Santa Clara Valley Health & Hospital System
Department of Alcohol & Drug Services
Best Practices In the Treatment
of Substance Abuse Disorders
Department of Alcohol & Drug Services Adult System of Care
Best Practices rev. 2-08
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BEST PRACTICE STANDARDS IN THE TREATMENT OF
SUBSTANCE ABUSE DISORDERS
CONTENTS:
1.
OVERVIEW, DESCRIPTION, AND RATIONALE
1.1 General Description
1.2 Treatment Goals
1.3 Theoretical Rationale/Mechanism of Action
1.4 Agent of Change
1.5 Conception of Drug Abuse/Addiction - Causative Factors
2.
CONTRAST TO OTHER COUNSELING PRACTICES
2.1 Most Similar Counseling Practices
2.2 Most Dissimilar Counseling Practices
3.
TREATMENT FORMAT
3.1 Treatment Approach
3.2 Duration of Treatment
3.3 Compatibility with Other Treatments
3.4 Role of Self-Help Programs
4.
CLINICAL DECISIONS
4.1 Continued Service
4.2 Client Transfers
4.3 Client Discharge
5. COUNSELOR CHARACTERISTICS & TRAINING
5.1.
Educational Requirements
5.2.
Counselor’s Recovery Status
5.3.
Ideal Personal Characteristics of Counselor
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6.
7.
5.4.
Counselor’s Behaviors Prescribed
5.5.
Counselor’s Behaviors Proscribed
5.6.
Counselor Supervision and Training
CLIENT-COUNSELOR RELATIONSHIP
6.1
What Is the Counselor’s Role?
6.2
Who Talks More?
6.3
How Directive Is the Counselor?
6.4
The Therapeutic Alliance
6.5
Counselor’s Clinical Paperwork
TARGET POPULATIONS
7.1 Targeted Clinical Populations
7.2 Clients With Co-Occurring Disorders
7.3 Clients With Prescription Medications
7.4 Pregnant Clients
8.
9.
CLINICAL QUALITY ASSURANCES
8.1
Assessment
8.2
Client Data Collection and Review
SESSION FORMAT AND CONTENT
9.1
Format For a Typical Session
9.2
Typical Session Topics or Themes
9.3
Session Structure
9.4
Strategies for Dealing With Common Clinical Problems
9.5
Strategies for Dealing with Denial or Treatment
Resistance
9.6
Counselor’s Response To Relapse Behaviors
9.7
Counselor’s Response To Client Violence
9.8
Counselor’s Response To Client Sexual Relations At Treatment Facilities
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9.9
Counselor’s Response To Client Homicidality/Suicidality
9.10
Clinical Documentation
10.
OUTCOMES
11.
COMMUNICATION
12.
CONFIDENTIALITY
13.
CLIENT RIGHTS
ATTACHMENTS:
A. RESEARCH-BASED PRINCIPLES OF DRUG ADDICTION TREATMENT (NIDA. 2009)
B. RESEARCH-BASED GUIDELINES FOR DRUG TREATMENT IN THE CRIMINAL
JUSTICE SYSTEM
C. THE CLINICIAN’S GUIDE TO WRITING TREATMENT PLANS AND PROGRESS NOTES
(Can download this document from the DADS website at: www.sccdads.org under the QuickLinks
section on the right hand column).
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BEST PRACTICE STANDARDS IN THE TREATMENT OF
SUBSTANCE ABUSE DISORDERS
1. OVERVIEW, DESCRIPTION, AND RATIONALE
1.1 General Description
A review of the research and literature relating to most effective elements and dynamics of a
successful treatment program was conducted to determine what is considered best practices in the
treatment of substance abuse disorders. The current research-based best practices tend to merge the
biopsychosocial theoretical perspective of addictive disorders. This includes supportive counseling,
motivating client readiness for change and coping skills-training techniques. The goals of treatment
are to establish and maintain abstinence from the illicit use of all psychoactive drugs, foster
development of (nonchemical) coping and problem-solving skills to stop and ultimately eliminate
impulses to "self-medicate" with psychoactive drugs, and to enhance and sustain client motivation
for change. The approach is based on 12- Step facilitation therapy, cognitive-behavioral,
motivational, and insight-oriented techniques according to each client's individual needs. These best
practices counseling standards can be applied in any level of care and throughout the continuum of
addictions treatment.
