in group sessions.
This arrangement particularly helps clients

166 Chapter 9
with severe co-occurring psychiatric dis- the client are (1) a skills-based approach, (2)
orders. Establishing a separate track may dual-recovery therapy, (3) assertive commu-
entail organizational change as the agency nity treatment, and (4) money-management
modifies its scheduling, staffing, and train- therapy (Ziedonis and D’Avanzo 1998).
ing needs.
The treatment of clients with substance use
Staged approaches. Staged approaches pro- and mood or anxiety disorders incorporates
vide successive interventions geared to the approaches such as cognitive–behavioral
client’s current stage of motivation and therapy, which addresses both disorders.
recovery and address varying levels of Several other components, such as relax-
severity and disability of the co-occurring ation training, stress management, and skills
disorders (Drake et al. 1998a; Minkoff 1989). training, are emphasized in the treatment of
The model developed by Osher and Kofoed both types of disorders (Petrakis et al. 2002).
(1989) includes four overlapping stages—
engagement, persuasion, active treatment, Some clients may have cognitive deficits that
and relapse prevention—that integrate treat- make it difficult for them to comprehend
ment principles from both fields. The model written material or
advocates treatment components consisting to comply with pro-
of low-intensity, highly structured programs; gram assignments. Pharmacological
case management services; provision of Materials can be
appropriate detoxification; toxicology screen- adapted to express
advances...
ing; family involvement; and participation in ideas and con-
mutual-help groups. Other staged approach- cepts simply and
concretely, incor- have resulted
es are described in Minkoff (1989) and
Prochaska and DiClemente (1992). porating stepped
assignments and in medications
using visual aids
Working with clients with to reinforce infor- with improved
co-occurring psychiatric mation. TIP 29,
disorders Substance Use effectiveness and
Disorder Treatment
When mental and substance use disorders for People
co-occur, both disorders require specific and fewer side effects.
With Physical
appropriately intensive primary treatment and Cognitive
and need to be individualized for each client Disabilities (CSAT 1998e), provides more
according to diagnosis, phase of treatment, information on accommodating clients with
level of functioning, and assessment of level disabilities.
of care based on acuteness, severity, medical
safety, motivation, and availability of recov-
ery support (Minkoff 2002). The therapeutic relationship
Establishing a trusting, therapeutic rela-
The treatment of clients with substance tionship is essential during the engagement
use and high-severity psychiatric disorders process and throughout treatment. TIP 42,
(schizophrenia or schizoaffective disorder) Substance Abuse Treatment for Persons With
differs from the treatment of clients who Co-Occurring Disorders (CSAT 2005e), sug-
have anxiety or mood disorders and a sub- gests the following guidelines for developing
stance use disorder. Clients with severe a therapeutic relationship with clients with
disorders often are the most difficult to treat. both disorders:
Examples of approaches that attempt to
integrate and modify psychiatric and sub- • Maintain a belief that recovery is possible.
stance abuse treatments to meet the needs of • Manage countertransference.

Adapting IOT for Specific Populations 167


• Monitor psychiatric symptoms. despairing because of the complexity of
• Provide additional structure and support. having two disorders and the slow pace of
• Use supportive and empathic counseling. improvement in symptoms and functioning.
• Use culturally appropriate methods. Inspiring hope is a necessary task of the IOT
program clinician. Some suggestions include
The clinician’s ease in establishing and
maintaining a therapeutic alliance is affect- • Demonstrating an understanding and
ed by comfort with the client. IOT program acceptance of the client
clinicians may find working with some • Helping the client clarify the nature of his
clients with psychiatric illnesses unsettling or her difficulties
or feel threatened by them and may have • Communicating to the client that the clini-
difficulty forming a therapeutic alliance cian will help the client help himself or
with them. Consultation with a supervisor herself
is important, and with experience, training, • Expressing empathy and a willingness to
supervision, and mentoring, the problem can listen to the client
be overcome. • Assisting the client in solving external
problems immediately
Confrontational approaches may be ineffec- • Fostering hope for positive change
tive for clients with co-occurring psychiatric
disorders because they may be unable to
tolerate stress- Group treatment
ful interpersonal Group treatment, a mainstay of IOT, is
Group treatment... challenges. When used widely and effectively with clients
counseling clients with co-occurring disorders (Weiss et al.
is used widely and with co-occurring 2000), including clients with schizophrenia
psychiatric disor- (Addington and el-Guebaly 1998). Several
effectively with ders, it is helpful approaches can be used: 12-Step based,
if the counselor is educational, supportive, and social skills
clients with co- empathic and firm improvement. These group interventions
at the same time. have demonstrated success in increasing
occurring disorders. By setting limits on treatment engagement and abstinence rates
negative behaviors, and decreasing the need for hospitaliza-
counselors pro- tion (Drake et al. 1998a). Some examples of
vide structure for clients. Another assertive groups follow:
intervention involves counselors’ supplying
feedback that consists of a straightforward • Psychoeducational groups increase cli-
and factual presentation of the client’s ents’ awareness of both problems in a safe
conflicting thoughts or problem behavior. and positive environment.
Provided in a caring manner, such feedback • Psychiatric disorders groups present top-
can be both “confrontive” and caring. The ics such as signs and symptoms of mental
ability to do this well is often critical in disorders, use of medications, and the
maintaining the therapeutic alliance with a effects of mental disorders on substance
client who has co-occurring psychiatric disor- use problems.
ders (see chapter 5 in TIP 42 [CSAT 2005e]). • Medication management groups provide
TIP 35, Enhancing Motivation for Change in a forum for clients to learn about medi-
Substance Abuse Treatment (CSAT 1999c, p. cation and its side effects and help the
41), provides more information. counselor develop solutions to compliance
problems.
Clients with co-occurring psychiatric dis- • Social skills training groups provide
orders may become demoralized and opportunities to learn how to handle

