Clinical Issues in Intensive Outpatient Treatment PDF

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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 client care and treatment decisions. Numerous people contributed to the development 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 instruments, 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 treatment 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 agencies 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 recommendations 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 contents 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 outpatient 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 panelists 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 Consensus Panelists Clinical Director 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 reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians 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 treatment 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

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 treatment (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 expansion 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 population 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 approaches 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 common 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- Used in IOT ship. Balancing administrative tasks and 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 graduation 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, clinicians 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 volume, 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 represents 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 service, 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 consensus 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 treatment 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 adolescents, 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 IOT vs. IOP the IOT clinic for occasional followup visits, 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 Although IOT traditionally has consisted of ...mutual-help groups policy stating at least 9 hours of treatment per week, usu- that clients with ally delivered in three 3-hour sessions, some are an important 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 that mutual-help treatment, but they 6 hours per day, should be considered a par- groups should tial hospitalization program. But does such serve as adjuncts cannot substitute a program differ by kind or just by degree to a treatment plan from an IOT program? At what point does devised within the for substance abuse 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, transportation, adjunctive therapies, and parenting Summary of This TIP classes. 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, treatment. 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 grounded 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 competent 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. 2. Ease entry. Principle 8: Monitor Abstinence 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 7. Provide ongoing care. Medications if Indicated 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, 12. Engage families, employers, and significant others. 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 compromised (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 evidence 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 outpatient 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 interviewing 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 Principle 4: Enhance element (see CSAT 2006f). 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 outcomes. 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). therapeutic alliance and make changes in their behavior while 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 initiation 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 programs 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 Mutual-Help and chronic nature of substance use disorders. Other Community- Following their successful completion of 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 Integrating Into Mutual-Help from several therapeutic contacts per week 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 Principle 10: Use mutual-help groups, such as AA (www.alcoholics-anonymous.org) and Medications if Narcotics Anonymous (NA) (www.na.org), Indicated during treatment. IOT programs should 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 is a chronic illness who are seeking recovery. Other individuals had been averse to have benefited from support groups such as medications of any similar...to other Rational Recovery (www.rational.org), Smart 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 treatment 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 and Gordon 1985; Mercer and Woody 1999). Ideally, IOTs ents maintained on methadone. Clients should be provided with up-to-date 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 tion that clients might need to support and medication combined with nal- their recovery, programs are encouraged oxone (Fudala et al. to explore the use of videotapes, written 1998; Mendelson et management on site. 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 undermine 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 student 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 treatment 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 Focus on Financial, • Cognitive–behavioral therapy (Carroll 1998) • 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, settings, 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 treating 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- Continuum of Care ment services to achieve or maintain abstinence 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, whenever 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 programs 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 maintenance 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 prevention 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 management 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 continuing 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 programs. 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 studies 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 determine 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 physical 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 agreements 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 exercise (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 information 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 written 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 dosing 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 support abstinence, in limiting drink- programming. 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, diabetes, 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 remaining 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 treatment 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 understanding 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, monitoring, 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 counterparts in other agencies to find and access services for individual clients. • Informal partnership model. Staff members from several agencies link into collaborative 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 clients’ 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 indicated, can contact an IOT program staff member. • Oncall clinicians. A few large IOT programs that serve a particularly troubled population (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 meeting 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 psychological 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 developed during the 1980s as alternatives to the 12-Step model. These groups address recovery 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 themselves 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 themselves 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 addition 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 community 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 provided 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 product 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 symptomatic 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 positive 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 during 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 usually 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 schedule 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 conduct 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 daughter 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 problems” 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 disulfiram 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 chlordiazepoxide, 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 appropriate 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 counseling (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 participating 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 meetings 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 worsening 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 appointments 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 participating 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’ understanding 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 appreciation 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 participate 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 supervisory position at work. After 6 months of continuing care, Tom is discharged 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 person 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 violence, 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 space. result in no-shows or crises, and remove 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 transportation 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 fundamental 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 availability, 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 clients’ 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 Initial Response Procedures training staff in customer service skills.) 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 building 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 encourage 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 screening 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 decisions, 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 proof 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 who can be admitted safely. If medically asked about any 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 relationship? Is someone threatening you now or making you feel unsafe? The program Crises and should have arrangements with appropri- Emergencies ate shelters, domestic violence counselors, 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 Potential for Violence or information. 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 psychosis. 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 experiencing 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 recommendations, 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 problems 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 problem 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 environment 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 questionnaire 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, written 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 questions that can be self-rated on a 5-point Likert scale. A shorter 12-item version addresses 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 significant 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 • The general program philosophy, poli- around available clinician regarding ambulatory detoxi- cies, and services offered. Clients should be informed of the program’s treatment transportation. fication. TIP 45, Detoxification and philosophy, approach (e.g., individual 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 criteria). 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 comprehensive 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 childcare 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 perform 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 screening 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 outcomes 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 disulfiram (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 treating 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 current probation Families and has depended on this assistance. care goals and types To support her drug habit, Alice turned to officer has told her 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 treatment 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 situation 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 coming 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, consulting 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 assistance 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

† Signs Observed Frequency/ Duration of Duration Extended UseExtended Route/Mode Smell of alcohol, marijuana, or methamphetamine (production) Unusual speech pattern (slurred, rapid, incoherent) Unsteady gait of Daily Use Usual Amount Last Use Date/Time Tremors Nodding Sores/abscesses Use Current Use* Year Year of First of First Burns on inside of lips Incoherence Swollen hands or feet Appendix 5-A. Substance Use History Form Agitation Flushed face Scratching . f , 1994 a Drug Type Street Name Used Ever Needle track marks Burns or stains on fingers Dilated or constricted pupils Circle observed signs, if any, of currently used drugs: Client’s Name: Date: Interviewer: Date: Name: Client’s † Alcohol Cocaine Methamphetamine Stimulant Anxiolytic Heroin Methadone Other Opioid Sedative-Hypnotic Hallucinogen PCP Cannabis Inhalant Nicotine Other Note if just released from controlled environment. * Sources: CSAT 1994

84 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 dating 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 [email protected].) 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 obligations 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 likely 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 referrals 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 drug use • Client’s availability of health insurance 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 status financial solvency or indebtedness • 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 satisfaction 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 persons 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 incorporate 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 programs 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 expressing their emotions, achieving intimacy, and solving problems. They frequently may experience but may not express anger, shame, guilt,

93 sadness, and hopelessness. To function, Planning for Family families often subscribe to the following: 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 Increasingly, treat- the strength and include people who are important to the cli- ment professionals ent. These people can include a spouse, a view substance use duration of the boyfriend or girlfriend, a same-sex partner, disorders from a parents, siblings, children, extended family family systems per- client’s recovery. members, friends, co-workers, employers, spective (Crnkovic 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 technique 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 individuals 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 warning substances. ing signs. Family members who understand 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 interviews 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 family (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 program. 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 individuals 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 violence 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 providing 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, in IOT Alateen, Adult Children of Alcoholics (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. • Reaching many family members. begin to dispel any fallacies. The counselor 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- • Prepare the family members as well as able sources of help for many families. the client for the possibility of relapse. Family members should be encouraged to 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, independent 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:

Alcohol Heroin 2nd generation: W m (year)

3rd generation: W Cocaine

4th generation:

Symbols Useful for Genograms

Symbols Relationships

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

= 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 m 1978 many times 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 criminal 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 support 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 person 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 number 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 How How Long Known 1. < 1 yr. 2. 1-5 yrs. 3. > 5 yrs. How How more per week Often Seen Often 0. Does not see 1. Few times/yr. 2. Monthly 3. Weekly 4. Daily/twice or very close 1. Never 2. Sort of close 3. Very close of Help Closeness both ways Direction 1. Goes 2. You to them 3. They to you Client Critical of 1. Hardly ever 2. Sometimes 3. Almost always Infor- Advice mation/ 1. Hardly ever 2. Sometimes 3. Almost always Support Emotional Emotional 1. Hardly ever 2. Sometimes 3. Almost always Exhibit 6-3. Social Network Grid Used in Conjunction With Network Map Support Concrete Concrete 1. Hardly ever 2. Sometimes 3. Almost always Area of Life 1. Household 2. Other family 3. Work/School 4. Organizations 5. Other friends 6. Neighbors 7. Formal services 11 14 10 13 15 01 12 07 02 03 05 06 08 09 04 ID ______Respondent ______Name #

Family-Based Services 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 probe 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 alcoholism 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 professional 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 colleagues (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 retention problems, which include lack of transportation, language barriers, and shame over lapses to his previous drinking pattern.

116 Chapter 7 probation officers, ministers, employee Relapse and Continued assistance program counselors, friends, 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 dedication 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 opportunity 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 understanding 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 appropriate 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 Family Members involve clients in writing the contract, 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 Group Work Issues friend, spouse, or a boyfriend or girlfriend 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 Developing Group Cohesion who are using substances (see chapter 6). 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 clients 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 experienced 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 medications. 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 inhibit 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 comfortable 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 attendance 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 client 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 feelings 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 session. 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 psychiatrist 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 confirming 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 something 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 another 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 concerning 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 counselor 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 activities 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 members 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 balance 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 priorities 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 expectation 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 programs 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 evening 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 possible 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 confidentiality 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 supervisor 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 administered 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 versions 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- Approach cational efforts present alcoholism as a 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 compatible 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 Clients little difference in outcomes by type of treatment, 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 programs, 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 treatment 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. The Basics Exhibit 8-2 summarizes the strengths and 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 pregroup, 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 Approaches listening and skillful interviewing, the counselor 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 current 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 treatment 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 significant staff training, reorientation, and ongoing supervision. • Motivational approaches may be difficult to combine with disease- or therapeutic community-oriented approaches that expect adherence to program- imposed goals. • MI and MET were developed as individual 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 patterns 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, clients. 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 values 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; unemployment; 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 The Basics version began with 6 months of intensive 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 discussion 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, providing 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 Reinforcement People With Stimulant Use Disorders (CSAT 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 motivation to stop without too much cost or expenditure of staff with a client’s energy. The rewards and punishments must treatment goals using drugs… be tailored carefully to clients’ responses, as 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 accomplishments 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 incentives) 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 reducing 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 information 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 legislation, 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 percent 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 psychosocial, 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- IOT providers is to Offenders often are affected by the stigma 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 influence of alcohol or Implications for IOT system processes. drugs at the time 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 treatment, 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 management 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 different 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- bilities, structure, For all referrals from munications and reportings required operations, and between the partners goals of the justice the justice system...an • 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 Women help with transportation, educational services, 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 A woman entering Barriers to treatment entry of victimization 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 history 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 sessions or refer for treatment

Psychiatric disorders Refer for or provide evaluation and treatment of psychiatric disorders, medication management, and therapy

Parenting, child care, and child custody Hold parenting classes Develop substance abuse prevention services 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 personal 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 tendency 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 presented 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 not receiving personality disor- separate settings, and it was believed that der, 11.7 percent one disorder must be stabilized before the other disorder could be treated, resulting appropriate care. met criteria for a major depressive in fragmented services. Clients were caught 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 window). 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 settings and may need consultation services for Core treatment needs and prevention and early intervention services. service elements Clients in categories II and III generally present 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 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 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 Mental Disorder severity

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 disorder 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 common; 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 criteria for clients with co-occurring psychiatric Many programs have rigid guidelines for the disorders (Mee-Lee et al. 2001). initial mental health assessment and evaluation, 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 working 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 psychotropic 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 proof 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 concepts simply and mutual-help groups. Other staged approach- have resulted es are described in Minkoff (1989) and concretely, incor- 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 fewer side effects. co-occur, both disorders require specific and 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 recovery 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; members 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 families. 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 inconsistent 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 screening 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 disorders (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. with a substance use Treatment of the family. Family-oriented 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 adolescent program. A thorough assessment is Staff Training needed to determine appropriate placement. IOT program staff members need to understand 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 develop 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 involving 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 development. 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 minority 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 following 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 station 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 experiences 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- Culture is only to their racial or petitive and places great value on individual ethnic group. For achievement and on being oriented to the example, a Chinese a starting point future. For many people in U.S. society, life American also is fast paced, compartmentalized, and orga- may be Catholic, for exploring nized around some combination of family 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 • Holistic worldview. Many cultures, such and wishes. than with other Chinese Americans. as Native-American and Asian cultures, 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 family. 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, Issues of Special learning often comes through parables 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 religious 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 program 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 therefore 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 communities. 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. culture may be unaware that substance abuse treatment is available or how to access it. Clinical Implications of • Hire counselors and administrators Culturally Competent and appoint board members from the diverse populations that the program Treatment serves. Chapter 4 of TIP 46, Substance IOT programs should take the following Abuse: Administrative Issues in Outpatient steps to ensure culturally competent treat- Treatment (CSAT 2006f), provides more ment for their clients: information about recruiting and hiring diverse staff members. • Assess the program for policies and prac- • Incorporate elements from the culture of tices that might pose barriers to culturally the populations being served by the pro- competent treatment for diverse popula- gram (e.g., Native-American healing rituals tions. Removing these barriers could entail or Talking Circles). something as simple as rearranging furni- • Partner with agencies and groups that ture to accommodate clients in wheelchairs deliver community services to provide or as involved as hiring a counselor who enhanced IOT services, such as child care, is from the same cultural group as the transportation, medical screening and population the program serves. Chapter 4 services, parenting classes, English-as-a- of TIP 46, Substance Abuse: Administrative second-language classes, substance-free Issues in Outpatient Treatment (CSAT housing, and vocational assistance. These 2006f), provides more information about services may be necessary for some clients assessing program needs. to be able to stay in treatment. • Ensure that all program staff receive train- • Provide meals at the program facility. This ing about the meaning and benefits of cul- may bring some clients (e.g., those who are tural competence in general and about the elderly or homeless) into treatment and specific cultural beliefs and practices of cli- induce them to stay. ent populations that the program serves. • Make case management services available • Incorporate family and friends into treat- for clients who need them. ment to support the client. Although fam- • Emphasize structured programming, as ily involvement is often a good idea in opposed to open-ended discussion, in an IOT program, it may be particularly group therapy settings. effective given the importance of family in • Base treatment on clients’ strengths. many cultures. Some clients left families Experienced providers report that this and friends behind when they came to the approach works well with clients from United States. Helping these clients build many cultures and is the preferred support systems is critical. approach for clients struggling with self- • Provide program materials on audiotapes, esteem or empowerment. in Braille, or in clients’ first languages. All • Use a motivational framework for treat- materials should be sympathetic to the cul- ment, which seems to work well with cli- ture of clients being served. ents from many cultures. Basic principles