The therapeutic approach is empathic, client centered, and flexible. Strong emphasis is placed on
developing a good working alliance with the client to facilitate behavioral change. With clients who
are referred from Criminal or Dependency Courts, the counselor takes advantage of the leverage
from this referral to help motivate the client to participate in a treatment/recovery process.
The counselor attempts to work with and through rather than against a client's resistance to change.
Aggressive confrontation of denial, the hallmark of traditional addiction counseling, is seen as
counterproductive and antithetical to this approach.
Group and individual counseling are delivered within the context of a flexible treatment program
that also includes psych-education (PE), pharmacotherapy for coexisting psychiatric disorders and
where indicated, urine testing and alcohol breathalyzer tests to encourage and verify abstinence.
Client participation in self-help is encouraged but not mandated.
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1.2 Treatment Goals
The broad goals of treatment are reduction of drug/alcohol use and/or abstinence. In order to attain
these goals, clients need to: recognize their problem, understand the effect of drugs/alcohol on their
lives and the implications for recovery, and learn to successfully apply effective coping and relapse
prevention skills.
1.3 Theoretical Rationale/Mechanism of Action
Psychoactive drug addiction is viewed as a multidetermined addictive behavior and maladaptive
(self-medication) coping style with biological, psychological, and social components (a
biopsychosocial perspective).
Accordingly, treatment must provide the structure, support, and feedback required to break the
behavioral cycle of compulsive psychoactive drug use and provide opportunities to learn adaptive
(nonchemical) problem solving skills to prevent relapse.
1.4 Agent of Change
Best practice standards promotes the development of a strong therapeutic alliance between client and
counselor along with positive bonding among clients within a group. Caseload size may vary
according to the given needs of each program.
1.5 Conception of Drug Abuse/Addiction - Causative Factors
According to the American Society on Addiction Medicine (ASAM) drug addiction is seen, and
clinically treated as a chronic disease that is progressive, relapsing, incurable and potentially fatal
with genetic, psychosocial and environmental factors influencing its development and
manifestations. The disease is set into motion by experimentation with a drug by a susceptible host
in an environment conducive to drug misuse. The susceptible user quickly experiences a
compulsion to use and will continue to use despite adverse physical, emotional or life consequences.
2. CONTRAST TO OTHER COUNSELING PRACTICES
2.1 Most Similar Counseling Practices
This set of best practice principles incorporates features of other methods, including systems
approaches described by Duncan (1993), social learning dynamics, motivational counseling
techniques described by Miller and Rollnick (1991), relapse prevention (RP) strategies described by
Marlatt and Gordon (1985), and psychodynamic techniques described by Tarnoff (1998) and also by
Brehm and Khantzian (1992). Participation in self-help programs is actively encouraged and is seen
as helpful and highly desirable, but it is not mandatory. Self help groups can provide clients with the
benefits of social learning dynamics and can bridge the gap between clinic appointments and
counseling sessions.
2.2 Most Dissimilar Counseling Practices
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The hallmarks of these best practice standards are clinical flexibility and careful attention to
individual needs. As such, they contrast sharply with aggressive confrontational approaches
commonly found in traditional treatment programs. In addition, the program should conform to the
client’s needs rather than the client conforming to the program.
3. TREATMENT FORMAT
In the treatment of drug addiction, the use of an assessment model that has a biopsychosocial focus
is a best practice standard. An example of this is the multidimensional assessment model used by
DADS and developed by the American Society of Addiction Medicine (ASAM) Patient Placement
Criteria for Substance Related Disorders, Second Edition (PPC-2R). This assessment tool is used as
the basis for determining client placement at every stage in the treatment process.
Each client is provided with a comprehensive assessment utilizing the ASAM PPC-2R to determine
the most appropriate level of care and to develop a treatment plan. An individualized treatment plan
contains concrete and behaviorally measurable short and long term goals. Treatment plans are
updated every 3 months at a minimum.