168 Chapter 9
common social situations by teaching cli- Mutual-help groups in the
ents to solicit support, develop drug and community
alcohol refusal skills, and develop effective
strategies to cope with pressures to discon- The consensus panel encourages the use
tinue their prescribed psychiatric medica- of “double trouble” mutual-help recovery
tion. Group participants role play situa- groups for people with co-occurring psychi-
tions and practice appropriate responses. atric disorders. Because all attendees have
Reinforcing the difference between sub- a co-occurring psychiatric disorder, they
stances of abuse and treatment medica- are less likely to be subject to the misunder-
tions is another simple but important standing and conflicting messages about
activity of these groups. their psychiatric symptoms or use of psycho-
• Onsite support groups are led by an IOT tropic medications that sometimes occur in
staff facilitator and provide an arena for traditional 12-Step-oriented groups (Magura
discussing problems and practicing new et al. 2003). These groups do not provide
coping skills. clinical or counseling interventions; mem-
bers help one another achieve and maintain
Group treatment may need to be modified recovery and be responsible for their per-
and augmented with individual counseling sonal recovery.
sessions for clients with both disorders. The
clients’ ability to participate in counseling Various dual recovery organizations have
depends on their level of functioning, stabil- been established by people in recovery and
ity of symptoms, response to medication, usually are based on the AA model but
and mental status. Some clients cannot toler- adapted for people with both disorders,
ate the emotional intensity of interpersonal including
interactions in group sessions or may have • Double Trouble in Recovery
difficulty focusing or participating. Many (www.doubletroubleinrecovery.org)
clients with a serious mental illness (schizo- • Dual Disorders Anonymous
phrenia, schizoid and paranoid personality) • Dual Recovery Anonymous
have difficulty participating in groups but (www.draonline.org)
can be incorporated gradually into a group • Dual Diagnosis Anonymous
setting at their own pace. Clients with less
severe psychiatric disorders may have little The research on traditional 12-Step groups
problem participating in group sessions. is not definitive, but attendance at such
Some suggestions for working with groups of groups may be beneficial for some clients
clients with co-occurring disorders include with co-occurring psychiatric disorders (Kelly
et al. 2003). However, clients with severe
• Orally communicate in a brief, simple, mental disorders may have difficulty attend-
concrete, and repetitive manner. ing these groups (Jordan et al. 2002). Some
• Affirm accomplishments instead of using people with co-occurring disorders attend
disapproval or sanctions. both dual disorder and traditional mutual-
• Address negative behavior rapidly in a help groups (Laudet et al. 2000b). In one
positive manner. study, most AA respondents had positive
• Be sensitive and responsive to needs of the attitudes toward people with co-occurring
client. disorders and 93 percent indicated that such
• Shorten sessions. individuals should continue taking their
• Organize smaller groups. psychotropic medications (Meissen et al.
• Use more focused, but gentle directional 1999). AA has published The A.A. Member—
techniques. Medications and Other Drugs (Alcoholics
Anonymous World Services 1991), a helpful
booklet that discusses AA members’ use of

Adapting IOT for Specific Populations 169


medications when prescribed by a physician be in need of intensive family therapy and
knowledgeable about alcoholism (visit www. should be referred for appropriate care.
alcoholics-anonymous.org to order).
Peer networks. Developing supportive
peer networks to replace friends who use
Relapse prevention substances is an important component
In addition to learning techniques to prevent of recovery and needs to be addressed in
relapse to substance abuse, clients with co- treatment. When a client’s family is not sup-
occurring psychiatric disorders may benefit portive, other, more supportive networks can
from learning to recognize worsening psychi- be sought.
atric symptoms, manage symptoms, or seek
support from a “buddy” or a mutual-help Discharge planning and
group. Some providers suggest that clients keep
“mood logs” to increase their awareness of continuing care
how they feel and the situational factors that Because people with co-occurring psychiatric
trigger negative feelings or symptoms. Other disorders have two chronic conditions, they
techniques include affect or emotion man- often require long-term care that supports
agement, including how to identify, contain, their progress and can respond quickly to a
and express feelings appropriately. Several relapse of either disorder. Some clients may
relapse prevention interventions for clients need to continue intensive mental health care
with both disorders have been developed but can manage their substance use disorder
(Evans and Sullivan 2000; Weiss et al. 2000). by participation in support groups. Other
clients may need minimal mental health care
Other issues but require some form of continued formal
substance abuse treatment. Participation in
Family education and support. Clients continuing care tends to improve treatment
with co-occurring disorders frequently have outcomes (Moggi et al. 1999).
unsatisfactory relationships with their fami-
lies. Some clients with psychiatric disorders
remain dependent on their families for an Cross-Training
extended period, creating complicated fam- Ideally, an interdisciplinary staff that pro-
ily dynamics. Other clients may be estranged vides both substance abuse treatment and
from or have strained relationships with psychiatric services works as an integrated
family members, partners, or children. unit, and providers have training and exper-
Groups for family members can be a venue tise in both fields. Cross-training about the
for education and support. Psychoeducation differing views of treatment and challenges
combines fundamental information, guid- helps staff members from both fields reach
ance, and support and allows for low-key a common perspective and approach for
engagement and continued assessment treating clients with co-occurring psychiatric
opportunities. Family members and sig- disorders.
nificant others need to understand the
implications of both disorders and the ways A helpful training resource is the Mid-
that one disorder, if not properly monitored America Addiction Technology Transfer
and treated, can worsen the symptoms of the Center’s A Collaborative Response:
other. Addressing the Needs of Consumers With
Co-Occurring Substance Use and Mental
At times more intensive family intervention Health Disorders, an eight-session curricu-
may require removing clients from stress- lum designed to promote a cross-disciplinary
ful family relationships and helping them understanding between mental and sub-
toward independence. Some families may stance use disorder clinicians (available at

170 Chapter 9
www.mattc.org). SAMHSA’s Strategies for include rapid growth, development of sec-
Developing Treatment Programs for People ondary sex characteristics, and fluctuations
With Co-Occurring Substance Abuse and in hormonal levels. Cognitively, adolescents
Mental Disorders (Substance Abuse and often have shorter
Mental Health Services Administration attention spans
2003) provides information on starting than adults, have IOT for adolescents
a program for treating people with both limited perspec-
disorders. tives on the future, should differ from
may be inconsis-
tent in applying that provided for
Adolescents abstract thinking
It is important to recognize that youth are skills, and may be adult populations.
not little adults, and IOT for adolescents impulsive. During
should differ from that provided for adult adolescence, mor-
populations (Deas et al. 2000). Adolescents als, values, and ideals continue to develop,
experience many developmental changes, and intellectual interests expand. During
may require habilitation rather than reha- late adolescence, youth become more intro-
bilitation, may be considered dependents spective and sensitive to the consequences of
legally, and may require parental consent for their actions (CSAT 1999f) and improve their
treatment. capacity for setting goals.