188 Chapter 10 of respect and collaboration are the basis education, economic status, and labor force of a motivational approach, and these participation. In 2002, the Hispanic/Latino qualities are valued by most cultures. population totaled 37.4 million, more than • Encourage clients to participate in mutual- 13 percent of the total U.S. population, help programs to support their recovery. and it is now Although the mutual-help movement’s the largest eth- roots are in White, Protestant, middle-class nic group in the All [program] American culture, data show that members Nation. Mexican of minorities benefit from mutual-help Americans are the materials should be programs to the same extent as do Whites largest subgroup, (Tonigan 2003). representing more sympathetic to the than two-thirds of all Hispanics/ culture of clients Sketches of Diverse Latinos in the IOT Client Populations United States (Ramirez and de la being served. The following demographic sketches focus Cruz 2003). on diverse clients who may be part of an IOT caseload. These descriptions character- Two-thirds of the Hispanic/Latino people ize entire groups (e.g., number of people, in the United States were born here. As a geographic distribution, rates of substance group, they are the most urbanized ethnic use) and include generalized cultural char- population in the country. Although pov- acteristics of interest to the clinician. This erty rates for Hispanics/Latinos are high type of cultural overview is only a starting compared with those of Whites, by the third point for understanding an individual. To generation virtually no difference in income serve adequately clients from the diverse exists between Hispanic/Latino and non- groups described here, IOT providers need to Hispanic/Latino workers who have the same get to know their clients and educate them- level of education (Bean et al. 2001). selves. Appendix 10-A (page 197) contains Celebrations and religious ceremonies are an annotated list of resources on cultural an important part of the culture, and use competence in general, as well as resources of alcohol is expected and accepted in these listed by population group. These resources celebrations and ceremonies. In the interest include free publications available from gov- of family cohesion and harmony, traditional ernment agencies—in particular the Center Hispanic/Latino families tend not to discuss for Substance Abuse Treatment and the or confront the alcohol problems of family Center for Substance Abuse Prevention—and members. Among Hispanics/Latinos with a describe population-specific treatment guide- perceived need for treatment of substance lines and strategies. use disorders, 23 percent reported the need was unmet—nearly twice the number of Hispanics/Latinos Whites who reported unmet need (Wells et al. 2001). Studies show that Hispanics/ Hispanics/Latinos include individuals Latinos with substance use disorders receive from North, Central, and South America, less care and often must delay treatment, as well as the Caribbean. Hispanic people relative to White Americans (Wells et al. can be of any race, with forebears who may 2001). De La Rosa and White’s (2001) review include American Indians, Spanish-speaking of the role social support systems play in Caucasians, and people from Africa. Great substance use found that family pride and disparities exist among these subgroups in parental involvement are more influential

Addressing Diverse Populations in IOT 189 among Hispanic/Latino youth than among Foreign-born Africans living in America White or African-American youth. The have had distinctly different experiences 2000 Substance Abuse and Mental Health from U.S.-born African-Americans. As one Services Administration’s (SAMHSA’s) demographer points out, “Foreign-born National Household Survey on Drug African-Americans and native-born African- Abuse (NHSDA) Americans are becoming as different from found that nearly each other as foreign-born and native-born ...only 20 percent of 40 percent of Whites in terms of culture, social status, Hispanics/Latinos aspirations and how they think of them- American Indians and reported alcohol selves” (Fears 2002, p. A8). Nearly 8 percent use. Five percent of of African-Americans are foreign born; many Alaska Natives live on Hispanics reported have grown up in countries with majority use of illicit sub- Black populations ruled by governments con- reservations or trust stances, with the sisting of mostly Black Africans. highest rate occurring among Puerto The 2000 NHSDA found that 34 percent lands... Ricans and the of African-Americans reported alcohol use, lowest rate among compared with 51 percent of Whites and 40 Cubans (Office of percent of Hispanics/Latinos. Only 9 percent Applied Studies 2001). Hispanics/Latinos of African-American youth reported alco- accounted for 9 percent of admissions to hol use, compared with at least 16 percent substance abuse treatment in 2000 (Office of of White, Hispanic/Latino, and Native- Applied Studies 2002). American youth (Office of Applied Studies 2001). Six percent of African-Americans Spanish-language treatment groups are help- reported use of illicit substances, compared ful for recently arrived Hispanic/Latino with 6 percent of Whites and 5 percent of immigrants. Programs in areas with a large Hispanics/Latinos (Office of Applied Studies population of foreign-born Hispanics/ 2001). African-Americans accounted for 24 Latinos should consider setting up such percent of admissions to substance abuse groups, using Spanish-speaking counselors. treatment in 2000 (Office of Applied Studies AA has Spanish-language meetings in many 2002). Among African-Americans with a per- parts of the country, especially in urban ceived need for substance abuse treatment, areas. 25 percent reported the need was unmet— more than twice the number of Whites who reported unmet need (Wells et al. 2001). African-Americans African-Americans make up 13 percent of the U.S. population and include 36 mil- Native Americans lion residents who identify themselves as The Bureau of Indian Affairs recognizes Black, more than half of whom live in a 562 different Native-American tribal enti- metropolitan area (McKinnon 2003). The ties. (The term “Native American” as it is African-American population is extremely used here encompasses American Indians diverse, coming from many different cultures and Alaska Natives.) Each tribe has unique in Africa, Bermuda, Canada, the Caribbean, customs, rituals, languages, beliefs about and South America. Most African-Americans creation, and ceremonial practices. On the share the experience of the U.S. history of 2000 census, about 2.5 million Americans slavery, institutionalized racism, and segre- listed themselves as Native Americans and gation (Brisbane 1998). 1.6 million Americans listed themselves as at least partly Native American, accounting for

190 Chapter 10 4.1 million people or 1.5 percent of the U.S. Asian Americans and Pacific population (Ogunwole 2002). Islanders Currently only 20 percent of American Asian Americans and Pacific Islanders Indians and Alaska Natives live on res- are the fastest growing minority group in ervations or trust lands, where they have the United States, making up more than 4 access to treatment from the Indian Health percent of the U.S. population and total- Service. More than half live in urban areas ing more than 12 million. They account for (Center for Substance Abuse Prevention more than one-quarter of the U.S. foreign- 2001). The 2000 NHSDA found that 35 per- born population. The vast majority live in cent of Native Americans reported alcohol metropolitan areas (Reeves and Bennett use. Thirteen percent of Native Americans 2003); more than half live in three States: reported use of illicit substances (Office of California, New York, and Hawaii (Mok et al. Applied Studies 2001). Among all youth ages 2003). Nearly 9 out of 10 Asian Americans 12 to 17, the use of illicit substances was either are foreign born or have at least one most prevalent among Native Americans—22 foreign-born parent (U.S. Census Bureau percent (Office of Applied Studies 2001). 2003). Asian Americans represent many Native Americans begin using substances distinct groups and have extremely diverse at higher rates and at a younger age than cultures, histories, and religions. any other group (U.S. Government Office of Technology Assessment 1994). Native Pacific Islanders are peoples indigenous to Americans accounted for 3 percent of admis- thousands of islands in the Pacific Ocean. sions to substance abuse treatment in 2000 Pacific Islanders number about 874,000 or (Office of Applied Studies 2002). More than 0.3 percent of the population. Fifty-eight three-quarters of all Native-American admis- percent of these individuals reside in Hawaii sions for substance use are due to alcohol. and California (Grieco 2001). Alcoholism, often intergenerational, is a seri- Grouping Asian Americans and Pacific ous problem among Native Americans (CSAT Islanders together can mask the social, cul- 1999b). One study found that rates for alco- tural, linguistic, and psychological variations hol dependence among Native Americans that exist among the many ethnic subgroups were higher than the U.S. average (Spicer et this category represents. Very little is known al. 2003) but not as high as often had been about interethnic differences in mental dis- reported. Thirty percent of men in cultur- orders, seeking help, and use of treatment ally distinct tribes from the Northern Plains services (U.S. Department of Health and and the Southwest were alcohol dependent, Human Services 2001). compared with the national average of 20 percent of men. Among the Northern Plains The 2000 NHSDA found that 28 percent community, 20 percent of women were alco- of Asian Americans and Pacific Islanders hol dependent, compared with the national reported alcohol use. Only 7 percent of average of 8.5 percent. Only 8.7 percent of adolescent Asian Americans and Pacific all women in the Southwest were found to be Islanders reported alcohol use, compared alcohol dependent. with at least 16 percent of White, Hispanic/ Latino, and Native-American youth (Office Among Native Americans, there is a move- of Applied Studies 2001). Three percent ment toward using Native healing traditions of Asian Americans and Pacific Islanders and healers for the treatment of substance reported use of illicit substances (Office of use disorders. Spiritually based healing is Applied Studies 2001). As a group Asian unique to each tribe or cultural group and is Americans and Pacific Islanders have the based on that culture’s traditional ceremo- lowest rate of illicit substance use, but nies and practices. significant intragroup differences exist.

Addressing Diverse Populations in IOT 191 Koreans (7 percent) and Japanese (5 percent) HIV/AIDS. However, these new treatment use illicit substances at much greater rates protocols require clients to take multiple than Chinese (1 percent) and Asian Indians medications on a complicated regimen. (2 percent) (Office of Applied Studies 2001). Clients with HIV often present with a cluster Asian Americans and Pacific Islanders of problems, including poverty, indigence, accounted for less than 1 percent of admis- homelessness, mental disorders, and other sions to substance abuse treatment in 2000 medical problems. (Office of Applied Studies 2002). Lesbian, Gay, and Bisexual Persons With HIV/AIDS Clients In the United States, more than 918,000 peo- LGB individuals come from all cultural ple are reported as having AIDS (Centers for backgrounds, ethnicities, racial groups, and Disease Control and Prevention 2004). HIV regions of the country. Cultural groups dif- is still largely a disease of men who have sex fer in how they view their LGB members. In with men and people who inject drugs; these Hispanic culture, matters of sexual orienta- groups together account for nearly four-fifths tion tend not to be discussed openly. LGB of all cases of HIV/AIDS (Centers for Disease members of minority groups often find them- Control and Prevention 2004). Minorities selves targets of discrimination within their have a much higher incidence of infection minority culture and of racism in the general than does the general population. Although culture. African-Americans make up only 13 percent of the U.S. population, they accounted for Because of inconsistent research methods 50 percent of new HIV infections in 2004 and instruments that do not ask about (Centers for Disease Control and Prevention sexual orientation, no reliable information is 2004). HIV is spreading most rapidly among available on the number of people who use women and adolescents. In 2000, females substances among LGB individuals (CSAT accounted for nearly half of new HIV cases 2001). Studies indicate, however, that LGB reported among 13- to 24-year-olds. Among individuals are more likely to use alcohol 13- to 19-year-olds, females accounted for and drugs, more likely to continue heavy more than 60 percent of new cases (Centers drinking into later life, and less likely to for Disease Control and Prevention 2002). abstain from using drugs than is the general HIV/AIDS is increasing rapidly among population. They also are more likely to have African-American and Hispanic/Latino used many drugs, including such drugs as women. Although they represent less than a Ecstasy, ketamine (“Special K”), amyl nitrite quarter of U.S. women, these groups account (“poppers”), and gamma hydroxybutyrate for more than four-fifths of the AIDS cases during raves and parties. These drugs affect reported among women; African-American judgment, which can increase risky sexual women account for 64 percent of this total behavior and may lead to HIV/AIDS or (Centers for Disease Control and Prevention hepatitis (Centers for Disease Control and 2004). Gay people who abuse substances Prevention 1995; Greenwood et al. 2001; also are at high risk because they are more Woody et al. 1999). likely to engage in risky sex after alcohol or drug use (Greenwood et al. 2001). Persons With Physical and The development of new medications—and Cognitive Disabilities combinations of medications—has had a significant effect on the length and qual- Nearly one-sixth of all Americans (53 mil- ity of life for many people who live with lion) have a disability that limits their

192 Chapter 10 functioning. More than 30 percent of those tan population with disabilities live below the poverty line increased 10.2 and generally spend a large proportion of percent from 1990 Treating substance use their incomes to meet their disability-related to 2000 (Perry and needs (LaPlante et al. 1996). Most people Mackun 2001). The disorders in persons with disabilities can and want to work. But economic base and those with skills tend to be underemployed ethnic diversity of with disabilities is an or unemployed. The combination of depres- these populations, sion, pain, vocational difficulties, and not just their isola- functional limitations places people with tion, are critical emerging field physical disabilities at increased risk of sub- factors. This popu- stance use disorders (Hubbard et al. 1996). lation includes of study. people of Anglo- Those with cognitive or physical disabilities European heritage are more likely than the general population in Appalachia and to have a substance use disorder but less in farming and ranching communities of the likely to receive effective treatment (Moore Midwest and West, Hispanic/Latino migrant and Li 1998). Many community-based treat- farm workers across the South, and Native ment programs do not currently meet the Americans on reservations. Federal requirements of the Americans with Disabilities Act. An IOT program is likely to Despite this diversity, rural communities have clients who present with a variety of from different parts of the country have com- disabilities. Experienced clinicians report monalities: low population density, limited that an appreciable number of individuals access to goods and services, and consid- with substance use disorders have unrecog- erable familiarity with other community nized learning disabilities that can impede members. People living in rural situations successful treatment. People who have the also share broad characteristics that affect same disability may have differing function- treatment. These characteristics are al capacities and limitations. • Overall higher resistance to seeking help Treating substance use disorders in per- because of pride in self-sufficiency sons with disabilities is an emerging field • Concerns about confidentiality and of study. Culture brokering is a treatment resistance to participating in group work approach that was developed to mediate because in small communities “everyone between the culture of a foreign-born person knows everyone else” and the health care culture of the United • A sense of strong individuality and pri- States. This model helps rehabilitation pro- vacy, sometimes coupled with difficulty in viders understand the role that culture plays expressing emotions in shaping the perception of disabilities • A culturally embedded suspicion of treat- and treatment (Jezewski and Sotnik 2001). ment for substance use and mental disor- Culture brokering is an extension of tech- ders, although this varies widely by area niques that IOT providers already practice, including assessment and problemsolving. Among adults older than age 25, the rate of alcohol use is lower in rural areas than in metropolitan areas. But rates of heavy alco- Rural Populations hol use among youth ages 12 to 17 in rural In 2000, nearly 20 percent of the U.S. areas are almost double those seen in met- population (55.4 million people) lived in ropolitan areas (Office of Applied Studies nonmetropolitan areas; the nonmetropoli- 2001). Women in rural areas have higher

Addressing Diverse Populations in IOT 193 rates of alcohol use and alcoholism than Approximately two-thirds of people who are women in metropolitan areas (American homeless report having had an alcohol, Psychological Association 1999). However, in drug, or mental disorder in the previous one study, urban residents received month (Urban Institute et al. 1999). Three- substance abuse treatment at more than quarters of people who are homeless and double the rate of their rural counterparts need substance abuse treatment do not (Metsch and McCoy 1999). Researchers receive it (Magura et al. 2000). For 50 per- attribute this disparity to the relative unavail- cent of people who are homeless and ability and unacceptability of substance abuse admitted to treatment, alcohol is the primary treatment in rural areas of the United States substance of abuse, followed by opioids (18 (Metsch and McCoy 1999). percent) and crack cocaine (17 percent) (Office of Applied Studies 2003b). Twenty- three percent of people who are homeless Homeless Populations and in treatment have co-occurring disor- Approximately 600,000 Americans are home- ders, compared with 20 percent who are not less on any given night. One census count homeless (Office of Applied Studies 2003b). of people who are homeless found about 41 People who are homeless are more than percent were White, 40 percent were African- three times as likely to receive detoxification American, 11 percent were Hispanic, and 8 services as people who are not homeless (45 percent were Native American. Compared percent vs. 14 percent) (Office of Applied with all U.S. adults, people who are home- Studies 2003b). less are disproportionately African-American and Native American (Urban Institute et al. In addition to the resources found in appen- 1999). Homeless populations include groups dix 10-A, the following clinical guidelines of people who are will assist providers in treating people who are homeless: • Transient. These individuals may stay temporarily with others or have a living • Clients who are homeless often drop out of pattern that involves rotating among a treatment early. Meeting survival needs of group of friends, relatives, and acquain- clients who are homeless is integral to suc- tances. These individuals are at high risk cessful outcomes. An IOT program needs of suddenly finding themselves on the to provide safe shelter, warmth, and food, street. For some, continued living in other in addition to the components of effective people’s residences may be contingent on treatment provided to other clients who providing sex or drugs. use substances, including extensive con- • Recently displaced. Some people may tinuing care (Milby et al. 1996). be employed but have been evicted from • Individuals who are homeless benefit their homes. Their housing instability may from intensive contact early in treatment. be related to financial problems resulting Clients who attend treatment an average of from substance use. 4.1 days per week are more successful than • Chronically homeless. These individuals those attending fewer days (Schumacher et may have severe substance use and mental al. 1995). disorders and are difficult to attract into • The Alcohol Dependence Scale, the traditional treatment settings. Reaching Alcohol Severity Index, and the personal these individuals requires the IOT pro- history form have been found to be reli- gram to bring its services to the homeless able and valid screening tools for this through a variety of creative outreach and population (Joyner et al. 1996). Reliability programming initiatives. is higher when items are factual and based on a recent time interval and when individuals are interviewed in a protected setting.