Treatment involves group therapy at a rate determined by the clients need and program capacity and
can be supplemented by individual counseling as needed. If the program cannot meet the individual
needs of the client, the client is referred to another program that can best meet their needs. Although
group therapy is the core treatment modality, those clients who are not “group ready” are given the
option of individual counseling.
Many of these clients subsequently agree to enter group therapy once they have formed a positive
relationship with their assigned primary counselor and worked through their initial concerns about
participating in a group. Some clients are not able to tolerate group as a result of psychiatric and/or
interpersonal impairments, and are seen individually.
3.1 Treatment Approach
This clinical approach takes into account the biopsychosocial perspective of the client’s various
needs. Regardless of the type of treatment setting, the biopsychosocial approach recognizes that the
client is continuously faced with the pressures and stressors of daily life and has easy access to
psychoactive drugs. Treatment should take into account that a driving motivational force for the
chemically dependent person is the severity and intensity of drug craving behaviors, the desire to
self-medicate the symptoms of drug withdrawal and the compulsive need to change the way they
feel. It also recognizes that typical for any treatment setting, the client is always free to drop out of
treatment; accordingly, strong emphasis is placed on therapeutic engagement and retention
strategies.
3.2 Duration of Treatment
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A distinguishing feature from the best practices research is the variable-length treatment format. The
length of a client's participation in the program from admission through completion can range from
several weeks to many years as determined by modality of treatment and the objective measures of
clinical progress (i.e., providing clean urines, attending scheduled sessions, developing a sober
support network that includes involvement in self-help, and exercising adaptive (nondrug) problem
solving skills). For instance, in methadone maintenance treatment, which can last for the client’s
lifetime, reducing medication dose levels and/or defining a medication/treatment program
completion date are not necessarily goals in the client’s treatment.
3.3 Compatibility With Other Treatments
Operating from a basic philosophy of using whatever best-practice treatment intervention seems to
work best, these best practice standards are compatible with a variety of other treatment approaches.
For example, there is no anti-medication bias so long as the medications being offered are clinically
appropriate and monitored closely if they are mood enhancing (i.e. pain medication, anti-anxiety
medicines, benzodiazepines used in detox, OTCs, etc.). Clients with diagnosed psychiatric disorders
are treated with psychotropic medication (e.g., antidepressants, antipsychotics) as clinically required.
3.4 Role of Self-Help Programs
The program actively encourages but does not mandate the client's participation in self-help groups.
All clients are given a basic orientation to self-help and what it has to offer that professional
treatment does not. They are also given a list of meetings in their community. Clients are not
threatened with termination from treatment for failure to attend self-help meetings, nor is their
reluctance or refusal to attend self-help meetings seen as intractable resistance or denial.
4. CLINICAL DECISIONS
All clinical decisions, i.e. assessment, level of care placement and treatment, continued services,
transfers, and discharge plans are based on an evaluation of the client using the six ASAM PPC
assessment dimensions and the client’s stage of change.
4.1 Continued Service
Clients are continually assessed during the course of treatment. During the assessment process,
problems and priorities are identified which justify admission and continued treatment. The
resolution of those problems and priorities determines when a client may be ready for discharge.
The appearance of new problems and priorities may require continued service either at the current
level of service or at a more or less intensive level of service. The six ASAM PPC assessment
dimensions are reviewed to assess the clients progress and to determine the need for continued, more
or less intensive services.
4.2 Client Transfers
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Throughout a treatment episode clients may be transferred from one level of care to another as their
treatment needs change. Providers: (a) continually assess a client’s treatment needs and treatment
progress to determine when the client should be transferred to another level of care, (b) arrange the
client’s transfer, and (c) collaborate with staff at the next Provider site in order to facilitate a smooth
transition for the client.
4.3 Client Discharge
It is appropriate to discharge the client from the current level of service when the client has achieved
the goals articulated in the individualized treatment plan, thus resolving the problem(s) that justified
admission to the current level of service. Each of the six ASAM PPC assessment dimensions is
reviewed to assess the progress related to the problem(s) that justified admission. When these have
been resolved and there are no new problems to address at the current level of service, the client is
considered for discharge.
