Substance Abuse
Treatment 2014
Clinical Service Delivery Using the Practice Dimensions
Michael W. Herring
Screening (TAP 21 – Pg 37)


Process for determining appropriateness and
eligibility for admission to program.
DSM-IV-TR criteria for Abuse and
Dependency, no matter what the substance,
it’s the same. Not assessing for treatment
plan, just enough for determining
appropriateness/eligibility. Ask questions in a
different format, not just reading off list.
Clinical Evaluation
Abuse
1 or more of the following within a 12month period
1). Failure to fulfill major role obligations
(ever quit job)
2). Recurrent use in situations that are
hazardous (Drive/Wk)
3). Recurrent legal problems (DWI, Public
Drunk, shoplift)
4). Continued use despite knowledge of
problems
Clinical Evaluation
Dependency
3 or more of the following occurring at the
same time in the same 12 month period.
1). Tolerance
2). Withdrawal
3). Substance taken in larger amounts or over
longer period of time than was intended
4). Desire or efforts to cut down or control use
5). Great deal of time getting, using or
recovering from effects
6). Important activity given up or reduced due
to use
7). Use despite knowledge of a problem
Clinical Evaluation
In evaluating signs/symptoms of
use/abuse/dependency be familiar
with:

Psychological: Mental status, oriented x4 (person, place,
time, and situation), aggressive behavior, arrested
emotional development, cognitive clouding, inappropriate
affective responses (crying when happy, laughing when
sad). *Be careful of diagnosing Bi-Polar* -always remember
Substance-Induced, Mood Disorders, Dementia, Delirium,
etc. Paranoia, excessive suspiciousness, suicidal/homicidal
ideation, etc.

Social: Listen for - # of friends, alienated, ostracized,
withdrawn, lonely/alone. Short social hx – recreation
activity, vocational hx. How do friends and family feel about
use? Prostitution, promiscuity, poor judgment/problem
solving skills. Legal problems, financial problems.

Physiological: Liver problems, wt loss, recurrent medical
problems, stomach, pancreas, and internal organ problems.
Substance-Induced medical problems. Hx of malingering.
Clinical Evaluation
In looking for appropriateness and eligibility
remember:
Appropriate: Suitable; fitting
Eligible: Qualified; worthy of choice


Appropriateness: determined by being suitable for environment
and modality (in-patient, out-pt), residential/non-residential
chemotherapy (methadone, detox), daycare (DRC, JDRC, out-pt
detox, and intensive out-pt). Physical condition of client, psych
functioning (level of articulation, ed level, disability), outside
supports, resources, previous tx hx, motivation and philosophy of
program.
Eligibility of client determined by focus (harm reduction,
re/habilitation), target population (males, females, adolescents,
gays, etc), funding requirements (only county/state residents).
Other eligibility requirements include age, legal status, veteran
status, income level, and referral source.
Clinical Evaluation



The procedures by which a counselor/program
evaluate an individual’s strengths, problems and
needs for the development of a Tx Plan.
A continuing procedure in which the counselor
IDs and evaluates the client’s strengths,
weaknesses, problems and needs in order to asst
in the development of a tx plan. This process is
used to evaluate major life areas (i.e. physical
health and functioning, vocational development,
social adaptation, and legal involvement). Also to
assess the extent to which alc/drugs has
interfered with the client’s functioning in each of
these areas.
The result of this assessment should suggest the
focus of tx!!
Clinical Evaluation
Clinical Evaluation

Always use appropriate interview techniques – closed and openended questioning, “miracle” questioning, summarizing,
clarification. Specific facts from hx are important. Once info is
gained, counselor will use this info to assess [job loss,
married 4x (relational diff), no recreational activity (avocation
deficiency), few friends (no supports), meets DSM criteria
(social
obligations, multiple DWI’s)].

Focus should be on how this relates to alco/drug use of client.

This leads to the development of diagnostic evaluation of results
of assessment. Usually including a DSM-IV five axes Dx:
I: Clinical Disorders; Other Conditions That May be a Focus
of Clinical Attention
II: Personality Disorders; Mental Retardation
III: General Medical Conditions
IV: Psychosocial and Environmental Conditions
V: Global Assessment of Functioning
 Process
in that the counselor and client ID
and rank problems, establish agreed upon
immediate and long-term goals, and decide
upon a tx process and resources to be
utilized.
 This is a tx contract, based on the results of
the assessment and is the product of a
negotiation b/t client and counselor. The
language of the problems, goals and strategy
statements should always be specific,
intelligible to the client and expressed in
behavioral terms. The statement of the
problem precisely elaborates on a client need
ID’ed previously.
Treatment Planning
 The
goal statements refer specifically to the
ID’ed problem and may need 1 objective or a
set of objectives intended to resolve or
mitigate the problem. Behavioral terms are
used in the goals in order for the client and
counselor to determine progress in tx.
 The intervention or strategy is a specific
activity used to link the problem with the
goal. It describes the services, who is
responsible, when to be provided, and at
what frequency.
 Tx plans are dynamic and regularly reviewed
and modified PRN.
Treatment Planning
SMART Goals:
S: Specific
M: Measureable
A: Attainable
R: Realistic
T: Time-Limited
Treatment Planning

The results of the assessment are usually
explained to the client. Dx’s should be
communicated tactfully.