Treatment for adolescents requires a com- Development of substance


prehensive approach that addresses their
social, medical, and psychological needs. abuse in adolescents
The best candidates for adolescent IOT are Many factors are associated with the onset of
youth who are experiencing problems as a substance use problems in adolescents includ-
result of recent, moderate-to-heavy use of ing genetic background, parental substance
legal or illegal substances, who have func- use and troubled family relations, individual
tional but ineffective coping skills, and who characteristics such as cognitive dysfunction,
need a marginally structured setting, not and to some extent peer influence (Weinberg
complete removal from their living situation et al. 1998). Risk factors for developing a
(CSAT 1999f). substance use disorder include a history of
personality problems such as aggression or
TIP 31, Screening and Assessing Adolescents an affective disorder, school failure, distant
for Substance Use Disorders (CSAT 1999d), or hostile relations with parents or guardians,
and TIP 32, Treatment of Adolescents With family disruption, or a history of victimiza-
Substance Use Disorders (CSAT 1999f), tion (Weinberg et al. 1998).
provide additional information about screen-
ing and treating adolescents for substance
abuse. Implications for IOT
Adolescents reach IOT by a number of paths,
Description of the Population including parental request, school referral,
and juvenile justice system mandate. The
Developmental changes IOT provider must be prepared to meet
developmental, family, psychiatric, behav-
Adolescence is a period characterized by ioral, and other treatment challenges that
physical, emotional, and cognitive changes. may resemble those of adult clients only
Developmental tasks include the many superficially.
transformations that move adolescents from
childhood to adulthood. Physical changes

Adapting IOT for Specific Populations 171


Adolescents need thorough biopsychosocial, deficit/hyperactivity disorder (Weinberg et
medical, and psychological assessments al. 1998). Adolescents should be assessed for
and may need educational, medical, men- suicide risk as well.
tal health, and social services. Unlike adult
clients, adolescents are likely to be entering Diagnosis
treatment for the first time, may have little
knowledge of the treatment process, and Although some adolescents may meet the
need more orientation than adults. diagnostic criteria for substance dependence,
many are in the early stage of involvement
The assessment process involves a com- with alcohol or drugs. The Diagnostic and
prehensive evaluation of the adolescent’s Statistical Manual of Mental Disorders,
risks, needs, strengths, and motivation. Fourth Edition, Text Revision (American
Psychosocial assessment instruments Psychiatric Association 2000) does not con-
appropriate for adolescents should be tain diagnostic criteria specific to adolescent
used. Information to gather includes school substance dependence, and some adult
records, class schedule, and school involve- diagnostic criteria, such as withdrawal symp-
ment; relationships with peers; sexual toms and alcohol-related medical problems,
activity and pressures; relationship with present differently in adolescents. For these
family members; mental and physical health reasons, the DSM criteria have limitations
status; history of abuse and trauma; and when applied to adolescents (Martin and
involvement with the juvenile justice system. Winters 1998).

Family assessment Clinical Issues and Strategies


The adolescent’s family consists of the
main caregivers (usually parents) and any- Family involvement
one the client considers family. Family Because outpatient family therapy may offer
issues to assess include family structure benefits superior to other outpatient treat-
and functioning, financial and housing sta- ments (Williams et al. 2000), IOT providers
tuses, substance use history and treatment are encouraged to work with the family
episodes, mental and physical health, the as much as possible. Chapter 6 on family
family’s feelings about the adolescent, and therapy in this TIP and TIP 39, Substance
family members’ problems with violence Abuse Treatment and Family Therapy (CSAT
and involvement in the legal system. The 2004c), provide more information.
strengths and resources available to the
family need to be identified as well. IOT pro- Engaging the family. The IOT counselor can
gram staff members may want to interview engage family members by
the adolescent in private initially and then
meet with family members. • Emphasizing how critical family members
are to the adolescent’s recovery
• Requiring (whenever possible) that a fam-
Psychiatric assessment ily member accompany the adolescent to
Every client can benefit from a thorough psy- the initial intake interview and including
chiatric assessment by a mental health time for the family assessment during that
professional trained in adolescent care. As meeting
many as 60 percent of adolescents with a • Encouraging family attendance at the
substance use disorder also have co-occurring program’s family education and therapy
psychiatric disorders (Armstrong and sessions
Costello 2002), such as anxiety, mood disor-
ders (Kandel et al. 1999), or attention

172 Chapter 9
• Helping family members participate in sessions, and
developing and reinforcing the behavioral can be used with As many as 60
contract (see below) any standard
• Supporting family members in encourag- adolescent treat- percent of adolescents
ing the adolescent to attend treatment ment approach
(Hamilton et al.
Treatment of the family. Family-oriented with a substance use
2001).
interventions have long been used to • The family inter-
treat adolescents who abuse substances. vention program disorder also have co-
Szapocznik and colleagues (1983, 1986) (see exhibit
helped establish the effectiveness of family 9-3) addresses occurring psychiatric
therapy in treating adolescents. The premise many problems
of family therapy is that the family plays a experienced by disorders...
role in creating conditions leading to ado- families with an
lescent drug use and that family elements adolescent who
help adolescents recover (Liddle et al. 2001). uses substances. It includes the family
Evidence shows that youth who receive fam- and systems that affect the family, such as
ily therapy have less drug use at treatment schools and the community.
completion than those who receive peer
group therapy or whose families participate
in parent education or a multifamily inter- The behavioral contract
vention (Liddle et al. 2001). Adolescents who abuse substances may
behave in disruptive, destructive, or some-
Some family-based approaches are as follows: times criminal ways, such as skipping school,
• Multidimensional family therapy and having poor school performance, violat-
multisystemic therapy expand classic fam- ing curfew, being argumentative with or
ily therapy models to focus on promoting withdrawing from family members, joining
change in four areas: (1) the adolescent, (2) gangs, or committing crimes.
family members, (3) family interaction pat- To address these behaviors, a behavioral
terns, and (4) influences from outside the contract can be a valuable therapeutic tool.
family (Liddle 1999, 2002). The clinician works with the adolescent (and
• Family cognitive–behavioral therapy inte- his or her family) to develop a contract that
grates traditional family systems theory specifies treatment goals, acceptable and
with techniques of cognitive–behavioral unacceptable behaviors, and the rewards or
therapy. This approach considers adoles- consequences associated with each.
cent substance abuse as a conditioned
behavior that is reinforced by cues and The conditions defined in the contract help
contingencies within the family (Latimer et the youth and the family understand the
al. 2003). treatment process and what is expected of
• The adolescent community reinforcement them. Once the contract is completed, the
approach focuses on teaching adolescents client and each family member indicate
coping skills and changing environmental their agreement by signing the contract.
influences related to continued substance IOT program staff uses the contract to guide
use (Godley et al. 2001). discussions during family group sessions, to
• The family support network interven- monitor progress, and to minimize the under-
tion increases parental support of an mining of treatment by family members.
adolescent’s recovery through developing a
support group for parents, provides home
therapy sessions combined with group

Adapting IOT for Specific Populations 173


Exhibit 9-3

The Family Intervention Program

This approach partners a family therapist with a community resource specialist. The
specialist helps the family establish healthy community networks. Working as a team, the
therapist and specialist conduct five family therapy sessions and perform the following:

1. Assess the family system; explore the family’s resources, concerns, and goals; and
create a treatment plan.
2. Explore relationships among family members, identify areas of difficulty and stress,
and determine the effect on the family system.
3. Determine the effect of other systems, such as schools, on the family.
4. Focus on the family’s concerns and goals and include others who can help resolve
problems.
5. Work on how the family can resolve issues without staff help and develop a followup plan.