5. COUNSELOR CHARACTERISTICS AND TRAINING
5.1 Educational Requirements
Psychologists have master's degrees or doctorates. Services they provide include:
• Assessment and diagnosis
• Drug and alcohol counseling including relapse prevention education and planning
• Crisis intervention
• Psychological testing and evaluation (doctoral level)
• Psychotherapy, including family therapy, for clients with dual diagnoses and with
complicated psychiatric conditions
• Pre- and posttest HIV counseling
• Skills training, including vocational skills, parenting skills, and life skills
• Supervision of other staff who provide these services
• Consultation to program staff about behavioral therapy strategies
• Research and development
Marriage/Family Therapists and Clinical Social Workers typically have master's degrees, may be
licensed and have training in a wide range of useful skills. Depending on their background and
training, they can provide a similar range of services as described above.
Addiction Specialists and Drug Counselors
Most chemical dependency treatment programs hire persons with bachelor's degrees or less formal
education to serve as addiction specialists or rehabilitation counselors (RC). Many have no training
in a specific discipline but have an interest in treating addicted individuals. Many have learned
drug-counseling techniques through their work experience in drug treatment programs or through
their own recovery experiences. Generally, they provide services such as:
• Assessments
• Address addiction issues and concrete problems via individual and group counseling
• Drug and alcohol counseling including relapse prevention education and planning
• Psycheducational groups on addiction and related topics
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•
•
•
Case management and referrals.
Training in vocational and general life skills
Crisis intervention
5.2 Counselor’s Recovery Status
A counselor’s recovery status (i.e. they are or they are not in recovery) should not effect hiring
decisions. Rather, hiring decisions should be based on demonstrated clinical competence. However,
counselors who are in recovery are expected to have a minimum length of sobriety (2 years), which
may vary according to the modality.
5.3 Ideal Personal Characteristics of Counselor
Ideally, the counselor should be warm, empathetic, engaging, tolerant, nonjudgmental, and flexible
in interacting with clients. The counselor should have a well-developed observing ego and be able to
receive and use constructive feedback, particularly with regard to the types of countertransference
and control problems likely to arise with highly ambivalent (resistant) clients. The counselor must
have excellent verbal communication skills and be capable of defining and implementing appropriate
behavioral limits with clients in a consistently therapeutic (nonpunitive) manner.
5.4 Counselor's Behaviors Prescribed
The counselor's role is to motivate, engage, guide, educate, and retain clients during their treatment
episode in the program. Using an array of, client-centered, problem solving and motivational
techniques, counselors are expected to:
♦ Emphasize the client's strengths rather than weaknesses.
♦ Join rather than assault resistance.
♦ Avoid aggressive confrontation and power struggles.
♦ Negotiate rather than dictate treatment goals.
♦ Emphasize the client's personal responsibility for change.
5.5 Counselor's Behaviors Proscribed
The counselor is cautioned against being dogmatic and controlling, especially in response to
reluctant and resistant clients. It is easy for the counselor to lose sight of the fact that the first and
foremost goal of treatment is to engage the client in a friendly, cooperative, positive interaction that
increases the client's willingness to examine and change his or her drug-using behavior. Counselors
are taught how to avoid the most common therapeutic blunders and negative countertransferential
responses with drug-abusing clients. These blunders include:
♦ Predicting abject failure and misery if the client does not follow the counselor's advice.
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♦ Telling the client that what he or she really needs is more drug-related negative consequences to
acquire the motivation for change.
♦ Ignoring the client’s goals in favor of the counselor’s or the program’s goals
♦ Feeling frustrated and angry with clients who do not meet the counselor’s expectations.
♦ Wanting to impose negative consequences on noncompliant clients (e.g., depriving them of
further help by "throwing them out of treatment") rather than negotiating a change in a treatment
plan based on clarification of the client's ambivalence about change.
5.6 Counseling Supervision and Training
Counseling and Supervision: Clinical supervision is an essential component of clinical best practice.