194 Chapter 10 • Case management must be available to individuals with substance use disorders also ease access to and coordinate the variety of are ashamed of the problem and rationalize services needed by clients who are home- the substance use or choose not to address it. less and abuse substances. Case manage- Diagnosing and treating substance use disor- ment should arrange for stable, safe, and ders are more complex in older adults than drug-free housing. The availability of in other populations because older people housing is a powerful influence on recov- have more—and more interconnected—physi- ery. Making such housing contingent on cal and mental health problems. Barriers to abstinence has been shown to be a useful effective treatment include lack of transpor- strategy (Milby et al. 1996). Case manage- tation, shrinking social support networks, ment also should coordinate medical care, and financial constraints. including psychiatric care, with vocational training and education to help individuals Oslin and colleagues (2002) find that older sustain a self-sufficient life. adults had greater attendance and lower • Providers should work with homeless incidence of relapse than younger adults in shelters to provide treatment services. treatment and conclude that older adults Strategies include (1) working with staff can be treated successfully in mixed-age members at shelters and with public hous- groups, provided that they receive age- ing authorities to find and arrange for appropriate individual treatment. When housing, (2) locating the IOT program with- treating older clients, IOT programs need in a homeless shelter or at least providing to be involved actively with the local net- core elements of IOT at the shelter, and (3) work of aging services, including home- and placing a substance abuse treatment spe- community-based long-term care providers. cialist at the shelter as a liaison with the Older individuals who do not see themselves IOT program. as abusers—particularly those who misuse over-the-counter or prescription drugs Older Adults or do not under- ...older adults ha[ve] The number of older adults needing treat- stand the problems ment for substance use disorders is expected caused by alcohol greater attendance to increase from 1.7 million in 2001 to 4.4 and drug interac- million by 2020. This increase is the result of tions—need to be and lower incidence a projected 50-percent increase in the num- reached through ber of older adults as well as a 70-percent wellness, health of relapse than increase in the rate of treatment need among promotion, social older adults (Gfroerer et al. 2003). America’s service, and other younger adults... aging cohort of baby boomers (people born settings that serve between 1946 and 1964) is expected to older adults. In place increasing demands on the substance addition, IOT programs can broaden the abuse treatment system in the coming years, multicultural resources available to them by requiring a shift in focus to address their working through the aging service network to special needs. This older generation will be link up with diverse language, cultural, and more ethnically and racially diverse and ethnic resources in the community. have higher substance use and dependence IOT programs that develop geriatric exper- rates than current older adults (Korper and tise can provide an essential service by Council 2002). making consultation available to staff As a group, older people tend to feel shame members at IOT programs that face similar about substance use and are reluctant to challenges, along with inservice training, seek out treatment. Many relatives of older coordination of interventions, and care

Addressing Diverse Populations in IOT 195 conferences designed to solve problems and interdisciplinary care (e.g., a support group develop care plans for individuals. There for family caregivers or a discussion group also may be opportunities to make this for participants at a social daycare or adult expertise available to caregivers and partici- day health center). pants in settings where older adults receive

196 Chapter 10 Appendix 10-A. Cultural Competence Resources

Many resources listed below are volumes in outreach to attract clients and involve the the TIP and Technical Assistance Publication community. This chapter also includes a list (TAP) Series published by CSAT. TIPs and of resources for assessment and training, in TAPs are free and can be ordered from addition to culture-specific resources. SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at www.ncadi. The forthcoming TIP Improving Cultural samhsa.gov or (800) 729-6686 (TDD, [800] Competence in Substance Abuse Treatment 487-4889). The full text of each TIP can be (CSAT forthcoming a)—This volume address- searched and downloaded from www.samhsa. es screening, assessment, and treatment gov/centers/csat2002/publications.html. planning; case management; counseling for specific cultural groups; and engaging and The Health Resources and Services retaining diverse clients in the context of cul- Administration lists cultural competence tural competence. assessment tools, resources, curricula, and Web-based trainings at www.hrsa.gov/ “Alcohol Use Among Special Populations” culturalcompetence. (National Institute on Alcohol Abuse and Alcoholism 1998)—This special issue of General the journal Alcohol Health & Research World (now called Alcohol Research & The Journal of Ethnicity in Substance Abuse— Health) includes articles on alcohol use This quarterly journal (formerly Drugs in Asian Americans and Pacific Islanders, and Society) explores culturally competent African-Americans, Alaska Natives, Native strategies in individual, group, and family Americans, and Hispanics/Latinos. Authors treatment of substance abuse. The journal also address such topics as alcohol availabil- also investigates the beliefs, attitudes, and ity and advertising in minority communities, values of people who abuse substances to special populations in AA, and alcohol understand the origins of substance abuse consumption in India, Mexico, and Nigeria. for different populations. Visit www. Visit pubs.niaaa.nih.gov/publications/arh22- haworthpress.com/web/JESA to find out 4/toc22-4.htm to download the articles. more. Mental Health: Culture, Race, and Ethnicity Cultural Issues in Substance Abuse Treatment (U.S. Department of Health and Human (CSAT 1999b)—This booklet contains Services 2001)—This publication describes population-specific discussions of treatment the disparities in mental health services for Hispanic Americans, African-Americans, that affect minorities, presents evidence of Asian Americans and Pacific Islanders, and the need to address those disparities, and American Indians and Alaska Natives, along documents promising strategies to eliminate with general guidelines on cultural compe- them. Visit www.mentalhealth.samhsa.gov/ tence. Order from SAMHSA’s NCADI. cre/default.asp to download a copy of this publication. Chapter 4, “Preparing a Program To Treat Diverse Clients,” in TIP 46, Substance Abuse: Cultural Competence Works: Using Cultural Administrative Issues in Outpatient Treatment Competence To Improve the Quality of Health (CSAT 2006f)—This chapter includes an Care for Diverse Populations and Add Value introduction to cultural competence and to Managed Care Arrangements (Health why it matters to treatment programs, as Resources and Services Administration well as information on assessing a diverse 2001)—This booklet bases its recommenda- population’s treatment needs and conducting tions for implementing cultural competence

Addressing Diverse Populations in IOT 197 on practices already in place in health care Bennett 1991)—This book focuses on aspects programs across the country. Along with its of American culture that are central to general discussions of culturally competent understanding how American society func- care, the publication includes descriptions of tions. The authors examine perceptions, the programs from which the recommenda- thought processes, language, and nonverbal tions are drawn and a list of resources. Visit behaviors and their effect on cross-cultural minority-health.pitt.edu/archive/00000278 to communication. download a copy of this publication. Promoting Cultural Diversity: Strategies for Counseling the Culturally Different: Theory Health Care Professionals (Kavanagh and and Practice, Third Edition (Sue and Sue Kennedy 1992)—This text discusses strategies 1999)—This book offers a conceptual frame- for learning about diversity and techniques work for counseling across cultural lines for communicating effectively with culturally and includes treatment recommendations diverse populations. Case studies are used to for specific cultural groups, with individual illustrate the practical applications of cross- chapters on counseling Hispanics/Latinos, cultural communication. African-Americans, Asian Americans, and Native Americans and special sections on women, gay and lesbian people, and persons Hispanics/Latinos who are elderly and disabled. Materials for clients Bridges to Recovery: Addiction, Family NCADI has publications and videotapes for Therapy, and Multicultural Treatment clients, parents, and employers available in (Krestan 2000)—This volume of essays Spanish. Visit www.ncadi.samhsa.gov. discusses substance abuse treatment for Native-American, African-American, West The National Institute on Drug Abuse Indian, Asian-American, Mexican-American, (NIDA) offers a number of publications in and Puerto Rican families. Spanish. Visit www.nida.nih.gov. The Cultural Context of Health, Illness, and Relapse prevention workbooks in Spanish Medicine (Loustaunau and Sobo 1997)—This can be purchased at www.tgorski.com. book, written by a sociologist and an anthro- pologist, examines the ways in which cultural The Hazelden Foundation offers a collection and social factors shape understandings of of Spanish fellowship books and videotapes health and medicine. Although its discus- approved by AA and Narcotics Anonymous. sions are not specific to substance abuse, Visit www.hazelden.org. they address the effect of social structures on health, differing conceptions of wellness, and Materials for counselors cross-cultural communication. CSAP Substance Abuse Resource Guide: Pocket Guide to Cultural Health Assessment, Hispanic/Latino Americans (Center for Third Edition (D’Avanzo and Geissler Substance Abuse Prevention 1996b; www. 2003)—This quick reference guide has indi- ncadi.samhsa.gov/govpubs/MS441/)—This vidual sections on 186 countries, each of resource guide provides information and which lists demographic information (e.g., referrals to help prevention specialists, edu- population, ethnic and religious descrip- cators, and community leaders better meet tions, languages spoken), political and social the needs of the Hispanic/Latino commu- information, and health care beliefs. nity. Order from SAMHSA’s NCADI. American Cultural Patterns: A Cross-Cultural Quality Health Services for Hispanics: The Perspective, Second Edition (Stewart and Cultural Competency Component (National

198 Chapter 10 Alliance for Hispanic Health 2000)—This book from the co-founder of the Institute on book includes sections on the culture, lan- Black Chemical Abuse explores the dynamics guage, and history of Hispanics/Latinos of race, culture, and class in treatment and in the United States, Hispanic/Latino examines substance abuse and recovery in health status, guidelines for education and the context of racial identity. outreach, recommendations for working cross-culturally, and case studies. Visit Cultural Competence for Health Care www.ask.hrsa.gov/detail.cfm?id=PC00029 to Professionals Working With African-American order this volume. Communities: Theory and Practice (Center for Substance Abuse Prevention 1998a)—This “Counseling Latino Alcohol and Other book provides tips for health care workers. Substance Users/Abusers: Cultural Order from SAMHSA’s NCADI or download Considerations for Counselors” (Gloria at www.hawaii.edu/hivandaids/links.htm. and Peregoy 1996)—This article discusses Hispanic/Latino cultural values as they Relapse Prevention Counseling for African relate to substance use and presents a sub- Americans: A Culturally Specific Model stance abuse counseling model for use with (Williams and Gorski 1997)—This book Hispanic/Latino clients. examines the way that cultural factors interact with relapse prevention efforts in “Drugs and Substances: Views From a African-Americans. Latino Community” (Hadjicostandi and Cheurprakobkit 2002)—The researchers Relapse Prevention Workbook for African explore perceptions and use of licit and illicit Americans: Hope and Healing for the Black substances in a Hispanic/Latino community. Substance Abuser (Williams and Gorski The primary concerns of the community are 1999)—This workbook leads readers through the increasing availability and use of sub- clinical exercises designed to help them stances among Hispanic/Latino youth. avoid relapse due to race-related issues. “Acculturation and Latino Adolescents’ “Drug Treatment Effectiveness: African- Substance Use: A Research Agenda for the American Culture in Recovery” (Bowser and Future” (De La Rosa 2002)—This article Bilal 2001)—This article endeavors to explain reviews literature on the effects of accultura- African-Americans’ high rates of substance tion to Western values on Hispanic/Latino abuse and low rates of recovery. Culture adolescents’ mental health and substance is seen as both a problem and a solution; use, discusses the role that acculturation- some African-American coping strategies act related stress plays in substance use, and as barriers, but successful treatment pro- suggests directions for treatment and further grams incorporate African-American cultural research. elements. “Cultural Adaptations of Alcoholics Anonymous To Serve Hispanic Populations” Native Americans (Hoffman 1994)—This article evaluates two specific adaptations to 12-Step fellowship: Materials for clients one adapts conceptions of machismo and the GONA (Gathering of Native Americans) is a other is less confrontational. community development and empowerment training process that uses Native-American trainers. A GONA curriculum provides African-Americans structure for Native-American community Chemical Dependency and the African gatherings and is available from SAMHSA. American: Counseling and Prevention Visit p2001.health.org/CTI05/Cti05ttl.htm. Strategies, Second Edition (Bell 2002)—This

Addressing Diverse Populations in IOT 199 A significant recovery movement for Substance Abuse Resource Guide: American Native-American people is the Red Road Indians and Native Alaskans (Center for to Recovery developed by Gene Thin Elk, a Substance Abuse Prevention 1998b)—A sub- Lakota elder. Many individuals, especially in stance abuse resource guide for American urban areas, have achieved and maintained Indians and Alaska Natives, including books, sobriety by following the Red Road. The Red articles, classroom materials, posters, and Road to Recovery addresses the cognitive, Web sites. Order from SAMHSA’s NCADI. affective, and experiential needs of Native Americans who are rebuilding their lives “Addiction and Recovery in Native America: from substance use and mental disorders Lost History, Enduring Lessons” (Coyhis and and presents a system of cultural values that White 2002)—This journal article provides promote an abstinent and balanced lifestyle. recommendations for treatment based on The following Web sites offer information on the history of addiction in Native-American GONA, the Red Road to Recovery, and other communities. Native-American recovery resources: Promising Practices and Strategies To Reduce • www.naigso-aa.org. This Web site of the Alcohol and Substance Abuse Among Native-American Indian General Service American Indians and Alaska Natives Office of Alcoholics Anonymous includes (American Indian Development Associates a link to information on Talking Circles. 2000)—This report collects descriptions of Talking Circles are common practice in successful substance abuse prevention efforts Native-American treatment settings. by Native-American groups. It also includes a • www.whitebison.org. This Web site literature review and list of Federal resources. offers information about the Wellbriety Visit www.ojp.usdoj.gov/americannative/ Movement (a Native-American recovery promise.pdf to download the report. movement that emphasizes health and “Morning Star Rising: Healing in Native abstinence), which includes information American Communities” (Nebelkof et al. about Wellbriety for youth, children of 2003)—This special issue of the Journal of people who abuse alcohol, and people in Psychoactive Drugs is devoted to healing prison. The site also includes a Talking in Native-American communities, with 13 Circle chat room, training information articles on various aspects of prevention and materials, and books, videotapes, and and treatment. Contact Haight-Ashbury audiotapes on recovery. Publications at (415) 565-1904. Materials for counselors Walking the Same Land—This videotape presents young Indians who are returning to Health Promotion and Substance Abuse traditional cultural ways to strengthen their Prevention Among American Indian and recovery from substance abuse. It includes Alaska Native Communities: Issues in aboriginal men from Australia and Mohawk Cultural Competence (Center for Substance men from New York. Order from SAMHSA’s Abuse Prevention 2001)—This volume frames NCADI. the development of substance abuse prevention and treatment efforts in the context of health disparities that have affected Native- Asian Americans and Pacific American and Alaskan-Native communities Islanders in rural and urban settings, as well as on reservations. Grounded in traditional healing Asian and Pacific Islander American Health practices, the volume examines innovative Forum (www.apiahf.org/resources/ approaches to substance abuse prevention. index.htm)— This site provides links to infor- Order from SAMHSA’s NCADI. mation and resources.