Source: Fishman and Andes 2001.

Case management services groups, perhaps because of the complexities


for adolescents just mentioned. The consensus panel reports
that, with this population, approaches
The IOT provider may need to provide exten- emphasizing structured discussions around
sive case management services. The case a topic introduced by the counselor are
manager works with schools to monitor a more successful than open-ended sessions.
youth’s compliance with the behavioral con- Same-gender groups can provide a safe
tract; coordinates medical, mental health, environment in which to explore such issues
and social services; and works with the juve- as sexuality, intimacy, self-esteem, and rela-
nile justice system, if needed. Caseloads are tionships. If programs do not have enough
best kept to about 8 to 10 adolescents per adolescent clients to have a treatment group,
staff member. a gender-specific group session can be held
weekly to discuss sensitive issues.
Group work strategies for
To foster productive group work, it is helpful
adolescents to enforce clear, specific, concrete rules. IOT
Treating adolescents involves bringing program staff can post the rules in the ses-
together youth from different areas, back- sion room and ask each participant to sign
grounds, and developmental levels. Many a copy. Rules should prohibit bullying and
practitioners recommend, if possible, that teasing. Groups also commonly prohibit nos-
the groups consist of adolescents of the same talgic stories of substance use.
gender, with similar levels of motivation for
change, and of similar age. Clients in middle- Group members frequently are asked to sign
to-late adolescence (ages 16 to 18) usually a confidentiality statement promising that
have different life experiences, developmen- information shared in the group will not be
tal levels, and concerns than do younger repeated outside group. Other suggestions
adolescents. There is limited evidence of for treating adolescents in groups are
the effectiveness of treating adolescents in

174 Chapter 9
• Including activities and keeping discus- • Be able to set firm behavioral limits in a
sions short nonjudgmental or nonpunitive manner.
• Varying session content, activity level, and • Know about the substances and combina-
purpose tions that adolescents use, the slang in use,
• Including frequent breaks and the physical and behavioral effects of
any new drugs.
CSAT’s Cannabis Youth Treatment Series • Have substantial knowledge of the school
offers many specific ideas for use with ado- system.
lescents (Godley et al. 2001; Hamilton et • Understand family dynamics.
al. 2001; Liddle 2002; Sampl and Kadden
2001; Webb et al. 2002). Core program staff members should include
a clinical coordinator who is trained in
A co-counselor is helpful in running groups adolescent treatment. Skills development
for adolescents because of the complexity of training for staff should occur regularly on
adolescent issues and behavior management topics appropriate for adolescent treatment.
challenges.

Clinical considerations Young Adults


Providing incentives acknowledges the efforts Some caregivers may find it difficult to rec-
of youth and encourages them to persevere. ognize or accept that young adults (ages 18
Incentives should be meaningful to the to 24) are no longer legal dependents. Even
youth, such as gift certificates from a music though a youth still may live at home or be
store, movie theater, or clothing store. in school, parental responsibility changes
and the young adult can make his or her
Other key points about treating adolescents own choices. Counselors may find that they
include the following: need to help both the young adult client
and parents realize that the client can make
• A cognitive–behavioral model and motiva-
choices and is responsible for actions. Some
tional enhancement techniques are useful.
young adult clients may be totally on their
• Not all adolescents who use substances are
own, with little family contact.
dependent, and prematurely diagnosing or
labeling adolescents or pressuring them to The use of alcohol or drugs at an early age
accept that they have an addictive disease may have delayed normal development.
may not work. Although these young clients are legally
• Many adolescents respond better to motiva- adults, they may not have grown into young
tional interviewing than to confrontation. adult social roles.
Exhibit 9-4 lists characteristics and behav- The young adult may be ready clinically for
iors of adolescents in treatment and placement in an adult treatment group or
practical treatment suggestions. may be placed more appropriately in an ado-
lescent program. A thorough assessment is
needed to determine appropriate placement.
Staff Training
IOT program staff members need to under-
stand adolescent development and treatment IOT Programming for
needs. Clinicians working with youth should Young Adults
• Be flexible and able to interact warmly To engage and retain these clients, IOT pro-
with adolescents. gramming can incorporate techniques used
• Observe clear and appropriate personal in adolescent programs. To involve young
boundaries. adult clients in treatment, it is important to

Adapting IOT for Specific Populations 175


Exhibit 9-4

Characteristics and Behaviors of


Adolescents and Treatment Suggestions

Characteristics and Behaviors Suggestions for Improving the Treatment


of Adolescents in Treatment Experience for Adolescents

Inconsistent ability for abstract Limit abstract, future-oriented activities


thinking
Use mentors

Avoid scare tactics and labels

Impulsive, often with short Design activities to teach self-control skills; allow
attention spans practice time

Need to belong and identify Create opportunities for group members to bond
with others; vulnerability to
peer influence Help clients establish positive peer groups and devel-
op skills in resisting negative peer pressure

Promote positive peer feedback in group

Frequent emotional Validate feelings


fluctuations
Acknowledge the pressures and stresses of
adolescence

Help youth improve stress management skills

Lack of involvement in healthy Help clients develop daily schedules


recreational activities
Help youth find new recreational activities not involv-
ing substance use such as games, sports, hobbies, and
religious or spiritual groups

Tendency toward pessimistic or Recognize fatalist attitudes such as “I’m going to die
fatalistic attitudes soon, anyway,” and “Drugs are the only way out for
me”