Counselors should consider clinical supervision to be a normal part of their job duties. Quality
counseling requires regular, ongoing feedback regarding one’s clinical practices and the appropriate
attitude in the application of the feedback in a conscientious and responsible manner. The proper
attitude towards the experience of receiving clinical supervision is a part of a responsible clinicians
job function. While it may be difficult at times to receive feedback that seems to be judging one’s
work, it is essential that clinicians participate openly in supervision and not take a defensive,
argumentative stance with the clinical supervisor.
6. CLIENT-COUNSELOR RELATIONSHIP
6. 1 What Is the Counselor's Role?
The counselor serves a multidimensional role as collaborator, teacher, adviser, and changefacilitator. Counseling staff is not expected to function outside the scope of their training. Referring
clients for additional therapy or to someone who is trained to deal with certain situations is essential.
The counselor must become knowledgeable with the resources available in the community.
6.2 Who Talks More?
In general, the client talks more. The counselor does not hesitate to ask questions to elicit the client’s
participation and involvement in the treatment process.
6.3 How Directive Is the Counselor?
The counselor takes an active role, asking questions, offering advice and direction, particularly
during the early phases of treatment where immediate behavioral changes are required to establish
and maintain abstinence.
6.4 The Therapeutic Alliance
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One of the most important aspects of the therapeutic alliance (TA) is the development of a
cooperative relationship between client and counselor. Building a positive TA requires the counselor
to start where the client is (i.e., to accept and work within the client's frame of reference). This stands
in marked contrast to traditional approaches, which demand that the client submit to the counselor's
(program's) frame of reference as the starting point of treatment. For example, if the client at first
minimizes the seriousness of his or her drug use problem or rejects the idea that it is a problem at all,
the counselor refrains from accusing the client of being in denial (a tactic likely to heighten rather
than reduce the client's defensiveness) and instead asks the client to cooperate in a time-limited
experiment (usually involving a trial period of abstinence) to assess the nature and extent of his or
her involvement with psychoactive drugs.
Treatment does not need to be voluntary to be effective. Clients can appear for treatment angry,
suspicious, mistrustful, and “ready to do battle”. Building a relationship under these circumstances
requires a great deal of clinical finesse on the part of the counselor, who makes every effort to:
♦ Empathize with the client's experience and the fact that no one likes to be told what to do.
♦ Accept without challenge the client's primary motivation for coming to treatment—to get the
coercing agent (e.g., court, employer) "off my [the client's] back."
♦ Compliment the client for facing the realities of the situation by showing up at the session.
♦ Offer to help the client solve the problem or problems that led to the current situation.
6.5 Counselor’s Clinical Paperwork
The clinical counseling staff, whether licensed or unlicensed, has significant record keeping
responsibilities. They play a major role in developing the initial treatment plan, monitoring its
implementation, explaining the importance of treatment to the client, updating the plan at specified
intervals (at least every 3 months from admit date), and making sure the client understands the
reasons for modifications or adjustments in treatment. Behavioral health care treatment today relies
heavily on documentation of the client’s treatment episode. Therefore, good charting practices,
time-management skills, multi-tasking and the ability to focus on the charting aspects of the clinic
operations is essential.
7. TARGET POPULATIONS
7.1 Targeted Clinical Populations
These best practice principles are best suited for clients who meet DSM-IVTR criteria for substance
abuse/dependence as a primary condition. Programs admit clients who are actively using alcohol
and other drugs and who may also have co-occurring conditions of mental illness or medical
problems. Chronically unemployed, dysfunctional clients are sometimes treated in separate groups
from clients with substantially higher levels of psychosocial functioning.
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While treatment programs are coeducational, a special men’s and women's group should be available
to explore those specific areas unique to gender. A special dual-focus group (separate from the
mainstream program) can accommodate the special needs of clients with concurrent psychiatric
illness.
7.2 Clients with Co-occurring Disorders
All treatment providers should be dual-diagnosis capable and provide services that address the
client’s co-occurring disorders.
7.3 Clients With Prescription Medications
Clients who are taking prescription medications for any physical or mental conditions are provided
the same services and benefits as any other client.
7.4 Pregnant Clients
Best practices recognizes that pregnant women have special needs and make every effort to engage
these clients in treatment where they can receive specialized, coordinated substance abuse treatment
and perinatal care.