200 Chapter 10 Asian Community Mental Health Services Persons With HIV/AIDS (www.acmhs.org)—This site provides links to TIP 37, Substance Abuse Treatment for information and describes a substance abuse Persons With HIV/AIDS (CSAT 2000c)—This treatment program in Oakland, California. TIP discusses the medical aspects of HIV/ Substance Abuse Resource Guide: Asian AIDS (epidemiological data, assessment, and Pacific Islander Americans (Center for treatment, and prevention), the legal and Substance Abuse Prevention 1996a; ncadi. ethical implications of treatment, the samhsa.gov/govpubs/MS408)—This guide con- counseling of patients with HIV/AIDS, the tains resources appropriate for use in Asian integration of treatment and enhanced ser- and Pacific Islander communities. It also con- vices, and funding sources for programs. tains facts and figures about substance use and The Hawaii AIDS Education and Training prevention within this diverse group. Center has numerous resources available for Asian American Mental Health: Assessment download at www.hawaii.edu/hivandaids/ Theories and Methods (Kurasaki et al. links.htm. 2002)—This compendium of essays highlights conceptual, theoretical, methodological, and LGB Populations practice issues related to Asian-American mental health assessment. This text focuses The Web site of the National Association of on important questions about the cultur- Lesbian and Gay Addiction Professionals al nature of diagnostic and assessment is a clearinghouse for information and processes. resources, including treatment programs and mutual-help groups, organized by State. Visit Responding to Pacific Islanders: Culturally www.nalgap.org. Competent Perspectives for Substance Abuse Prevention (Center for Substance Abuse Substance Abuse Resource Guide: Lesbian, Prevention 1999)—This book examines the Gay, Bisexual, and Transgender Populations culture-specific factors that affect substance (Center for Substance Abuse Prevention abuse prevention in Pacific Islander commu- 2000)—This publication lists books, fact nities. Order from SAMHSA’s NCADI. sheets, magazines, newsletters, videos, posters, reports, Web sites, and organiza- “Communicating Appropriately With Asian tions that increase understanding of issues and Pacific Islander Audiences” (Center for important to lesbian, gay, bisexual, and Substance Abuse Prevention 1997)—This transgender clients. Download the resource Technical Assistance Bulletin discusses popu- guide from ncadi.samhsa.gov/referrals/ lation characteristics, lists cultural factors resguides.aspx?InvNum=MS489. related to substance use in nine distinct ethnic groups, and presents guidelines on A Provider’s Introduction to Substance Abuse developing effective prevention materials for Treatment for Lesbian, Gay, Bisexual, and these populations. Visit ncadi.samhsa.gov/ Transgender Individuals (CSAT 2001)—This govpubs/MS701 to download the bulletin. book addresses issues of interest to clinicians and administrators. It discusses treatment Opening Doors: Techniques for Talking With approaches for this population, ways to Southeast Asian Clients About Alcohol and improve services to LGB clients, steps for Other Drug Issues—This program is available starting LGB-sensitive programs, organiza- on videocassette in Vietnamese and Khmer tional missions, and strategies for building with English subtitles. Order from SAMHSA’s alliances to provide services. Order from NCADI, and visit store.health.org/catalog/ SAMHSA’s NCADI. productDetails.aspx?ProductID=15136 to view it on the Web.

Addressing Diverse Populations in IOT 201 Counseling Lesbian, Gay, Bisexual, and as well as a list of closed-caption videotapes, Transgender Substance Abusers: Dual AA books in American Sign Language on Identities, Second Edition (Finnegan and videotape, and easy-to-read literature, con- McNally 2002)—This guide examines dif- tact Alcoholics Anonymous General Service ferent counseling approaches and provides Office, P.O. Box 459, Grand Central Station, practical treatment suggestions for LGB pop- New York, NY 10163 or [email protected]. ulations. The book includes an organization audit of attitudes and practices, plus a list of Materials for counselors resources and other suggested readings. Coping With Substance Abuse After TBI—This Addiction and Recovery in Gay and Lesbian report answers basic questions about sub- Persons (Kus 1995)—This book examines the stance use and traumatic brain injury (TBI) incidence of substance use among gay and and includes recommendations from clients lesbian people and special concerns when with TBI who are now abstinent. Download treating this population, including HIV/ the publication at www.mssm.edu/ AIDS, homophobia, gay and lesbian mutual- tbicentral/resources/publications/ help groups, and special needs of rural gay tbi_consumer_reports.shtml. and lesbian clients. TIP 29, Substance Use Disorder Treatment Addictions in the Gay and Lesbian for People With Physical and Cognitive Community (Guss 2000)—This volume Disabilities (CSAT 1998e)—This volume includes personal experiences of substance discusses screening, treatment planning, use and recovery and research into the and counseling for clients with disabilities. sources of and treatment for substance use The book includes a compliance guide for disorders in gay and lesbian clients. The the Americans with Disabilities Act, a list book also includes techniques for assess- of appropriate terms to use when referring ing and treating LGB clients, including to people with disabilities, and screening adolescents. instruments for use with this population, including an Education and Health Survey and an Impairment and Functional Persons With Physical and Limitation Screen. Cognitive Disabilities TIP 27, Comprehensive Case Management for IOT programs should link with local groups Substance Abuse Treatment (CSAT 1998a)— that offer specialized housing, vocational This TIP discusses various models of case training, and other supports for people who management and provides information on are disabled. The Centers for Independent linking with service providers and evaluation. Living (CILs) are organizations run by and Chapter 5 explores the use of case manage- for persons with disabilities to provide ment services with special needs populations. mutual-help and advocacy. CILs and Client Assistance Programs were developed to pro- TIP 38, Integrating Substance Abuse vide a third party to broker the interaction Treatment and Vocational Services (CSAT between clients and the service system. The 2000a)—This volume examines the role that Special Olympics may be able to help locate employment plays in recovery from sub- recreational activities appropriate for indi- stance use disorders, with special attention vidual clients. to referral relationships and their capacity to expand the services available to clients and Materials for clients enhance the resources available to programs. For a catalog of AA literature available on Substance Abuse Resources and Disability audiocassettes, in Braille, and in large print, Issues Program at Wright State School

202 Chapter 10 of Medicine (www.med.wright.edu/citar/ Rural Populations sardi)—This Web site offers products for TAP 17, Treating Alcohol and Other Drug professionals and persons with disabilities, Abusers in Rural and Frontier Areas (CSAT including a training manual with an intro- 1995b)—The papers in this volume describe duction on substance abuse and the deaf providers’ experiences across a variety of culture, as well as a Web course on sub- treatment issues relevant to rural substance stance abuse and disability. abuse treatment, including domestic vio- National Center for the Dissemination of lence, enhanced service delivery, building Disability Research’s Guide to Substance coalitions and networks, and practical mea- Abuse and Disability Resources (www.ncddr. sures to improve treatment. org/du/products/saguide)—This Web site TAP 20, Bringing Excellence to Substance provides links to books, journal articles, Abuse Services in Rural and Frontier America newsletters, training manuals, audiotapes, (CSAT 1996)—The papers in this volume and videotapes on substance abuse and indi- examine innovative strategies and poli- viduals who are disabled. cies for treating substance use disorders in Minnesota Chemical Dependency Program rural and frontier America. Topics include for Deaf and Hard of Hearing Individuals rural gangs and crime, needs assessment (www.mncddeaf.org)—This Web site includes approaches, coalitions and partnerships, links to articles on substance abuse treat- and minorities and women in treatment. ment of individuals who are deaf and to Rural Substance Abuse: State of Knowledge manuals and videotapes for use in treatment. and Issues (Robertson et al. 1997)—This Co-Occurring and Other Functional Disorders NIDA Research Monograph examines rural Cluster Cultural Diversity Training Guide substance abuse from many perspectives, (www.med.wright.edu/citar/sardi/ looking at substance use among youth and at publications.html)—This guide recommends the health, economic, and social consequences topics and methods for initial staff training of substance use. The final section of the in cultural diversity for programs serving cli- book addresses ethnic and migrant popula- ents who are disabled and includes a list of tions, including rural Native Americans, references on multicultural counseling. African-Americans, and Mexican Americans. Visit www.nida.nih.gov/PDF/Monographs/ Ohio Valley Center for Brain Injury Monograph168/Download168.html to down- Prevention and Rehabilitation (www. load the monograph. ohiovalley.org/abuse)—This Web site includes guidelines for treating people with substance use disorders and traumatic brain Homeless Populations injury and links to other resources. National Resource Center on Homelessness and Mental Illness (www.nrchmi.samhsa.gov/ Center for International Rehabilitation pdfs/bibliographies/Cultural_Competence. Research and Information Exchange (cirrie. pdf)—This Web site has an annotated, online buffalo.edu/mseries.html)—This Web site bibliography of journal articles, resource includes downloadable versions of cultural guides, reports, and books that address cul- guides that describe the demographics and tural competence. Many resources discuss attitudes toward disability of 11 countries, substance use disorders. including countries in Asia, Central America, and the Caribbean. The site also includes “The Effectiveness of Social Interventions a booklet that describes culture brokering, for Homeless Substance Abusers” (American a practice in which counselors mediate Society of Addiction Medicine 1995)—This spe- between cultures to improve service delivery. cial issue of the Journal of Addictive Diseases

Addressing Diverse Populations in IOT 203 includes 11 articles that examine important abuse and offers guidance for screening, aspects of treating people who are homeless, assessing, and treating substance use disor- including retaining clients, residential versus ders in older adults. nonresidential treatment, enhanced services, treating mothers who are homeless, and cli- Substance Abuse Relapse Prevention for ents with co-occurring disorders. Older Adults: A Group Treatment Approach (CSAT 2005c)—This manual presents a The U.S. Department of Housing and Urban relapse prevention intervention that uses a Development has compiled a list of local cognitive–behavioral and self-management agencies by State and other resources to approach in a counselor-led group setting assist people who are homeless. Visit www. to help older adults overcome substance use hud.gov/homeless/index.cfm. disorders. Order from SAMHSA’s NCADI. The U.S. Department of Health and Human Substance Abuse by Older Adults: Estimates Services offers assistance and resources of the Future Impact on the Treatment for people who are homeless. For example, System (Korper and Council 2002)—This the Health Care for the Homeless Program report examines substance abuse treatment provides grants to community-based organi- services for older adults in the context of zations in urban and rural areas for projects increased demand in the future and calls aimed at improving access for the homeless for better documentation of substance abuse to primary health care, mental health care, among older adults and prevention and and substance abuse treatment. Visit aspe. treatment strategies that are tailored to sub- hhs.gov/homeless/index.shtml. groups of older adults, such as immigrants and racial and ethnic minorities. Download Substance Abuse Treatment: What Works for the report at www.drugabusestatistics. Homeless People? A Review of the Literature samhsa.gov/aging/toc.htm. (Zerger 2002)—This report links research on homelessness and substance abuse with Alcohol and Aging (Beresford and Gomberg clinical practice and examines various treat- 1995)—This book for clinicians covers top- ment modalities, types of interventions, ics such as diagnosis and treatment, mental and methods for engaging and retaining disorders, interactions of alcohol and pre- people who are homeless. Download the scription medications, and the biochemistry report from National Health Care for the of intoxication for older adults. Homeless Council’s Web site at www.nhchc. org/Publications/SubstanceAbuseTreatment Alcoholism and Aging: An Annotated LitReview.pdf. Bibliography and Review (Osgood et al. 1995)—This volume surveys 30 years of National Resource Center on Homelessness research on older adults who use alcohol, and Mental Illness (www.nrchmi.samhsa.gov)— providing abstracts of articles, books and This Web site lists trainings and workshops book chapters, and research studies on the (such as the National Training Conference on prevalence, effects, diagnosis, and treatment Homelessness for People With Mental Illness of alcohol use in older adults. and/or Substance Use Disorders), technical assistance, and fact sheets and other publica- Administration on Aging (www.aoa.gov/prof/ tions on homelessness. adddiv/adddiv.asp)—This Web site offers information on cultural competence, including resources on aging and ethnic minorities Older Adults and the booklet, Achieving Cultural TIP 26, Substance Abuse Among Older Adults Competence: A Guidebook for Providers (CSAT 1998d)—This volume discusses the of Services to Older Americans and Their relationship between aging and substance Families, which can be downloaded at www. aoa.gov/prof/adddiv/cultural/addiv_cult.asp.

204 Chapter 10 Appendix A— Bibliography

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236 Appendix A Appendix B— Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use

Urine testing is the best developed and most commonly used monitoring technique in substance abuse treatment programs. This appendix describes procedures for implementing this service and other methods for detecting clients’ substance use. The Substance Abuse and Mental Health Services Administration (SAMHSA) has a number of documents about drug testing available in the Workplace Resources section of its Web site, www.samhsa.gov.

Testing Schedule Urine specimens are collected • As part of the intake process to confirm a newly admitted client’s substance use history • As a routine part of therapy • To identify an intoxicated client or confirm abstinence Each intensive outpatient treatment (IOT) program should consider establishing a schedule for urine testing that takes into account Federal and State requirements (e.g., for methadone programs) and balances the therapeutic needs of the population being served with costs to the program or payer. Clients generally need more frequent monitoring during the initial stages of treatment when they are trying to achieve abstinence but still may be using substances. Routine specimen collection after admission should take place in conjunction with regular clinic visits. Under ideal conditions, the consensus panel believes that collection should occur not less than once a week or more frequently than every 3 days in the first weeks of treatment. It is important that the scheduled frequency of urine collection match the usual detection window for the primary drug. Too long an interval between urine tests can lead to unreliable results because most of the target drug and its metabolites will have been excreted. On the other hand, if the interval between tests is too short, a single incidence of drug use may

237 be detected twice in separate urine samples. Information about how to beat the drug test- Multiple positive urine test results produced ing system is widely available. Web sites by a single ingestion (carryover positives) can advertise inexpensive products that can be be discouraging for the client and mislead- added to urine specimens to absorb toxins as ing for the clinician (Preston et al. 1999). well as herbal remedies for consumption for a few hours before testing to cleanse the Once clients are stabilized in treatment, urine. Concentrated, “clean” specimens can they require less intensive monitoring of be purchased for mixing with warm water at abstinence. At this point, most programs the test site. A variety of low-cost, self-testing reduce the frequency of scheduled tests and kits also are available to preview likely randomize the collection times. Even with a results from more formal testing procedures. decreased and randomized testing schedule, specimen collection should be scheduled on As part of their orientation to the IOT pro- clinic days following weekends, holidays, or gram, clients need to be informed about paychecks—the times when clients are most the urine collection and testing proce- tempted to use. dures. Clients also should be advised that informed consent is necessary for release During IOT, monthly testing is standard of toxicology results to anyone other than in most programs. Random testing can be staff (see chapter 7 of TIP 46, Substance achieved by Abuse: Administrative Issues in Outpatient • Asking clients to produce specimens only Treatment [CSAT 2006f]). Most IOT pro- on random days grams do not comply with workplace • Requiring that all clients provide a speci- standards for testing or maintain an ade- men on every visit but analyzing only a quate chain-of-custody for specimens that randomly selected sample would meet court challenges. If employers, representatives of the criminal justice system, or children’s protection agencies feel Collection Procedures that such reporting is necessary, they can be advised to conduct their own testing or to and Policies accept other clinical evidence of client prog- Urine sample collection procedures need to ress in treatment. strike a balance between trusting clients and Clients should report any substance use ensuring that specimens are not contami- to their counselor before a urine sample is nated or falsified. Some programs insist that submitted so that the substance use can be a staff member of the same sex accompany a addressed therapeutically. It may be help- client into the bathroom to observe urine col- ful to remind clients that the clinic conducts lection. Others find that monitoring through drug monitoring to support their recovery. an open door and having clients leave pack- Because there may be some likelihood of ages and coats outside are sufficient. A sink cross-reactivity and false positive results that is separate from the toilet area also dis- on screening tests, clients need to keep courages attempts to dilute samples (Bureau counselors informed about any prescribed of Justice Assistance 1999). Many programs medications or over-the-counter (OTC) drugs use temperature strips to make certain that they have used. urine specimens are produced on site and are body temperature. Tests of creatinine Appropriate attention needs to be given to or specific gravity can determine whether a handling and storing collected specimens. sample has been diluted with water or the Collection bottles that are sent to an offsite client is consuming excessive fluids to lower laboratory should be clean and tamperproof. the concentration of drugs below detectable Waterproof labels attached to the bottles levels (Preston et al. 1999).