Validate clients’ anger, hopelessness, or perceived


obstacles to success, but challenge youth to think
positively

176 Chapter 9
reach out to them through family, colleges, unwilling to set limits, which fosters depen-
employers, and the court system. Treatment dence and intense attachment on the part
should be relevant to young adult concerns, of the clients. Parents need to understand
interests, and social activities and be flexible that their enabling behavior is a barrier to
enough to adapt to the client’s developmen- their young adult’s recovery. Young adult
tal deficits. The following issues are relevant: clients often require life skills develop-
ment. Treatment should focus on habilita-
• Education and employment. Educational tion, rather than rehabilitation.
and job skill levels need to be assessed and • Peer relationships. Some clients may
addressed. Some clients who have grown need assistance in developing and main-
up in poverty have witnessed the futility taining healthy peer networks and family
of working at a low-paying job versus the relationships.
financial benefits of selling illicit drugs. • Mentoring. A positive adult role model
These clients need special attention. provides a meaningful example.
• Family roles. Some clients may have chil- • Community service. Young adults in treat-
dren and family responsibilities and need ment can contribute to society and should
assistance in obtaining child care and be encouraged to participate in and volun-
developing parenting skills. teer for community or faith-based events.
• Separating from parents. Young adults
in treatment often have parents who are

Adapting IOT for Specific Populations 177


10 Addressing Diverse
Populations in
Intensive Outpatient
Treatment

Intensive outpatient treatment (IOT) programs increasingly are


called on to serve individuals with diverse backgrounds. Roughly
In This one-third of the U.S. population belongs to an ethnic or racial minor-
ity group. More than 11 percent of Americans, the highest percentage
Chapter... in history, are now foreign born (Schmidley 2003).
What It Means To Culture is important in substance abuse treatment because clients’
Be a Culturally experiences of culture precede and influence their clinical expe-
Competent rience. Treatment setting, coping styles, social supports, stigma
Clinician attached to substance use disorders, even whether an individual
seeks help—all are influenced by a client’s culture. Culture needs
Principles in to be understood as a broad concept that refers to a shared set of
Delivering beliefs, norms, and values among any group of people, whether
Culturally based on ethnicity or on a shared affiliation and identity.
Competent IOT
Services In this broad sense, substance abuse treatment professionals can be
said to have a shared culture, based on the Western worldview and
Issues of Special on the scientific method, with common beliefs about the relationships
Concern among the body, mind, and environment (Jezewski and Sotnik 2001).
Clinical Treating a client from outside the prevailing United States culture
Implications involves understanding the client’s culture and can entail mediating
of Culturally among U.S. culture, treatment culture, and the client’s culture.
Competent This chapter contains
Treatment
• An introduction to current research that supports the need for
Sketches of individualized treatment that is sensitive to the client’s culture
Diverse IOT Client • Principles in the delivery of culturally competent treatment services
Populations • Topics of special concern, including foreign-born clients, women
from other cultures, and religious considerations
• Clinical implications of culturally competent treatment
• Sketches of diverse client populations, including

– Hispanics/Latinos
– African-Americans
– Native Americans

179
– Asian Americans and Pacific Islanders • The gap between research and practice is
– Persons with HIV/AIDS worse for racial and ethnic minorities than
– Lesbian, gay, and bisexual (LGB) for the general public, with problems evi-
populations dent in both research and practice settings.
– Persons with physical and cognitive No ethnic-specific analyses have been done
disabilities in any controlled clinical trials aimed at
– Rural populations developing treatment guidelines.
– Homeless populations • In clinical practice settings, racial and eth-
– Older adults nic minorities are less likely than Whites to
receive the best evidence-based treatment.
• Resources on culturally competent treat- (It is worth noting, however, that given the
ment for various populations requirements established by funders and
managed care, clients at publicly funded
facilities are perhaps more likely than
What It Means To Be a those at many private treatment facilities
Culturally Competent to receive evidence-based care.)

Clinician Because verbal communication and the


It is agreed widely in the health care field therapeutic alliance are distinguishing fea-
that an individual’s culture is a criti- tures of treatment for both substance use
cal factor to be considered in treatment. and mental disorders, the issue of culture is
The Surgeon General’s report, Mental significant for treatment in both fields. The
Health: Culture, Race, and Ethnicity, states, therapeutic alliance should be informed by
“Substantive data from consumer and family the clinician’s understanding of the client’s
self-reports, ethnic match, and ethnic-specific cultural identity, social supports, self-esteem,
services outcome studies suggest that tailor- and reluctance about treatment resulting
ing services to the specific needs of these from social stigma. A common theme in cul-
[ethnic] groups will improve utilization and turally competent care is that the treatment
outcomes” (U.S. Department of Health and provider—not the person seeking treatment—
Human Services 2001, p. 36). The Diagnostic is responsible for ensuring that treatment is
and Statistical Manual of Mental Disorders, effective for diverse clients.
Fourth Edition (DSM-IV) (American Meeting the needs of diverse clients involves
Psychiatric Association 1994) calls on clini- two components: (1) understanding how to
cians to understand how their relationship work with persons from different cultures
with the client is affected by cultural differ- and (2) understanding the specific culture of
ences and sets up a framework for reviewing the person being served (Jezewski and Sotnik
the effects of culture on each client. 2001). In this respect, being a culturally
Mental Health: Culture, Race, and Ethnicity competent clinician differs little from being
is the first comprehensive report on the a responsible, caring clinician who looks
status of mental health treatment for minor- past first impressions and stereotypes, treats
ity groups in the United States. This report clients with respect, expresses genuine inter-
synthesizes research data from a variety of est in clients as individuals, keeps an open
disciplines and concludes that mind, asks questions of clients and other
providers, and is willing to learn.
• Disparities in mental health services exist
for racial and ethnic minorities. These This chapter cannot provide a thorough
groups face many barriers to availability, discussion of attributes of people from vari-
accessibility, and use of high-quality care. ous cultures and how to attune treatment
to those attributes. The information in this