Problems should be ID’ed and ranked in
order of priority. The client should be part
of this process, all the way through. The
Person-Centered approach should always
be utilized.
Treatment Planning

After problems are ID’ed and ranked,
then both set out to formulate immediate
(in tx) and long-term goals (post tx).
Always use
behavioral terms (Decrease drug use
impulsively by 75%, increase refusal skills
by 75%; decrease instances of cursing by
75%,
increase instances of affirming by 50%,
etc ).
Treatment Planning

Always identify methods and resources
used to assist the client (per their
individual
needs), so that they may accomplish
goals.

Any resources should be id’ed– which
planned
interventions (group, individual),
lectures,
equipment, books, videos, telephone,
TV, etc).
Treatment Planning
This is identifying the needs of the client
that cannot be met by the
counselor/agency and assisting the client
to utilize the supports and community
resources available.
 The counselor should be aware of the
community resources, both AOD and
others and be aware of the limitations of
each service and if these limitations could
adversely affect the client. He/she should
also be able to demonstrate a working
knowledge of the referral process,
including confidentiality requirements and
tracking outcomes of the referral.

Referral

The counselor must be aware of the
community resources, both AOD and
others and be aware of the limitations of
each service and if these limitations could
adversely affect the client. He/she also be
able to demonstrate a working knowledge
of the referral process, including
confidentiality requires and outcomes of
the referral.
Referral

This is closely related to case
management when integrated into the tx
plan. It also includes aftercare or
discharge planning referrals that take into
account the continuum of care.
Referral
A licensed/certified professional serving as
a clinical supervisor shall:
1. Be aware of his or her influential position
with respect to students, employees and
supervisees and therefore not exploit
the trust and dependency of such
persons.
2. Avoid dual relationships which could
impair professional judgment, increase
the risk of exploitation, or potentially
cause harm to the supervisee. To
implement this standard the supervisee
shall not:
Ethics: Supervisor to Supervisee
Ethics: Supervisor to
Supervisee
a). Instruct or supervise family members who
are related by blood to the second degree or
marriage or a member of the supervisor’s
household as students or supervisees
(related by marriage means related to
spouse, brother-in-law, mother and
father-in-law);
b). Provide therapy or therapeutic counseling to
students, employees or supervisees; or
c). Solicit or engage in sexual activity or contact
with students or supervisees during the
period of supervision.
3.
Be trained in and knowledgeable about
supervision methods and techniques.
4.
Shall supervise and consult only in his or her
knowledge training and competency.
5.
Guide his or her supervisee to perform services
responsibly competently, and ethically. The
supervisor shall assign to his or her employees,
supervisees and students only those tasks or
duties that these individuals can be expected to
perform competently, based on the supervisee’s
education, experience or training, either
independently or with the level of supervision
being provided.
Ethics: Supervisor to Supervisee
6. Not disclose the confidential information
provided by the supervisee except:
a). As mandated by law;
b). To prevent harm to a client, an organization, or other
persons involved with the supervision;
c). Where the supervisee is the respondent or defendant in a
civil, criminal, or disciplinary action;
d). In educational or training sessions where there are multiple
supervisors, and then only to the other professional
colleagues who share responsibility for the performance or
training of the supervisee; or
e). If consent is obtained in writing, and that such information
shall be revealed only:
i). In accordance with the terms of the consent; and
ii). After being clear to the supervisee regarding the limits to
confidentiality within the supervisory relationship, and
pursuant to 21 NCAC 68 .0508 of the North Carolina
Administrative Code.
Ethics: Supervisor to Supervisee
7.Establish and facilitate a process for providing
evaluation of performance and feedback to
supervisee. To implement this process the
supervisee shall be informed of the timing of
evaluations, methods, and levels of competency
expected.
8.Not endorse students or supervisees for
certification, licensure, employment, or completion
of an academic training program if they believe the
supervisees are not qualified for the endorsement
to become qualified.
9.Make financial arrangements for any remuneration
with supervisees and organizations only if these
arrangements are clear and in writing. All fees shall
be disclosed to the supervisee prior to the
beginning of supervision, if practical.
Ethics: Supervisor to Supervisee
Questions
&
Attempted Answers
Substance Abuse Treatment 2009