238 Appendix B should note either the client’s name or lites can be detected in urine samples identification number and be checked for depends on many interacting factors, accuracy by the client and the counselor or including technician. Collected specimens need to be kept cool—or refrigerated—until transmitted • Chemical properties (e.g., half-life) of the to the laboratory and should be stored in a selected drugs protected or locked room for security. Clients • Metabolism rates and excretion routes and staff members who touch the urine • Amount, administration route, frequency, collection bottles need to be reminded to and chronicity of the dose consumed wash their hands thoroughly. Rubber gloves • Sensitivity and specificity of the assay should be worn by technicians who perform • Individual variations in clients’ physical onsite analyses. health, exercise, diet, weight, gender, and fluid intake that affect excretion rates Most substances of abuse can be detected for Selection of Drug approximately 2 to 4 days (see exhibit B-1). Batteries and Testing However, the higher the dose taken and the more frequently the substance has been used Techniques over an extended time, the more likely that Programs need to test for a standard bat- it will be detected. Although substances are tery of drugs, which may include such drug excreted at various rates, they accumulate in groups as amphetamines, barbiturates, the body with continued use. Whereas a sin- benzodiazepines, cannabinoids, cocaine, gle use of cocaine may be detectable in urine methadone, methaqualone, opioids, phen- for only a day or less, continued daily use is cyclidine (PCP), propoxphene, or euphorics likely to be detectable for 2 to 3 days follow- (Ecstasy). In programs where the majority ing its discontinuation (Preston et al. 1999). of clients use only a few types of substances, Chronic use of such drugs as marijuana, the standard battery can be small, and only PCP, and benzodiazepines may be detectable selected individual clients need be tested for up to 30 days, whereas alcohol remains in for other specified substances. Programs the system for 24 hours or less. Realistically, should add substances to the routine battery, it may be difficult to detect illicit substances temporarily or permanently, if patterns of in most clients who stop all use for several substance use change in the target popula- days before a drug screen. An accurate pro- tion or in the community. It is helpful to file of a client’s substance use over more stay up to date about local drug use pat- than a few days requires both urine test terns identified by the nearest Community results and a good retrospective history. Epidemiology Work Group (www.nida.nih. gov/CEWG/CEWGHome.html) or the Single State Authority. For example, oxycodone Selecting an Appropriate (OxyContin®) has become a serious drug of Testing Technique abuse in particular locales. Fads come and A program should consider a variety of fac- go for abuse of a wide variety of substances tors in selecting a method and source for ® (e.g., Ecstasy, PCP, pentazocine [Talwin ], drug testing. None of the methods are inex- ® propoxyphene [Darvon ]). pensive, with costs ranging from less than $5 to more than $100 per assay for a particular Detection Limits for the drug. Turnaround time in receiving results is another important determinant. Whereas Substances Being Tested onsite methods can provide results in a mat- The length of time during which different ter of minutes, more accurate and expensive licit and illicit substances or their metabo- commercial laboratory analyses may take

Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 239 Exhibit B-1

Urine Toxicology Detection Periods for Different Substances

Substance Typical Urine Detection Period

Amphetamine or methamphetamine 2–4 days

Barbiturates Short-acting—Secobarbital 1–2 days Long-acting—Pentobarbital 2–4 days Phenobarbital 10–20 days

Benzodiazepines Therapeutic dose 3–7 days Chronic dosing Up to 30 days

Cocaine 1–3 days

Cannabinoids Casual use 1–3 days Daily use 5–10 days Chronic use Up to 30 days

Ethanol (alcohol) 12–24 hours

Opioids (e.g., codeine, morphine) 1–3 days

Methadone 2–4 days

Propoxyphene 6–48 hours

Ecstasy/euphorics 1–5 days

PCP Acute use 2–7 days Chronic use Up to 30 days

Copyright © 1999 by the American Psychological Association. Adapted with permission. No further reproduction or distribution is permitted without the written permission of the American Psychological Association (Preston et al. 1999, p. 286).

several days or longer. Reliability is a major for clinical purposes do not require the same consideration. However, substance abuse accuracy (i.e., workplace standards) as agen- treatment programs that are using results cies that make important, one-time decisions

240 Appendix B about such issues as employment, safety, • Confirmatory tests. These provide more eligibility for sports competitions, or proba- definitive information about the quantita- tion or parole violations. Some cities and tive concentrations (nanograms/milliliter) States have assumed responsibility for select- of specific drugs or their metabolites in ing a single vendor for providers under their urine specimens and are more accurate jurisdiction to use and choosing a standard than drug screens (have higher specific- battery of drugs to be tested. Providers may ity and sensitivity). They are much more wish to create a buying collective to negotiate expensive (up to $100 per assay), techni- the best discounts from a local drug-testing cally complex, labor intensive, and time laboratory. consuming—often taking days to complete. If the results of a drug test will be used as Two categories of urine tests are available: a basis for actions taken against an indi- • Screening tests. These detect only the pre- vidual (e.g., in a justice system context), sumptive presence or absence of a class of positive findings should be followed by a drugs in the urine specimen, return results confirmatory test of equal or greater sen- rapidly, are relatively inexpensive ($1 to sitivity and better specificity (Bureau of $5 per assay), can be set to detect low con- Justice Assistance 1999). Although results centrations of drugs (have high sensitivity), from these quantitative tests can be more and are relatively simple to perform. But useful than a simple positive or negative these screening tests—the ones most fre- for monitoring intermediate changes in quently used by substance abuse treatment drug consumption patterns, the concentra- programs—do not distinguish specific drug tion in urine might be the same for a small metabolites (only groups), provide only amount of a drug administered recently as qualitative results (yes or no), and may for a large amount of the drug consumed mistake other chemically similar medica- several days ago. In addition, concentrations, OTC preparations, or substances for tions can be affected by fluid consumption the target drug class (Preston et al. 1999). levels and may be misleading (Preston et This potential for cross-reactivity is of more al. 1999). concern in detecting amphetamines, benzodiazepines, and opioids than cocaine or The Meaning of Test Results marijuana. More specifically, the following cross-reactive results may occur: Urine test results can be inaccurate. Counselors should keep this fact in mind – Some cough suppressors in OTC when discussing findings with a client. preparations may be reported as a Asking the client whether results are accu- positive result for opioids. rate and, if so, when and how much of a – Phenylpropanolamine or ephedrine in particular substance was used can be the cold remedies can cause false positives beginning of a therapeutic discussion that for amphetamines. includes the circumstances surrounding sub- – Ibuprofen and other anti-inflammatories stance use and the client’s triggers. may be interpreted as positives for marijuana on the enzyme-multiplied In interpreting test results, clinicians should immunoassay technique (EMIT) test. know the following: – Amitriptyline (an antidepressant) can be • Positive results show a presumptive or con- mistaken for opioids. firmed presence of targeted substances at a – Some antibiotics may cause false detectable level. Positive results also mean positives for cocaine. that the amount of the substance detected – Diazepam has been mistaken for PCP. is above the cutoff point for labeling a specimen positive. (SAMHSA has

Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 241 established Federal guidelines for cut- • Fluorescent polarization immunoassay off levels; see workplace.samhsa.gov/ TDx™ is highly sensitive and highly specific. DrugTesting/RegGuidance/UrineConcen. • Radioimmunoassay (RIA) is a more sensi- htm.) Findings cannot determine when, tive test than the EMIT and is used exten- how much, or how a drug was adminis- sively by the military. tered or the degree of impairment the drug • Kinetic interaction of microparticles in produced (Bureau of Justice Assistance solution is a screening test used with most 1999). substances. • Negative results do not guarantee that the • Thin-layer chromatography (TLC) involves individual did not consume the substances the addition of a solvent to the specimen tested. Despite a client’s use of the tar- that causes the target drugs and metabo- geted substance, results could be negative lites to move up a porous strip, leaving col- because (1) most evidence may have been ored spots at different distances that can excreted or metabolized before testing took be compared with known standards. The place, (2) the specimen may have been results are reported as positive or nega- diluted or switched, (3) the client may have tive, without any quantitative information, consumed an excessive amount of fluids and require skill to interpret. Because TLC to dilute the urine, or (4) the test may not returns many false positives, it is no longer have been sufficiently sensitive (Bureau of used widely. Justice Assistance 1999). • False-positive results that mistakenly find Confirmatory urine testing methods include the presence of a substance can result from • Gas liquid chromatography laboratory errors (e.g., outdated reagents • High performance liquid chromatography and labeling mistakes), specimen tamper- • Gas chromatography/mass spectrometry ing, or cross-reactivity of an immunoassay (GC/MS) (the gold standard for drug detec- test with a substance of similar chemical tion, but costly at $25 to $100 a test) structure.

Urine-Testing Alternative Testing Techniques Methods Several other body products are gaining Most screening tests are immunoassays that prominence in the search for simpler, less take advantage of antigen-antibody inter- expensive, noninvasive, and more accurate actions—using enzymes, radioisotopes, or techniques for detecting the recent and cur- fluorescent compounds—and compare the rent use of substances. Exhibit B-2 compares specimen with a calibrated quantity of the the effectiveness of urine, breath, saliva, substance being tested (Bureau of Justice sweat, blood, and hair testing methodologies Assistance 1999). for detecting drugs. • EMIT test is the least expensive, most widely used, and simplest test to conduct. It often Breath-Testing Techniques is used on site at a cost of about $5 per screen. It also has the poorest performance Because alcohol is metabolized rapidly at record, returning up to 30 percent false an average rate of 15 to 25 milligrams per positives. Although EMIT can be used to hour—and the detection period is hours, not test for a wide variety of drugs and alco- days—drinking usually is not monitored by hol, some sources report that as many as urine or blood tests. Instead, clinicians fre- 300 OTC preparations cause false-positive quently rely on other observations of current readings. use (e.g., an odor of alcohol, slurred speech)

242 Appendix B Exhibit B-2

Effectiveness of Drug Detection Methods That Use Different Biological Products

Drug Body Major Major Detection Primary Use Product Advantages Limitations Time

Urine 2–4 days Mature technique; Detects only Monitors recent established cutoffs recent use; needs drug use in many for detecting many costly confirma- populations drugs of abuse tion to be accurate

Breath 12–24 Easy to use; read- Short detection Confirms (alcohol) hours ily available and time observed well-established intoxication or method impairment

Saliva 12–24 Easy to obtain Very short detec- Links positive hours samples; good tion time; new drug test to behav- correlation with method; oral cavi- ioral impairment blood levels for ty is contaminated and intoxication some substances easily

Sweat 1–4 weeks Cumulative mea- High potential for Detects recent and sure; relatively contamination; less recent drug tamper-proof col- new technique use lection method

Blood 12–24 Accurate results; Invasive method; Detects drug hours established expensive; detects effects on method only current use crashes, medical or intoxication emergencies

Hair 4–6 Measures long- New technique; Confirms drug months term drug use; costly and time- use in past 4 to readily available consuming; no 6 months; preva- samples; accurate dose-response lence studies results relation established

Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 243 or an easily administered Breathalyzer™ test 30 seconds after someone blows into the unit to confirm alcohol intoxication or drinking for 10 seconds. within the past several hours. Blood alcohol concentrations—measured in milligrams (mg) of alcohol per deciliter (dl) of blood—usually Saliva are expressed as a percentage (i.e., 100 mg/ For alcohol, saliva is correlated closely with dl equals 100 mg percent or 0.1 percent) and blood concentrations 2 hours after consump- correspond closely with measures of alco- tion. However, routes of drug administration hol on the breath. One drink increases the that contaminate the oral cavity can change breath alcohol level (BAL) by approximately the pH levels of saliva. These changes can 0.025 percent. distort correlations of other drugs found in saliva with blood plasma levels (Magerl For most men, some impairment is observ- and Schulz 1995; Preston et al. 1999). One able at 0.05 percent BAL, and driving ability advantage of saliva testing is the ready avail- is appreciably affected at 0.07 percent. A ability of saliva specimens and the packaging woman weighing 150 pounds would reach a for onsite testing. However, the short time BAL of 0.1 percent if she consumed approxi- window for detecting substances limits the mately four drinks in an hour (compared effectiveness of this method to ascertaining with six drinks in an hour for a 200-pound only recent drug use (e.g., for accident inves- man), although individuals’ metabolism tigations and for pilots or other employees of alcohol varies considerably according to about to engage in safety-sensitive activities). gender, age, simultaneous ingestion of food, Most substances disappear from both blood and physical condition, as well as weight and and saliva within 12 to 24 hours of use; can- consumption rate. BALs between 0.10 per- nabinoids may be detectable for only 4 to 10 cent and 0.20 percent without obvious signs hours after marijuana is smoked. The U.S. of intoxication usually indicate tolerance for Food and Drug Administration (FDA) recent- alcohol and regular, heavy drinking charac- ly approved limited use of RIA-based saliva teristic of dependence (CSAT 1997a). tests. Kits that detect tetrahydrocannabinol Normally, with little or no tolerance for (the active component of marijuana), opioids, alcohol, the following impairment levels are and cocaine are available for about $30. observed: • 0.40 percent = lethal Sweat • 0.30 percent = unconscious Although a number of licit and illicit sub- • 0.20 percent = decreased consciousness stances can be detected in perspiration • 0.10 percent = intoxication (probably diffused from blood), perspiration • 0.07 percent = impaired driving ability is difficult to collect for monitoring purposes. • 0.05 percent = detectable effect Manufacturers have introduced a “sweat patch” with a tamper-proof adhesive that is In addition to Breathalyzer tests, several worn for about a week. It has been used suc- other simple-to-use but accurate techniques cessfully to detect amphetamines, cocaine, now exist for determining either a client’s ethanol, methadone, methamphetamine, BAL or his or her approximate blood alcohol morphine, nicotine, and PCP. The drugs concentration. One is a relatively inexpen- are absorbed gradually into the pad, which sive, portable, and disposable unit the size must be applied carefully on clean skin and of a cigarette containing crystals that turn removed carefully for analysis. Although no a particular color—from yellow to blue—to rapid methods for analysis are available, signify a blood alcohol concentration of 0.02 and the pads must be mailed to laboratories, percent, 0.08 percent, or 0.10 percent within the FDA has approved their use for detecting

244 Appendix B cocaine, amphetamines, and opioids. The Certain objections to this technique have pads are used primarily to monitor offenders not been resolved. Few laboratories conduct on parole or probation. the analyses. Questions exist about potential environmental contamination of hair, the relationship of dose to the concentrations of Hair the substance in hair, and whether biophysi- Hair analysis can be used for detecting illicit cal attributes affect outcome. However, a substance use in the workplace and for drug large random study of hair analysis found treatment screening. The exact mechanism little evidence of any bias in assay results by which drug metabolites are absorbed associated with hair color, race, or ethnicity into hair follicles remains unclear. Trace (Kelly et al. 2000). Because hair grows slowly amounts of metabolites in the bloodstream and recent drug use cannot be detected enter hair follicles; these metabolites then reliably, the methodology has limited appli- are trapped in the core of each hair strand. cation for routine monitoring of treatment It seems to take about a week after substance compliance. It could be useful for corrobo- use for hair follicles to absorb drug residues. rating an intake drug history and conducting Because hair grows at a rate of about ½-inch prevalence research (Preston et al. 1999). per month, a 2-inch strand retains the record of a person’s substance use over approxi- Hair testing involves dissolving about 50 mately the past 4 months—a much longer strands of hair in solvents and testing the historical record than can be found through liquefied sample with GC/MS. The technique urine testing (Mieczkowski et al. 1998). appears to be highly reliable for detecting cocaine and crack, opioids (heroin), metham- The advantages of this technique are phetamines, PCP, and synthetic substances such as methylenedioxyamphetamine and • The presence of larger concentrations of 3-4 methylenedioxymethamphetamine or the substance use than in urine samples Ecstasy. It may be less reliable for detecting • The ease of specimen collection; hair usu- marijuana (Mieczkowski and Newel 1997). ally is taken from the scalp, but any body hair can be used • The difficulties in falsification or tampering and the simplicity of storage and shipping

Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 245

Appendix C— Resource Panel

James Callahan, D.P.A. Gil Hill Executive Vice President & CEO Director, Office of Substance Abuse American Society of Addiction Medicine American Psychological Association Chevy Chase, Maryland Washington, D.C.