180 Chapter 10
chapter provides a starting point for explor- it clearly is important for providers to have
ing these important issues in depth. More a genuine understanding of their clients
detailed information on these groups, plus from other cultures, as well as an awareness
discussions of substance abuse treatment of how personal or professional biases may
considerations, is found in the resources affect treatment.
listed in appendix 10-A (page 197). The fol-
lowing resources may be especially helpful Most IOT counselors are White and come
in understanding the broad concepts of cul- from the dominant Western culture, but
tural competence: nearly half of clients seeking treatment are
not White (Mulvey
• Mental Health: Culture, Race, and et al. 2003). This
Ethnicity (U.S. Department of Health and stark fact supports ...an individual’s
Human Services 2001) (www.mentalhealth. the argument that
org/cre/default.asp). Chapter 2 discusses clinicians consider culture is a
the ways in which culture influences men- treatment in the
tal disorders and mental health services. context of culture. critical factor to
Subsequent chapters explain the his- Counselors often
torical and sociocultural context in which feel that their own be considered in
treatment occurs for four major groups— social values are
African-Americans, American Indians the norm—that treatment.
and Alaska Natives, Asian Americans and their values are typ-
Pacific Islanders, and Hispanic/Latino ical of all cultures.
Americans. In fact, U.S. culture differs from most other
• Chapter 4 of TIP 46, Substance Abuse: cultures in a number of ways. IOT clinicians
Administrative Issues in Outpatient and program staff members can benefit from
Treatment (CSAT 2006f). This chapter learning about the major areas of difference
describes steps that an IOT administrator and from understanding the common ways
can take to prepare an IOT organization to in which clients from other cultures may dif-
treat diverse clients more competently and fer from the dominant U.S. culture.
sensitively. Chapter 4 also lists resources
not found in the appendix at the end of
this chapter. Treatment Principles
• The forthcoming TIP Improving Cultural Members of racial and ethnic groups are not
Competence in Substance Abuse Treatment uniform. Each group is highly heterogeneous
(CSAT forthcoming a) includes an inser- and includes a diverse mix of immigrants,
vice training guide. refugees, and multigenerational Americans
who have vastly different histories, languages,
spiritual practices, demographic patterns,
Principles in Delivering and cultures (U.S. Department of Health
Culturally Competent and Human Services 2001).

IOT Services For example, the cultural traits attributed


to Hispanics/Latinos are at best generaliza-
The Commonwealth Fund Minority Health tions that could lead to stereotyping and
Survey found that 23 percent of African- alienation of an individual client. Hispanics/
Americans and 15 percent of Latinos felt Latinos are not a homogeneous group. For
that they would have received better treat- example, distinct Hispanic/Latino cultural
ment if they were of another race. Only 6 groups—Cuban Americans, Puerto Rican
percent of Whites reported the same feelings Americans, Mexican Americans, and Central
(La Veist et al. 2000). Against this backdrop, and South Americans—do not think and act

Addressing Diverse Populations in IOT 181


alike on every issue. How recently immigra- including their education, socioeconomic sta-
tion occurred, the country of origin, current tus, and level of acculturation to U.S. society.
place of residence, upbringing, education,
religion, and income level shape the experi-
ences and outlook of every individual who Differences in Worldview
can be described as Hispanic/Latino. A first step in mediating among various
cultures in treatment is to understand the
Many people also have overlapping identi- Anglo-American culture of the United States.
ties, with ties to multiple cultural and social When compared with much of the rest of the
groups in addition world, this culture is materialistic and com-
to their racial or petitive and places great value on individual
Culture is only ethnic group. For achievement and on being oriented to the
example, a Chinese future. For many people in U.S. society, life
a starting point American also is fast paced, compartmentalized, and orga-
may be Catholic, nized around some combination of family
for exploring an older adult, and work, with spirituality and community
and a Californian. assuming less importance.
an individual’s This individual
may identify Some examples of this worldview that differ
perceptions, values, more closely with from that of other cultures include
other Catholics
than with other • Holistic worldview. Many cultures, such
and wishes. as Native-American and Asian cultures,
Chinese Americans.
Treatment provid- view the world in a holistic sense; that is,
ers need to be careful not to make facile they see all of nature, the animal world,
assumptions about clients’ culture and val- the spiritual world, and the heavens as
ues based on race or ethnicity. an intertwined whole. Becoming healthy
involves more than just the individual and
To avoid stereotyping, clinicians must his or her family; it entails reconnecting
remember that each client is an individual. with this larger universe.
Because culture is complex and not easily • Spirituality. Spiritual beliefs and ceremo-
reduced to a simple description or formula, nies often are central to clients from some
generalizing about a client’s culture is a cultural groups, including Hispanics/
paradoxical practice. An observation that Latinos and American Indians. This spiri-
is accurate and helpful when applied to a tuality should be recognized and consid-
large group of people may be misleading ered during treatment. In programs for
and harmful if applied to an individual. It Native Americans, for example, integrating
is hoped that the utility of offering broad spiritual customs and rituals may enhance
descriptions of cultural groups outweighs the the relevance and acceptability of services.
potential misunderstandings. When using • Community orientation. The Anglo-
the information in this chapter, counselors American culture assumes that treat-
need to find a balance between understand- ment focuses on the individual and the
ing clients in the context of their culture individual’s welfare. Many other cultures
and seeing clients as merely an extension of instead are oriented to the collective good
their culture. Culture is only a starting point of the group. For example, individual
for exploring an individual’s perceptions, identity may be tied to one’s forebears and
values, and wishes. How strongly individuals descendants, with their welfare considered
share the dominant values of their culture in making decisions. Asian-American and
varies and depends on numerous factors, Native-American clients may care more
about how the substance use disorder

182 Chapter 10
harms their family group than how they treatment. Cultures with this kind of rich
are affected as individuals. oral tradition and learning pattern include
• Extended families. The U.S. nuclear fam- Hispanics/Latinos, African-Americans,
ily consisting of parents and children is American Indians, and Pacific Islanders.
not what most other cultures mean by fam-
ily. For many groups, family often means Common issues affecting the counselor–
an extended family of relatives, including client relationship include the following:
even close family friends. IOT programs • Boundaries and authority issues. Clients
need a flexible definition of family, accept- from other cultures often perceive the
ing the family system as it is defined by the counselor as a person of authority. This
client. may lead to the client’s and counselor’s
• Communication styles. Cultural misun- having different ideas about how close the
derstandings and communication prob- counselor–client relationship should be.
lems between clients and clinicians may • Respect and dignity. For most cul-
prevent clients from minority groups from tures, particularly those that have been
using services and receiving appropri- oppressed, being treated with respect and
ate care (U.S. Department of Health and dignity is supremely important. The Anglo-
Human Services 2001). Understanding American culture tends to be informal in
manifest differences in culture, such as how people are addressed; treating others
clothing, lifestyle, and food, is not crucial in a friendly, informal way is considered
(with the exception of religious restrictions respectful. Anglo Americans generally pre-
on dress and diet) to treating clients. It fer casual, informal interactions even when
often is the invisible differences in expecta- newly acquainted. However, some other
tions, values, goals, and communication cultures view this informality as rudeness
styles that cause cultural differences to be and disrespect. For example, some people
misinterpreted as personal violations of feel disrespected at being addressed by
trust or respect. However, one cannot know their first names.
an individual’s communication style or • Attitudes toward help from counselors.
values based on that person’s group affili- There are wide differences across cultures
ation (see appendix 10-A for more infor- concerning whether people feel comfort-
mation and resources on cross-cultural able accepting help from professionals.
communication). Many cultures prefer to handle problems
• Multidimensional learning styles. The within the extended family. The clini-
Anglo-American culture emphasizes learn- cian and client also may harbor different
ing through reading and teaching. This assumptions about what a clinician is sup-
method sometimes is described as linear posed to do, how a client should act, and
learning that focuses on reasoned facts. what causes illness (U.S. Department of
Other cultures, especially those with an Health and Human Services 2001).
oral tradition, do not believe that written
information is more reliable, valid, and
substantial than oral information. Instead,
learning often comes through parables
Issues of Special
and stories that interweave emotion and Concern
narrative to communicate on several levels The IOT consensus panel recommends that
at once. The authority of the speaker may IOT programs look at the following areas of
be more important than that of the mes- special concern:
sage. Expressive, creative, and nonverbal
interventions that are characteristic of a • Whether the program is prepared to ade-
specific cultural group can be helpful in quately serve foreign-born clients living
within their catchment area