Caroline Cooper Thomas F. Hilton, Ph.D. Associate Director Program Official for Organization and Justice Programs Office Management Sciences Research School of Public Affairs Services Research Branch American University Division of Clinical and Services Research Washington, D.C. National Institute on Drug Abuse National Institutes of Health Jennifer Edwards Bethesda, Maryland Assistant to the Director Corrections Program Office Elizabeth (Beth) A. Peyton U.S. Department of Justice President Washington, D.C. Peyton Consulting Newark, New Jersey Jerry Flanzer, D.S.W., LCSW, CAC Social Science Analyst Barbara Ray Division of Clinical and Services Research Public Health Analyst National Institute on Drug Abuse Substance Abuse and Mental Health National Institutes of Health Services Administration Bethesda, Maryland Rockville, Maryland

Brenda Harding Barbara Roberts, Ph.D. Public Health Advisor Senior Policy Analyst Division of State and Community Office of Demand Reduction Assistance Office of National Drug Control Policy Center for Substance Abuse Treatment Executive Office of the President Rockville, Maryland Washington, D.C.

247 Mickey Smith Richard T. Suchinsky, M.D. Public Health Advisor Associate Chief for Addictive Disorders Division of State and Community and Psychiatric Rehabilitation Assistance Mental Health and Behavioral Center for Substance Abuse Treatment Sciences Services Rockville, Maryland Department of Veterans Affairs Washington, D.C.

248 Appendix C Appendix D— Cultural Competency and Diversity Network Participants

Faye Belgrave, Ph.D. Martin Hernandez Professor of Psychology Administrative Assistant Virginia Commonwealth University Ventura County Board of Supervisors, Richmond, Virginia Third District Ventura, California Thomas P. Beresford, M.D. Professor of Psychiatry Alixe McNeil University of Colorado Health Sciences Assistant Vice President Department of Veterans Affairs Medical National Council on the Aging Center Washington, D.C. Denver, Colorado Rhoda Olkin, Ph.D. Deion Cash Professor of Psychology Executive Director California School of Professional Community Treatment and Correction Psychology Center, Inc. Alameda, California Canton, Ohio David W. Oslin, M.D. Marty Estrada Assistant Professor Case Manager Geriatric Psychiatry General Relief Team University of Pennsylvania East County Intake and Eligibility Center Philadelphia, Pennsylvania Ventura, California Lawrence Schonfeld, Ph.D. Michael T. Flaherty, Ph.D. Professor, Department of Aging and Executive Director Mental Health Institute for Research Education and Louis de la Parte Florida Mental Health Training in Addictions Institute Pittsburgh, Pennsylvania University of South Florida Tampa, Florida Robin C. Halprin, Ph.D. Licensed Psychologist D.C. Department of Health/CSA Washington, D.C.

249 Antony P. Stephen, Ph.D., LCSW, RAS Ann Yabusaki, Ph.D. Executive Director Substance Abuse Director Mental Health & Behavioral Sciences Coalition for a Drug-Free Hawaii New Jersey Asian American Association for Kaneohoe, Hawaii Human Services, Inc. Elizabeth, New Jersey

250 Appendix D Appendix E— Field Reviewers

Lonnetta Albright Stephanie Covington, Ph.D. Director Consultant Great Lakes Addiction Technology La Jolla, California Transfer Center University of Illinois Michael Cunningham, Ph.D., CDP Chicago, Illinois Clinical Supervisor Triumph Treatment Services Thomas S. Baker, D.M., LPC Yakima, Washington Senior Consultant Employee Assistance Dennis C. Daley, Ph.D. Johnson & Johnson Corporate Headquarters Chief, Addiction Medicine Service New Brunswick, New Jersey Associate Professor of Psychiatry Western Psychiatric Institute and Clinic Toni Barrett, M.A., CAP Pittsburgh, Pennsylvania Senior Vice President of Programs Stewart-Marchman Center Philip Diaz, M.S.W. Daytona Beach, Florida Chief Executive Office Gateway Community Services Faye Belgrave, Ph.D. Jacksonville, Florida Professor of Psychology Virginia Commonwealth University John Edwards, Ph.D. Richmond, Virginia Family Therapy Trainer/Consultant Durham, North Carolina Thomas P. Beresford, M.D. Professor of Psychiatry Marty Estrada University of Colorado Health Sciences Center Case Manager Department of Veterans Affairs Medical Center General Relief Team Denver, Colorado East County Intake and Eligibility Center Ventura, California Allan J. Cohen, M.A., MFT Director of Research and Development Marvin E. Fangman, M.A., LMSW, ACADC Aegis Medical Systems, Inc. Program Manager Canoga Park, California First Step: Mercy Recovery Center Mercy Medical Center Des Moines, Iowa

251 Dorothy J. Farr, LSW, LADC Sheryl D. Hunter, M.D. Clinical Director Massachusetts Mental Health Center Bucks County Drug and Alcohol Commission Boston, Massachusetts Warminster, Pennsylvania Dick Jacobs, M.S., LMFT, CAP Michael T. Flaherty, Ph.D. Chief Operating Officer Executive Director Center for Drug-Free Living, Inc. Institute for Research, Education and Orlando, Florida Training in Addictions Pittsburgh, Pennsylvania Margaret M. Kotz, D.O. Addiction Psychiatrist Cyrus V. Galyon, CAP Cleveland Clinic Clinical Manager, Non-Residential Services Cleveland, Ohio Center for Drug-Free Living, Inc. Orlando, Florida Roland C. Lamb Manager, Provider Network Administration Stephen J. Gumbley, M.A., ACDP II, LCDP Community Behavioral Health of Project Director Philadelphia’s Behavioral Health System Discovery House/Smart Management Philadelphia, Pennsylvania Providence, Rhode Island Kimberly A. Lucas, M.S., CADC Diane E. Hague, M.S.S.W., LCSW, CADC Treatment Specialist Director Delaware Division of Substance Abuse and Jefferson Alcohol and Drug Abuse Center Mental Health Louisville, Kentucky New Castle, Delaware

James A. Hall, Ph.D., LISW Thomas E. Lucking, M.A., Ed.S. Associate Professor of Pediatrics Consultant Roy J. and Lucille A. Carver College of Kalamazoo, Michigan Medicine University of Iowa Pierluigi Mancini, Ph.D., NCAC II Iowa City, Iowa Executive Director Clinic for Education, Treatment and Robin C. Halprin, Ph.D. Prevention of Addiction, Inc. Licensed Psychologist (Hispanic Program) D.C. Department of Mental Health/CSA Atlanta, Georgia Washington, D.C. Michael J. McCann, M.A. Martin Hernandez Associate Director Administrative Assistant Matrix Institute on Addictions Ventura County Board of Supervisors, Los Angeles, California Third District Ventura, California James R. McKay, Ph.D. Scientific Director Anne M. Herron, M.S., CRC, CASAC Treatment Research Institute Director, Treatment Programming Philadelphia, Pennsylvania NYS Office of Alcoholism and Substance Abuse Services Albany, New York

252 Appendix E Cecilia McNamara, Ph.D. Harvey A. Siegal, Ph.D. Health Science Administrator Professor and Director Behavioral Treatment Development Branch Center for Interventions, Treatment, and National Institute on Drug Abuse Addictions Research National Institutes of Health Wright State University School of Medicine Bethesda, Maryland Dayton, Ohio

Alixe McNeil Thomas M. Slaven, Ph.D., LPC Assistant Vice President Consulting Associate National Council on the Aging Duke University Medical Center Washington, D.C. Durham, North Carolina

Terence McSherry, M.P.H., M.H.A. David Smith, M.D. President and Chief Executive Officer Founder and Medical Director Northeast Treatment Center Haight-Ashbury Free Clinics Philadelphia, Pennsylvania Medical Director California Alcohol and Drug Programs Delinda Mercer, Ph.D. San Francisco, California Treatment Research Center University of Pennsylvania Antony P. Stephen, Ph.D., LCSW, RAS Philadelphia, Pennsylvania Executive Director Mental Health & Behavioral Studies Ethan Nebelkopf, Ph.D. New Jersey Asian American Association for Director Human Services, Inc. Family and Child Guidance Clinic Elizabeth, New Jersey Native American Health Center Oakland, California Mary Ann Chutuape Stephens, Ph.D. Health Scientist Administrator Rhoda Olkin, Ph.D. Center for the Clinical Trials Network Professor of Psychology National Institute on Drug Abuse California School of Professional National Institutes of Health Psychology Bethesda, Maryland Alameda, California Erik Stone, M.S., CAC III David W. Oslin, M.D. Director of Compliance and Quality Assistant Professor of Geriatric Psychiatry Improvement University of Pennsylvania Signal Behavioral Health Network Philadelphia, Pennsylvania Denver, Colorado

Deborah J. Owens, M.S., LPC, CACD, CEAP Kathy J. Stone, M.B.A., LMSW Senior Consultant Associate Executive Director Employee Assistance Programs Magellan Behavioral Care of Iowa Fort Washington, Pennsylvania West Des Moines, Iowa

Lawrence Schonfeld, Ph.D. Philip Toal, Ed.D., LMHC Professor of Aging and Mental Health Clinical Manager, Non-Residential Services Louis de la Parte Florida Mental Health Center for Drug-Free Living, Inc. Institute Orlando, Florida University of South Florida Tampa, Florida

Field Reviewers 253 Tim Williams, M.S.W., LCSW Ann Yabusaki, Ph.D. Adult Services Director Substance Abuse Director Orange, Person and Chatham Area Coalition for a Drug-Free Hawaii Programs Kaneohe, Hawaii Carrboro, North Carolina

254 Appendix E Index

Because the entire volume is about clinical issues in intensive outpatient treatment (IOT), the use of these terms as entry points has been minimized in this index. Commonly known acronyms are listed as main headings. Page references for information contained in exhibits appear in italics.

12-Step facilitation, 138–139 Americans with Disabilities Act, 60, 193 strengths and challenges of, 139 anger, 123, 126. See also violence 12-Step groups. See mutual-help groups approaches to treatment 24-hour crisis coverage, 40, 41 12-Step facilitation, 138–139 cognitive-behavioral approach, 140–141 A community reinforcement and contingency abstinence management, 148–152 family life, 105–106 Matrix model, 146–148 monitoring, 12 motivational approaches, 141–142 acamprosate, 36 therapeutic community approach, 142–145 Addiction Severity Index, 11, 64, 74, 85 ASI. See Addiction Severity Index supplements to six assessment domains, 88–91 Asian Americans and Pacific Islanders, 191–192 Addiction Technology Transfer Centers, 2 resources, 200–201 adjunctive therapies, 45 assessment, biopsychosocial, 73–74 admission process, 9, 59–60 attrition of clients, 59 components of, 67 adolescents, 171 B Asian Americans and Pacific Islanders, 191 barriers to treatment behavioral contract, 173 addressing, 73 case management, 174 assessing, 64–66 characteristics and behaviors of, 176 engaging family members in treatment, 98 family involvement, 172–173 language, 185 group treatment, 174 mistrust of authority, 184 Hispanics/Latinos, 185 people with psychiatric disorders, 162 HIV, 192 physical, 60 ADS. See Alcohol Dependence Scale religious orientation, 187 adult education, 44 women, 159, 186 African Americans, 190 biopsychosocial assessment, 73–74 resources, 199 boundary issues, 132–134 Alcohol Abstinence Self-Efficacy Scale, 135 buprenorphine, 14, 36 Alcohol Dependence Scale, 64 Alcohol Effects Questionnaire, 135 C Alcohol-Specific Role Play Test, 135 CAGE questionnaire, 64 ambulatory detoxification, 34–35, 56 case management, 38–40 American Society of Addiction Medicine adolescents, 174 continuum of care levels, 17 clients who are homeless, 194 Patient Placement Criteria, 68, 69 psychiatric disorders, 166

255 qualifications and role of managers, 38 definition, 3 research outcomes and findings, 40 people with psychiatric disorders, 170 services, 39 continuing community care, 24, 40–41 child care, 45 goals of, 25 barrier to treatment, 73, 159 intensity and duration of, 26 child-focused therapy, 101 plan for, 76 chronic medical conditions continuum of care, 17–18 screening for at intake, 65 ASAM levels of care, 17 substance abuse, 12 assisting the client through, 18–19 CIDI. See Composite International IOT programs, 18 Diagnostic Interview core services of IOT, 27–44, 28 Circumstances, Motivation, Readiness, and counselor-client trust, 10 Suitability Scales–Revised, 70 couples therapy, 101 CIWA–Ar scale. See Clinical Institute cross-training, 170–171 Withdrawal Assessment–Alcohol, Revised cultural competence, 61 scale African Americans, 190 client issues Asian Americans and Pacific Islanders, attrition, 59 191–192 boundary issues, 132–134 clinical issues, 184, 188–189 counselor-client trust, 10 clinician issues, 180–181 disruptiveness, 123 disability, clients with, 192–193 education, 14 foreign-born clients, 184 employment-related challenges, 130–132 Hispanics/Latinos, 189–190 quiet, withdrawn clients, 123–124 HIV/AIDS, 192 retention, 10–11, 115–117 homeless populations, 194–195 socializing, 133 lesbian, gay, and bisexual clients, 192 under the influence in group, 127–128 Native Americans, 190–191 Clinical Institute Withdrawal Assessment– older adults, 195 Alcohol, Revised scale, 35, 64, 71–72 religious orientation, 187 Clinical Trials Network, National Institute resources, 197–204 on Drug Abuse, 2 rural populations, 193 CMRS. See Circumstances, Motivation, staff issues, 185–186 Readiness, and Suitability Scales–Revised treatment services, 181–182 cognitive-behavioral approach, 140–141 women, 186–187 strengths and challenges of, 141 worldview differences, 182–183 community reinforcement and contingency management approaches, 148–152 D research outcomes and findings, 151–152 definitions strengths and challenges of, 151 continuing care, 3 training, 97 family, 94 community support, 40–41 intensive outpatient treatment, 3 goals of, 24, 26 detoxification key aspects of, 41 ambulatory, 34–35, 56 compatible models of care, 20–21 providing, 70–72 Composite International Diagnostic withdrawal symptoms for four drug classes, Interview, 85 71 confidentiality, 61, 63, 72, 96, 128–130 Diagnostic Interview Schedule, 85 contingency management, 9–10, 148–152 DIS. See Diagnostic Interview Schedule continuing care, 2