Addressing Diverse Populations in IOT 183


• Whether the special needs of their minor- Vietnam, Cambodia, and Laos met diagnos-
ity or foreign-born women clients are being tic criteria for PTSD, compared with about
addressed adequately 4 percent with a prevalence for PTSD in the
• Whether the program needs to make any U.S. population as a whole (U.S. Department
content adjustments out of respect for the of Health and Human Services 1999). For
religious orientation of current or potential this reason, treatment for foreign-born cli-
clients ents often needs to address both substance
use and the client’s background of abuse
and violence.
Foreign-Born Clients
In 2002, according to the U.S. Census Other clinical issues include the following:
Bureau, about 32.5 million U.S. residents • Mistrust of authority. Immigrants and ref-
were foreign born, of whom 52 percent ugees from many regions of the world feel
came from Latin America and 26 percent extreme mistrust of government based on
from Asia (Schmidley 2003). Eleven percent the atrocities committed in their countries
were born in another country and may be of origin or fear of deportation by U.S.
speaking or learning English as a second lan- authorities. This mistrust can be a barrier
guage. Migration is a stressful life event, and to entering treatment and to obtaining
immigrants are at risk for substance abuse services.
because of stress, isolation, and the lack of • Extreme sense of stigma. Clients from
social support they experience in adjusting other cultures view mental disorders,
to their new country. including substance abuse, much more
The reason for a person’s immigration is negatively than does the general U.S.
considered an important factor in the level population (U.S. Department of Health
of stress that immigrants experience as they and Human Services 1999). In some Asian
settle into a new life. Refugees typically have cultures, this stigma is so strong that a
been forced to abandon their countries and person’s substance dependence is thought
former lives, leaving their belongings behind, to reflect poorly on the family lineage,
to relocate to a different and sometimes diminishing the marriage and economic
unwelcoming new world in which language, prospects for the client and for other fam-
social structures, and community resources ily members.
may be totally unfamiliar (Jezewski and • Level of acculturation. Providers should
Sotnik 2001). This displacement can be par- take into account a client’s level of accul-
ticularly difficult for older refugees. turation in assessment and treatment.
Generally speaking, foreign-born persons
have rates of substance use lower than
Clinical considerations U.S.-born counterparts; the more accultur-
Having a personal history of abuse and ated the person is to the United States, the
trauma is recognized as a major factor in more that person’s use approaches U.S.
substance use disorders and in the inability substance-using norms. Among Hispanics/
to maintain recovery. A large percentage of Latinos, substance use disorders are less
Asian-American and Hispanic-American frequent in those who were born out-
immigrants show clinical evidence of post- side the United States (Turner and Gil
traumatic stress disorder (PTSD) as a result 2002). For example, foreign-born Cuban
of exposure to severe trauma, such as Americans have lower lifetime use of alco-
genocide, war, torture, or extreme threat of hol and start drinking later in life than do
death or serious injury (U.S. Department of U.S.-born Cuban Americans (Vega et al.
Health and Human Services 2001). In some 1993). However, being born in the United
samples, up to 70 percent of refugees from States does not mean necessarily that a

184 Chapter 10
person is acculturated. In a later study, also can have a phone message in the cli-
Vega and colleagues (1998) found that the ents’ native language, with calls returned
highest rates of substance abuse among by a counselor who speaks the language.
Hispanic/Latino adolescents were seen in • The important issues that immigrants
those who were born in the United States face need to be addressed as part of the
but had low acculturation levels. The treatment program. These issues include
researchers attributed these results to the cultural differences between the dominant
fact that these adolescents faced the lan- culture and their native culture, sense of
guage problems of foreign-born Hispanics/ displacement, lack of community, language
Latinos and the acculturation conflicts of problems, accessing social services, and
U.S.-born Hispanics/Latinos. finding employment.
• The clients’ cultural attitudes and values
Implications for IOT providers about substance use should shape program
content. Clients need to acquire an under-
IOT providers who want to reach out to standing of how their native cultural atti-
foreign-born clients in their community tudes differ from the values of U.S. society,
and serve them better should become more which involves understanding U.S. laws,
knowledgeable about the history and experi- social expectations, and way of life.
ences of the newcomers. One way to start • Using the terminology of the treatment
is by researching and reading about these field becomes a challenge because many
cultural groups. Providers also should get words are difficult to translate and the
to know newcomer populations by visiting meanings can vary according to the cul-
community refugee and immigrant orga- ture. Often, the counselor needs to trans-
nizations, such as their Mutual Assistance late both a word
Associations. Representatives of these asso- and its meaning
ciations can identify the need for substance in the English ...mistrust can be a
abuse treatment among their constituents, as language and
well as provide advice and suggestions about U.S. culture. barrier to entering
designing culturally specific services. For example,
Providers can consider setting up an IOT in Russian the treatment and to
group in the immigrants’ native language. concept of denial
For example, it has been found that lin- is positive. This obtaining services.
guistic Spanish-only groups are helpful for concept gener-
recently arrived Hispanic/Latino immi- ally translates
grants. One note on language: In addition to into Russian as “It is good to deny that you
native-language treatment groups, programs have a problem.” Likewise, “defenses” also
should provide services in English for those translates as a positive concept. The word
clients who want them. Many immigrants “defense” in Russian refers to a tool for
understand that not knowing English can be addressing rude or disrespectful behavior
a barrier, and they are motivated to improve from another person. In translation, these
their English-language skills. words carry the connotation of “To be
defended and in denial are good tools to
Some suggestions for programs that estab- handle one’s problems.”
lish language-specific groups include the • Immigrant clients may need many social
following: and educational support services that may
be difficult for the clients to access because
• A program catering to a language-specific of language and cultural barriers. Often
population needs to facilitate communica- clients are not familiar with the existence,
tion in that language. All documents in the range, and purpose of these needed
program should be adapted. The program

Addressing Diverse Populations in IOT 185


Cultural Issues in a Russian-Language IOT Program
The ChangePoint IOT Program for Russian immigrants in Portland, Oregon, usually has about
15 clients in treatment at a time. Clients are immigrants from all over Russia, and most are reli-
gious refugees. The newcomers generally stay in family groups that immigrate together, so these
clients have close family connections.