256 Index disability expectations about treatment outcomes, clients with, 60, 192–193 103 resources, 202–203 goals of, 95 screening for, 66 multifamily groups, 100 disruptive clients, 123 mutual-help groups, 102 domestic violence, 125–126, 161. See also retreats, 101–102 violence sample treatment calendar, 99 barrier to family engagement, 98 therapy groups, 100–101 dropouts, multiple, 119 foreign-born clients, 184 drug dealers at facility, 125 funding, of community reinforcement and DSM-IV criteria for substance dependence contingency management approaches, 150 and substance abuse, 87 duration of treatment, 19 G gang members at facility, 125 E genogram, 94, 107–108 education gifts from clients to staff, 132–133 adult, 44 goals client, 14 family services, 95 eligibility for IOT, determining, 68 IOT, 19 employment outpatient treatment, 23 -related challenges, 130–132 stage 1 treatment, 20, 21 services, 42–44 stage 2 treatment, 20, 22 enhanced IOT services, 28, 44–46 stage 3 treatment, 24, 25 enhancing motivation to treatment, 9–10 stage 4 treatment, 24, 26 entry to treatment graduation from treatment program, 121 ease of, 9 group counseling and therapy, 27 women, 159 adolescents, 174 evidence-based approaches, 15 client under the influence, 127–128 developing cohesion, 120–121 F difficult clients, 122–124 family involvement in substance abuse treat- family therapy groups, 100–101 ment, 14–15, 94–95, 170 key aspects of, 30–32 abstinence, 105–106 multifamily groups, 100 adolescents, 172–173 psychiatric disorders, 168–169 definition of family, 94 types of groups, 28–29, 29–30 engaging the family in treatment, 95–97 estrangement, 103 H Family Intervention Program, 174 Health Insurance Portability and genogram, 107–108 Accountability Act (HIPAA), 72 resources, 112–113 Hispanics/Latinos, 189–190 response to relapse, 104 resources, 198–199 sabotage by family members, 105 history form, 84 sample treatment calendar, 99 HIV/AIDS, 128–129, 192 social network, 109–110, 111 resources, 201 substance use by family members, 119– homeless populations, 194–195 120 housing programs, 44 family services resources, 203–204 clinical issues, 102 education groups, 98–99

Index 257 I Texas Christian University Drug Screen (TCUDS), 64, 86 individual University of Rhode Island Change counseling, 32 Assessment Scale (URICA), 70 family therapy, 101 intake interviews, 61–62 infectious diseases, 37 effective techniques, 63 initial response procedures, 61 including family members, 96 inpatient treatment, versus intensive outpa- intensive outpatient treatment tient treatment, 8 case illustrations, 46–55 instruments, 85–86 core features and services, 4–5 Addiction Severity Index (ASI), 11, 64, 74, culturally competent services, 181 85 definition, 3, 19, 31 Alcohol Abstinence Self-Efficacy Scale, 135 engaging the client, 60–61 Alcohol Dependence Scale (ADS), 64, 85 functions of, 18 Alcohol Effects Questionnaire, 135 goals of, 19 Alcohol-Specific Role Play Test, 135 versus inpatient treatment, 8 assessing relapse potential, 135–136 the justice system, 155 CAGE questionnaire, 64 versus outpatient treatment, 23 Circumstances, Motivation, Readiness, and intoxication, symptoms at intake, 65 Suitability Scales–Revised (CMRS), 70 Clinical Institute Withdrawal Assessment– Alcohol, Revised scale, 35, 64, 71–72 J Composite International Diagnostic justice system Interview (CIDI), 85 clinical issues, 157 Diagnostic Interview Schedule (DIS), 85 communication between systems, 156 MINI International Neuropsychiatric female offenders, 154 Interview, 85 memorandum of understanding, 156–157 Mini-Mental State Examination (MMSE), population in, 152–154 66 staff issues, 157 Offender Profile Index, 64 stigma, 154 Psychiatric Research Interview for Substance and Mental Disorders L (PRISM), 85 LAAM, 36 Readiness Ruler, 70 lesbian, gay, and bisexual clients, 192 Readiness to Change Questionnaire– resources, 201–202 Treatment Version, 70 Short Michigan Alcoholism Screening Test M (S-MAST), 64 Simple Screening Instrument, 64 matching treatment services to client needs, Situational Confidence Questionnaire, 136 11 Stages of Change Readiness and Matrix model, 146–148 Treatment Eagerness Scale, 70 research outcomes and findings, 148 Structured Clinical Interview for Diagnosis strengths and challenges of, 147 of DSM-IV, Version 2, Substance Abuse medical treatment, 42 Disorders module (SCID), 64 medication management, 13–14, 32–34 Structured Clinical Interview for DSM-IV memorandum of understanding, 156–157 Axis I Disorders, 86 methadone, 36 Substance Abuse Screening Instrument Mini-Mental State Examination, 66 (SASI), 64 Minnesota Model. See 12-Step facilitation Substance Dependence Severity Scale, 86 MMSE. See Mini-Mental State Examination

258 Index models, 39, 66 principle 1: make treatment readily avail- Community Reinforcement Plus Vouchers able, 8 Approach: Treating Cocaine Addiction principle 2: ease entry, 9 (NIDA treatment model), 149 principle 3: build on existing motivation, compatible models of care, 20–21 9–10 monitoring principle 4: enhance therapeutic alliance, abstinence, 12 10 alcohol and drug use, 38 principle 5: make retention a priority, motivational approaches, 9–10, 68, 141–142 10–11 case sample, 77 principle 6: assess and address individual screening instruments to assess, 70 treatment needs, 11 strengths and challenges of, 143 principle 7: provide ongoing care, 11–12 working with uncommitted clients, 122 principle 8: monitor abstinence, 12 mutual-help groups, 12–13, 41–42, 138–139. principle 9: use mutual-help and other See also continuing community care community-based supports, 12–13 alternatives to, 42, 43 principle 10: use medications if indicated, families, 102 13–14 psychiatric disorders, 169 principle 11: educate about substance use versus substance abuse treatment, 3–4 disorders, recovery, and relapse, 14 principle 12: engage families, employers, N and significant others, 14–15 naltrexone, 14, 36 principle 13: incorporate evidence-based Native Americans, 190–191 approaches, 15 resources, 199–200 principle 14: improve program administra- nicotine cessation treatment, 45 tion, 15–16 PRISM. See Psychiatric Research Interview O for Substance and Mental Disorders privacy. See confidentiality Offender Profile Index, 64 program administration, 15–16 older adults, 195 psychiatric disorders, 90 resources, 204 ABC model for psychiatric screening, 66 Omnibus Transportation Employee Testing barriers to treatment, 162 Act of 1991, 131 clinical issues, 164 ongoing care, 11–12 establishing a therapeutic relationship, orientation to program, 72 167–168 outpatient treatment group treatment, 168–169 goals of, 23 the justice system, 154 versus intensive outpatient treatment, 23 medications to treat, 13–14 transition to, 20 mutual-help groups, 169 people with psychiatric disorders, 165 P symptoms at intake, 65 parenting issues, 90, 158, 187 theoretical background, 162–163 parent skill training, 45–46 working with clients who have, 122–123 Patient Placement Criteria, ASAM, 68 Psychiatric Research Interview for Substance six dimensions of, 69 and Mental Disorders, 85 pharmacotherapy, 13–14, 32–37, 166 psychoeducational counseling, 32 pregnancy, 158, 161 topics addressed in, 33–34 principles of intensive outpatient treatment, 7 psychotherapy, 42

Index 259 publications R A.A. Member—Medications and Other readily available treatment, 8 Drugs, 169 readiness for change, assessing, 68 Alcoholics Anonymous (the “Big Book”), 42 Readiness Ruler, 70 Assessing Alcohol Problems: A Guide for Readiness to Change Questionnaire– Clinicians and Researchers, 64 Treatment Version, 70 Assessing Drug Abuse Among Adolescents recreational activities, 44, 91 and Adults: Standardized Instruments, 64 relapse, 14, 36 Bridging the Gap Between Practice and family response, 104 Research (Institute of Medicine report), 2 instruments, 135–136 Confidentiality of Alcohol and Drug Abuse versus lapse, 117 Patient Records Regulation and the prevention quiz, 118 HIPAA Privacy Rule, The, 63 prevention strategies, 117–118, 170 Counselor’s Manual for Relapse Prevention religious orientation, 187. See also spirituality With Chemically Dependent Criminal research outcomes and findings Offenders (TAP 19), 118 12-Step approaches, 139–140 Diagnostic Source Book on Drug Abuse case management, 40 Research and Treatment, 64 cognitive-behavioral therapy, 140–141 Gender-Responsive Strategies: Research, community reinforcement and contingency Practice, and Guiding Principles for management approach, 151 Women Offenders, 154 Matrix model, 148 It Works: How and Why, 42 motivational approaches, 142 Living Sober, 42 therapeutic community approach, 145 Matrix Intensive Outpatient Treatment for respect for clients, 61 People With Stimulant Use Disorders, 148 retention, 10–11, 115–117 Mental Health: Culture, Race, and round-the-clock crisis coverage, 40, 41 Ethnicity (Surgeon General report), 180 rural populations, 193 Narcotics Anonymous, 42 resources, 203 Principles of Drug Addiction Treatment: A Research-Based Guide (National Institute S on Drug Abuse), 5, 7, 11 Psychotherapeutic Medications 2003: What safety, 125–128, 126. See also violence Every Counselor Should Know, 166 SASI. See Substance Abuse Screening Relapse Prevention and the Substance- Instrument Abusing Criminal Offender (TAP 8), 118 SCID. See Structured Clinical Interview for Strategies for Developing Treatment Diagnosis of DSM-IV, Version 2, Substance Programs for People With Co-Occurring Abuse Disorders module Substance Abuse and Mental Disorders screening (SAMHSA), 171 ABC model for psychiatric screening, 66 Therapeutic Community Curriculum (CSAT brief instruments that assess motivational manual), 145 stage, 70 Twelve Steps and Twelve Traditions, 42 chronic medical conditions, 65 Woman’s Way Through the Twelve Steps, A, collecting information, 62–64 161 psychiatric disorders, 164–165 sexuality, 90–91 Q Short Michigan Alcoholism Screening Test, 64 quiet, withdrawn clients, 123–124 Simple Screening Instrument, 64 Situational Confidence Questionnaire, 136

260 Index S-MAST. See Short Michigan Alcoholism TIPs cited Screening Test Clinical Guidelines for the Use of socializing, 133 Buprenorphine in the Treatment of social network, 94–95, 109–110 Opioid Addiction (TIP 40), 36 social network grid, 111 Comprehensive Case Management for spirituality, 91 Substance Abuse Treatment (TIP 27), 40, staff issues 166 adolescents, 175 Continuity of Offender Treatment for community reinforcement and contingency Substance Use Disorders From Institution management approaches, 150 to Community (TIP 30), 155 counselor-client trust, 10 Detoxification and Substance Abuse counselors with dual roles, 134 Treatment (TIP 45), 35, 72 cross-training, 170–171 Enhancing Motivation for Change in cultural competence, 185–186 Substance Abuse Treatment (TIP 35), 62, familiarity with 12-Step culture, 139 118, 141, 142, 168 familiarity with cognitive-behavioral thera- Guide to Substance Abuse Services for py, 140 Primary Care Clinicians, A (TIP 24), 35 female clients, 161–162 Improving Cultural Competence in the justice system, 157 Substance Abuse Treatment (forthcom- the Matrix model, 147 ing), 61, 181 motivational approaches, 142 Integrating Substance Abuse Treatment therapeutic community approaches, 144 and Vocational Services (TIP 38), 44 Stages of Change Readiness and Treatment Intensive Outpatient Treatment for Alcohol Eagerness Scale, 70 and Other Drug Abuse (TIP 8), 1 stepdown treatment, 23–24 Medication-Assisted Treatment for Opioid stigma, in the justice system, 154 Addiction in Opioid Treatment Programs Structured Clinical Interview for Diagnosis (TIP 43), 37, 67 of DSM-IV, Version 2, Substance Abuse Naltrexone and Alcoholism Treatment (TIP Disorders module, 64 28), 36 Structured Clinical Interview for DSM-IV Screening and Assessing Adolescents for Axis I Disorders, 86 Substance Use Disorders (TIP 31), 67, substance abuse, as a chronic illness, 12 171 Substance Abuse Screening Instrument, 64 Screening for Infectious Diseases Among Substance Dependence Severity Scale, 86 Substance Abusers (TIP 6), 37 suicidality, screening for at intake, 67 Simple Screening Instruments for Outreach summary report of assessment findings, for Alcohol and Other Drug Abuse and 74–75 Infectious Diseases (TIP 11), 64 Substance Abuse: Administrative Issues in T Outpatient Treatment (TIP 46), 1, 16, 32, TCUDS. See Texas Christian University Drug 61, 74, 166, 181, 188 Screen Substance Abuse Treatment: Addressing the Temporary Assistance for Needy Families, Specific Needs of Women (forthcoming), 77 157 Texas Christian University Drug Screen, 64, Substance Abuse Treatment and Domestic 86 Violence (TIP 25), 67, 89, 126, 157, 161 therapeutic alliance, 10 Substance Abuse Treatment and Family therapeutic community approach, 142–145 Therapy (TIP 39), 30, 93, 172 research outcomes and findings, 145 strengths and challenges of, 145

Index 261 Substance Abuse Treatment for Adults in V the Criminal Justice System (TIP 44), 127, violence, 126 157 domestic, 67, 89, 98, 125–126, 161 Substance Abuse Treatment for Persons screening for at intake, 67 With Child Abuse and Neglect Issues (TIP treating violent clients, 127 36), 90, 158 women, 158 Substance Abuse Treatment for Persons vocational training, 42–44 With Co-Occurring Disorders (TIP 42), 37, 42, 123, 165, 167 W Substance Abuse Treatment for Persons With HIV/AIDS (TIP 37), 37, 129 Web sites cited Substance Abuse Treatment: Group Adult Children Anonymous, 102 Therapy (TIP 41), 29, 120 Adult Children of Alcoholics, 102 Substance Use Disorder Treatment for Al-Anon/Alateen, 13, 99 People With Physical and Cognitive Alcohol Abstinence Self-Efficacy Scale, 135 Disabilities (TIP 29), 66, 167 Alcoholics Anonymous, 13, 42, 170 Treatment for Stimulant Use Disorders, American Family Physician, 35 (TIP 33), 14, 118 assessment instruments, 70 Treatment of Adolescents With Substance Center for Substance Abuse Prevention Use Disorders (TIP 32), 171 Workplace Resource Center, 131 Tuberculosis Epidemic: Legal and Ethical Center for Substance Abuse Treatment, Issues for Alcohol and Other Drug Abuse 138 Treatment Providers, The (TIP 18), 37 children and families, 46 transition Clinical Institute Withdrawal Assessment– outpatient treatment, 20 Alcohol, Revised scale, 72 planning, 23 Cocaine Anonymous, 42 transportation services, 44 Detoxification Clinical Practice Guidelines, 35 treatment domestic violence assessment, 89 duration of, 19 Double Trouble in Recovery, 169 entry to, 9, 159 Dual Recovery Anonymous, 169 graduation from, 121 Families Anonymous, 99 intensity of, 19 Fortune Society, 43 interventions, 15 General Services Offices of Alcoholics matching to client needs, 11 Anonymous, 42 medical, 42 Hazelden Foundation, 137 plan, 75–83 Hispanic Health Council, 43 settings, 19 Institute on Black Chemical Abuse, 43 stages of, 20 Jewish Alcoholics, Chemically Dependent well-known person, 129–130 Persons and Significant Others, 187 trust between counselor and client, 10 Medication Assisted Treatment, 37 Mini-Mental State Examination, 66 U Nar-Anon, 13, 99 Narcotics Anonymous, 13, 42 University of Rhode Island Change National Black Alcoholism and Addictions Assessment Scale, 70 Council, 43 URICA. See University of Rhode Island National Clearinghouse for Alcohol and Change Assessment Scale Drug Information, 138 urine drug tests, 12 National Head Start Association, 46 National Institute on Alcohol Abuse and Alcoholism, 135, 137