Clients learn about the social and legal expectations regarding substance use in the United
States. The group work focuses on the cultural attitudes that these Russian clients bring to their
substance use and treatment. Examples of differing U.S.–Russian cultural values that the pro-
gram helps clients understand include
• Acceptable levels of alcohol use. Alcohol use among Russian clients is higher than average for
the United States. In Russia, drinking enormous quantities of alcohol is tolerated provided the
person behaves appropriately.
• Legal expectations. Russians tend to view the law in a “black or white” context. In Russia,
there is zero tolerance for any blood alcohol level (BAL) when driving. When clients hear that a
BAL below 0.08 is legal in the United States, they think, “I can drink and drive as long as I’m
under 0.08 or as long as I’m careful.”
• Attitudes about money and treatment. Russian clients may assume that the program will
understand if they cannot pay their bills on time. Russian people expect that they will be paid
regularly, often lend money to family and friends, and feel a high level of trust that they will be
paid back. This translates into an expectation that the program also will trust them to pay their
bills at some time in the future.

supports, and some fear or are confused have the added barrier of being outsiders to
by the complexities of government proce- the culture.
dures; their access to these services may be
impeded by the documentation processes • View the woman’s behavior and treat-
that bureaucracies often require. IOT case ment goals in the context of her culture.
management can broker needed support Treatment needs to be sensitive to the
services. One model for doing this, called cultural mores and female roles in that
culture brokering, consists of conflict woman’s culture and to the client’s level
resolution and problemsolving strategies of acculturation. Some societies can be
designed to help two cultures communicate paternalistic and dominated by men, with
and cooperate. In the context of cultural women expected to play traditional roles
competence, the two cultures are repre- as wives and mothers. A woman client
sented by clients who are foreign born or may have values and attitudes that reflect
disabled and treatment providers. (See that culture. Her substance use disorder,
cirrie.buffalo.edu/cbrokering.html for more her attitudes about her addiction, and her
information.) perception of her recovery options occur
within that cultural framework. It is there-
fore important to understand the client’s
Women From Other Cultures level of comfort with what is expected in
Immigrant women face the same barriers treatment. Treatment goals should depend
to treatment that confront many Anglo- on the woman’s hopes and should conform
American women—restricted availability to the cultural role she wants for herself.
of child care, low income, unsupportive • Expect to work within complex, conflict-
spouses, lack of health insurance benefits, ing value systems. Women from male-
and lack of education and job skills—but dominated cultures often are raised to be

186 Chapter 10
gentle, passive, and selfless in serving their religions. Programs should address specifi-
husbands and families. Some counselors cally the following issues:
may want to push such women toward
independence and self-assertion but • Religious acceptance and tolerance
should be aware that these attributes may within the program. Local religious lead-
not be personally or culturally desirable ers can educate substance abuse treatment
for foreign-born female clients. providers about traditions and practices.
Providers, in turn, can educate religious
Often, treatment must be more inten- leaders about services that are available.
sive for poor immigrant women than for In the years immediately following the
immigrant women with more economic attacks of September 11, 2001, American
resources. Treatment programs that enhance Muslims experienced increased incidents
women’s economic autonomy through of bias, discrimination, overt hostility,
social and employment support are effec- abuse, and violence. Collaborating with
tive in reducing substance use (Gregoire local imams can help treatment providers
and Snively 2001). As with many women in and the religious community reach out
treatment, foreign-born women may need and aid people more effectively (Goodman
transportation to their medical and legal 2002). Intolerance by other clients in treat-
appointments, as well as to substance abuse ment should not be condoned and needs
treatment sessions. Other services should to be addressed. (For a brief introduction
include on responding to the mental health needs
of Arab Americans and American Muslims
• Domestic violence intervention. Staff in the wake of terrorism, see Goodman
members need to understand the factors in [2002].)
clients’ home life that interfere with recov- • Knowledge of religious customs.
ery, such as domestic violence or having a Providers need to understand and accom-
significant other who also uses substances. modate the religious customs of individual
• Multidisciplinary meetings with other clients. A culturally sensitive IOT program
caregivers. The IOT staff can organize should ask about clients’ dietary preferences,
multidisciplinary meetings for the client special holidays, and religious customs
that involve all referring agencies. Staff (e.g., daily prayers).
from the referring agencies should be • Preparing clients for mutual-help pro-
encouraged to attend and develop a plan grams. Non-Christian clients who are
to address any issues that may be interfer- referred to mutual-help programs for
ing with the client’s treatment. continuing care should be informed that
• Parenting classes. Parenting classes help meetings often incorporate elements of
women meet some of the stipulations Christianity. As an example, the Lord’s
required by State departments of child and Prayer, which comes from the Christian
family services. In addition, some child- Bible, frequently is selected for closing
rearing practices in other cultures may not Alcoholics Anonymous (AA) meetings.
be acceptable in American culture, and Because this is a Christian prayer, it poten-
classes offer the chance for women to learn tially is offensive to the religious point
more acceptable practices. of view of such groups as Jews, Muslims,
Hindus, and Buddhists. Jewish mutual-
Religious Orientation help meetings exist in many communi-
ties. The Web site of Jewish Alcoholics,
IOT providers need to ensure that their Chemically Dependent Persons and
program is welcoming to people from all reli- Significant Others at www.jacsweb.org pro-
gious faiths and that no treatment practices vides additional information. Many areas
are a barrier to those from non-Christian of the country have secular mutual-help

Addressing Diverse Populations in IOT 187


meetings. Providers should become famil- • Ensure that client materials are written at
iar with these meetings, so they can direct an appropriate reading level. People who
their non-Christian clients to them. are homeless and those for whom English
• Support from religious leaders. Clients is a second language may need materials
whose religious faith is central to their written at an elementary school reading
lives should be encouraged to seek help level.
from their religious leaders and from fel- • Include a strong outreach component.
low believers. People who are unfamiliar with U.S. cul-
ture may be unaware that substance abuse
treatment is available or how to access it.
Clinical Implications of • Hire counselors and administrators
and appoint board members from the
Culturally Competent