262 Index Office of Juvenile Justice and Delinquency women, 157–158 Prevention, 46 barriers to treatment, 159 Patient Placement Criteria, ASAM, 68 clinical issues, 159–161 Principles of Addiction Medicine, 35 culturally competent services, 186–187 Rational Recovery, 13 domestic violence, 158, 161 resources for family-based services, 112– entry to treatment, 159 113 the justice system, 154 Save Our Selves, 43 pregnancy, 158, 161 Secular Organizations for Sobriety, 43 Self-Management and Recovery Training, 43 Smart Recovery, 13 Y Women for Sobriety, 13, 43 young adults, 175–177 withdrawal symptoms at intake, 65 symptoms for four drug classes, 71

Index 263

CSAT TIPs and Publications Based on TIPs What Is a TIP? Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under CSAT’s Knowledge Application Program to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system. What Is a Quick Guide? A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so providers can refer back to the source document for more information. What Are KAP Keys? Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept within a treatment provider’s reach and consulted frequently. The Keys allow the busy clinician or program administrator to locate information easily and to use this information to enhance treatment services. TIP 1 State Methadone Treatment Guidelines—Replaced by TIP 15 Treatment for HIV-Infected Alcohol and Other Drug TIP 43 Abusers—Replaced by TIP 37 TIP 2* Pregnant, Substance-Using Women—BKD107 TIP 16 Alcohol and Other Drug Screening of Hospitalized Quick Guide for Clinicians QGCT02 Trauma Patients—BKD164 KAP Keys for Clinicians KAPT02 Quick Guide for Clinicians QGCT16 TIP 3 Screening and Assessment of Alcohol- and Other KAP Keys for Clinicians KAPT16 Drug-Abusing Adolescents—Replaced by TIP 31 TIP 17 Planning for Alcohol and Other Drug Abuse TIP 4 Guidelines for the Treatment of Alcohol- and Other Treatment for Adults in the Criminal Justice Drug-Abusing Adolescents—Replaced by TIP 32 System—Replaced by TIP 44 TIP 5 Improving Treatment for Drug-Exposed Infants— TIP 18 The Tuberculosis Epidemic: Legal and Ethical BKD110 Issues for Alcohol and Other Drug Abuse Treatment Providers—BKD173 TIP 6 Screening for Infectious Diseases Among Substance Abusers—BKD131 Quick Guide for Clinicians QGCT18 Quick Guide for Clinicians QGCT06 KAP Keys for Clinicians KAPT18 KAP Keys for Clinicians KAPT06 TIP 19 Detoxification From Alcohol and Other Drugs— Replaced by TIP 45 TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice TIP 20 Matching Treatment to Patient Needs in Opioid System—Replaced by TIP 44 Substitution Therapy—Replaced by TIP 43 TIP 8 Intensive Outpatient Treatment for Alcohol and TIP 21 Combining Alcohol and Other Drug Abuse Other Drug Abuse—Replaced by TIPs 46 and 47 Treatment With Diversion for Juveniles in the Justice System—BKD169 TIP 9 Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Quick Guide for Clinicians and Administrators QGCA21 Drug Abuse—Replaced by TIP 42 TIP 22 LAAM in the Treatment of Opiate Addiction— TIP 10 Assessment and Treatment of Cocaine-Abusing Replaced by TIP43 Methadone-Maintained Patients—Replaced by TIP 43 TIP 23 Treatment Drug Courts: Integrating Substance Abuse TIP 11 Simple Screening Instruments for Outreach for Treatment With Legal Case Processing—BKD205 Alcohol and Other Drug Abuse and Infectious Quick Guide for Administrators QGAT23 Diseases—BKD143 TIP 24 A Guide to Substance Abuse Services for Primary Quick Guide for Clinicians QGCT11 Care Clinicians—BKD234 KAP Keys for Clinicians KAPT11 Quick Guide for Clinicians QGCT24 TIP 12 Combining Substance Abuse Treatment With KAP Keys for Clinicians KAPT24 Intermediate Sanctions for Adults in the Criminal TIP 25 Substance Abuse Treatment and Domestic Justice System—Replaced by TIP 44 Violence—BKD239 TIP 13 Role and Current Status of Patient Placement Linking Substance Abuse Treatment and Domestic Criteria in the Treatment of Substance Use Violence Services: A Guide for Treatment Providers Disorders—BKD161 MS668 Quick Guide for Clinicians QGCT13 Linking Substance Abuse Treatment and Domestic Quick Guide for Administrators QGAT13 Violence Services: A Guide for Administrators MS667 KAP Keys for Clinicians KAPT13 Quick Guide for Clinicians QGCT25 TIP 14 Developing State Outcomes Monitoring Systems for KAP Keys for Clinicians KAPT25 Alcohol and Other Drug Abuse Treatment—BKD162 *Under revision

265 TIP 26 Substance Abuse Among Older Adults—BKD250 TIP 36 Substance Abuse Treatment for Persons With Child Substance Abuse Among Older Adults: A Guide for Abuse and Neglect Issues—BKD343 Treatment Providers MS669 Quick Guide for Clinicians QGCT36 Substance Abuse Among Older Adults: A Guide for KAP Keys for Clinicians KAPT36 Social Service Providers MS670 Helping Yourself Heal: A Recovering Woman’s Substance Abuse Among Older Adults: Physician’s Guide—PHD981 (English), PHD981S (Spanish) Guide MS671 Helping Yourself Heal: A Recovering Man’s Good Mental Health is Ageless PHD881 (English), Guide—PHD1059 (English), PHD1059S (Spanish) PHD881S (Spanish) TIP 37 Substance Abuse Treatment for Persons With HIV/ Aging, Medicines and Alcohol PHD882 (English), AIDS—BKD359 PHD882S (Spanish) HIV/AIDS: Is Your Client at Risk? MS965 Quick Guide for Clinicians QGCT26 Drugs, Alcohol and HIV/AIDS: A Consumer Guide KAP Keys for Clinicians KAPT26 PHD1126 (English), PHD1134 (Spanish) TIP 27 Comprehensive Case Management for Substance Quick Guide for Clinicians MS678 Abuse Treatment—BKD251 KAP Keys for Clinicians KAPT37 Case Management for Substance Abuse Treatment: A Guide for Treatment Providers MS673 TIP 38 Integrating Substance Abuse Treatment and Vocational Services—BKD381 Case Management for Substance Abuse Treatment: A Guide for Administrators MS672 Quick Guide for Clinicians QGCT38 Quick Guide for Clinicians QGCT27 Quick Guide for Administrators QGAT38 Quick Guide for Administrators QGAT27 KAP Keys for Clinicians KAPT38 TIP 28 Naltrexone and Alcoholism Treatment—BKD268 TIP 39 Substance Abuse Treatment and Family Therapy— BKD504 Naltrexone and Alcoholism Treatment: Physician’s Guide MS674 Quick Guide for Clinicians QGCT39 Quick Guide for Clinicians QGCT28 Quick Guide for Administrators QGAT39 KAP Keys for Clinicians KAPT28 TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction—BKD500 TIP 29 Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities—BKD288 Quick Guide for Physicians QGPT40 Quick Guide for Clinicians QGCT29 KAP Keys for Physicians KAPT40 Quick Guide for Administrators QGAT29 TIP 41 Substance Abuse Treatment: Group Therapy— BKD507 KAP Keys for Clinicians KAPT29 Quick Guide for Clinicians QGCT41 TIP 30 Continuity of Offender Treatment for Substance Use Disorders From Institution to Community—BKD304 TIP 42 Substance Abuse Treatment for Persons With Co- Occurring Disorders—BKD515 Quick Guide for Clinicians QGCT30 Quick Guide for Clinicians QGCT42 KAP Keys for Clinicians KAPT30 Quick Guide for Administrators QGAT42 TIP 31 Screening and Assessing Adolescents for Substance Use Disorders—BKD306 KAP Keys for Clinicians KAPT42 See companion products for TIP 32. TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs—BKD524 TIP 32 Treatment of Adolescents With Substance Use Disorders—BKD307 Quick Guide for Clinicians QGCT43 Quick Guide for Clinicians QGC312 KAP Keys for Clinicians KAPT43 KAP Keys for Clinicians KAP312 TIP 44 Substance Abuse Treatment for Adults in the Criminal Justice System—BKD526 TIP 33 Treatment for Stimulant Use Disorders—BKD289 Quick Guide for Clinicians QGCT44 Quick Guide for Clinicians QGCT33 KAP Keys for Clinicians KAPT44 KAP Keys for Clinicians KAPT33 TIP 45 Detoxification and Substance Abuse Treatment— TIP 34 Brief Interventions and Brief Therapies for BKD541 Substance Abuse—BKD341 TIP 46 Substance Abuse: Administrative Issues in Outpatient Quick Guide for Clinicians QGCT34 Treatment—BKD545 KAP Keys for Clinicians KAPT34 Quick Guide for Administrators QGAT46 TIP 35 Enhancing Motivation for Change in Substance TIP 47 Substance Abuse: Clinical Issues in Intensive Abuse Treatment—BKD342 Outpatient Treatment—BKD551 Quick Guide for Clinicians QGCT35 KAP Keys for Clinicians KAPT35 Faces of Change PHD1103

266 Treatment Improvement Protocols (TIPs) from the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT)

Place the quantity (up to 5) next to the publications you would like to receive and print your mailing address below.

___ TIP 2* BKD107 ___ TIP 26 BKD250 ___ TIP 36 BKD343 ___ QG† for Clinicians QGCT02 ___ Guide for Treatment Providers MS669 ___ QG for Clinicians QGCT36 ___ KK† for Clinicians KAPT02 ___ Guide for Social Service Providers MS670 ___ KK for Clinicians KAPT36 ___ Physician’s Guide MS671 ___ Brochure for Women (English) ___ TIP 5 BKD110 ___ Good Mental Health PHD881 PHD981 ___ Good Mental Health PHD881S ___ Brochure for Women (Spanish) ___ TIP 6 BKD131 (Spanish) PHD981S ___ QG for Clinicians QGCT06 ___ Aging, Medicine PHD882 ___ Brochure for Men (English) ___ KK for Clinicians KAPT06 ___ Aging, Medicine PHD882S (Spanish) PHD1059 ___ QG for Clinicians QGCT26 ___ Brochure for Men (Spanish) ___ TIP 11 BKD143 ___ KK for Clinicians KAPT26 PHD1059S ___ QG for Clinicians QGCT11 ___ KK for Clinicians KAPT11 ___ TIP 27 BKD251 ___ TIP 37 BKD359 ___ Guide for Treatment Providers MS673 ___ Your Client At Risk MS965 ___ TIP 13 BKD161 ___ Guide for Administrators MS672 ___ Drugs, Alcohol & HIV/AIDS PHD1126 ___ QG for Clinicians QGCT13 ___ QG for Clinicians QGCT27 ___ Drogas, Alcohol y el VIH/SIDA PHD1134 ___ QG for Administrators QGAT13 ___ QG for Administrators QGAT27 ___ QG for Clinicians QGCT37 ___ KK for Clinicians KAPT13 ___ KK for Clinicians KAPT37 ___ TIP 28 BKD268 ___ TIP 14 BKD162 ___ Physician’s Guide MS674 ___ TIP 38 BKD381 ___ QG for Clinicians QGCT28 ___ QG for Clinicians QGCT38 ___ TIP 16 BKD164 ___ KK for Clinicians KAPT28 ___ QG for Administrators QGAT38 ___ QG for Clinicians QGCT16 ___ KK for Clinicians KAPT38 ___ KK for Clinicians KAPT16 ___ TIP 29 BKD288 ___ QG for Clinicians QGCT29 ___ TIP 39 BKD504 ___ TIP 18 BKD173 ___ QG for Administrators QGAT29 ___ QG for Clinicians QGCT39 ___ QG for Clinicians QGCT18 ___ KK for Clinicians KAPT29 ___ QG for Administrators QGAT39 ___ KK for Clinicians KAPT18 ___ TIP 30 BKD304 ___ TIP 40 BKD500 ___ TIP 21 BKD169 ___ QG for Clinicians QGCT30 ___ QG for Physicians QGPT40 ___ QG for Clinicians & Administrators ___ KK for Clinicians KAPT30 ___ KK for Physicians KAPT40 QGCA21 ___ TIP 31 BKD306 ___ TIP 41 BKD507 ___ TIP 23 BKD205 (see products under TIP 32) ___ QG for Clinicians QGCT41 ___ QG for Administrators QGAT23 ___ TIP 32 BKD307 ___ TIP 42 BKD515 ___ TIP 24 BKD234 ___ QG for Clinicians QGC312 ___ QG for Clinicians QGCT42 ___ QG for Clinicians QGCT24 ___ KK for Clinicians KAP312 ___ QG for Administrators QGAT42 ___ KK for Clinicians KAPT24 ___ KK for Clinicians KAPT42 ___ TIP 33 BKD289 ___ TIP 25 BKD239 ___ QG for Clinicians QGCT33 ___ TIP 43 BKD524 ___ Guide for Treatment Providers MS668 ___ KK for Clinicians KAPT33 ___ QG for Clinicians QGCT43 ___ Guide for Administrators MS667 ___ KK for Clinicians KAPT43 ___ QG for Clinicians QGCT25 ___ TIP 34 BKD341 ___ KK for Clinicians KAPT25 ___ QG for Clinicians QGCT34 ___ TIP 44 BKD526 ___ KK for Clinicians KAPT34 ___ QG for Clinicians QGCT44 ___ KK for Clinicians KAPT44 ___ TIP 35 BKD342 ___ QG for Clinicians QGCT35 ___ TIP 45 BKD541 ___ KK for Clinicians KAPT35 *Under revision ___ Faces PHD1103 ___ TIP 46 BKD545 †QG = Quick Guide; KK = KAP Keys ___ TIP 47 BKD551

Name: Address: City, State, Zip: Phone and e-mail: You can either mail this form or fax it to (240) 221-4292. Publications also can be ordered by calling SAMHSA’s NCADI at (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889. TIPs can also be accessed on line at www.kap.samhsa.gov. FOLD

STAMP

SAMHSA’s National Clearinghouse for Alcohol and Drug Information P.O. Box 2345 Rockville, MD 20847-2345

FOLD

Substance Abuse: Clinical Issues in Intensive Outpatient Treatment

This TIP, Substance Abuse: Clinical Issues in Intensive Outpatient Treatment, addresses the practical needs of treatment providers as they design and implement intensive outpatient treatment programs. The TIP provides specific information on the principles of intensive outpatient treatment; services and treatment models; modifications for distinct population groups; culturally competent treatment; screening and patient placement criteria; counseling methods and techniques, including involvement of families; and the continuum of care. The TIP also covers such important issues as how to improve early retention, provide the appropriate length and intensity of services, provide the most promising mix of wrap-around services for positive client outcomes, and arrange ongoing care in the community.

Collateral Products Based on TIP 47

Quick Guide for Clinicians KAP Keys for Clinicians

DHHS Publication No. (SMA) 06-4182 NCADI Publication No. BKD551 Printed 2006

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