8. CLINICAL QUALITY ASSURANCES
8.1 Assessment
A best practice standard in the treatment of drug addiction requires a biopsychosocial assessment.
For example, DADS uses a multidimensional assessment developed by ASAM that allows for a
biopsychosocial assessment along six key domains.
1.
2.
3.
4.
5.
6.
Acute Intoxication and/or Withdrawal Potential
Biomedical Conditions and Complications
Emotional/Behavioral or Cognitive Conditions and Complications
Readiness to Change
Relapse/Continued Use or Continued Problem Potential
Recovery/Living Environment
The clinician gathers pertinent collateral information to complete the assessment where necessary
(e.g. psychiatric, medical).
During the subsequent clinical interviews, the counselor continues to assess, clarify and expand on
the information provided. Where indicated, the assessment may require one or more additional
sessions and may also include a formal psychiatric assessment. Within the first two weeks of
admission, the client and counselor develop a treatment plan.
8.2 Client Data Collection and Review
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Clinical progress is reviewed and measured on a regular basis throughout the client’s treatment
episode. An office data management system stores and reports clinical information on all clients
during the course of their participation in the program. These data include:
♦ Urine test results.
♦ Attendance at scheduled sessions.
♦ Progress toward achieving treatment goals.
♦ Client satisfaction and attitudes toward the treatment experience.
♦ Outcome evaluation measures
The data are reviewed on a regular basis to continuously adjust the treatment to improve overall
treatment effectiveness.
9. SESSION FORMAT AND CONTENT
9.1 Format for a Typical Session
A typical group session begins with each client stating what issue he or she wishes to discuss in that
session. Every client is expected to identify at least one issue for discussion at each session. The
counselor or group leader may pull together the issues of two or more group members into a theme
for that session or, alternatively, may begin the session with a specific topic as part of a revolving
sequence.
In general, group sessions are devoted to day-to-day concerns and struggles raised by the clients
themselves (with appropriate guidance and framing of the discussion supplied by the counselor); or
to a specific informational or skills-training topic where the counselor presents a brief lecture and
guides a focused discussion (i.e. environmental triggers and relapse prevention theory). A typical
session may also review the clients treatment plan and progress made since the last review.
9.2 Typical Session Topics or Themes
The following is a partial list of topics and themes: tips for quitting; finding your motivation to quit;
how serious is your problem—taking a closer look; identifying your high-risk situations; coping with
your high-risk situations; dealing with cravings and urges; warning signs of relapse; rating your
relapse potential—a realistic assessment; tips for handling slips; managing anger and frustration;
finding balance in your life; how to have fun without getting high; defining your personal goals;
managing problems in your relationships; building your self-esteem; nutrition and personal health;
AIDS and other sexually transmitted diseases—how to avoid them; overview of treatment and
recovery; how your family can help without hurting—a look at coaddiction.
9.3 Session Structure
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The purpose of each session is to improve the client’s ability to cope adaptively with the problems of
everyday life without reverting to psychoactive drug use and also to enhance the client's motivation
for change. To accomplish this task successfully, sessions are neither highly structured nor totally
unstructured. The sessions serve more to stimulate discussion than present material in a didactic
manner. The group leader takes an active role in helping each group member relate the topic to his or
her own personal situation. The goal is to foster emotional and behavioral change rather than merely
supply factual information.
9.4 Strategies for Dealing With Common Clinical Problems
Lateness, absenteeism and positive UAs are addressed therapeutically as behavioral manifestations
of a client's ambivalence about change. The importance of clients arriving at counseling and group
sessions on time and attending the program reliably is emphasized, starting with the initial intake
interview.
9.5 Strategies for Dealing with Denial or Treatment Resistance
Enhancing a client's motivation for change is an essential part of the counselor's role in addiction
treatment. Toward that end, it is counterproductive to label a client as being in denial, resistant to
change, or poorly motivated. Instead, these issues are framed in terms of a client’s natural
reluctance, fear, and ambivalence about change. The counselor actively joins the client's reluctance
and works collaboratively with the client to overcome obstacles to treatment.
Although best practices avoid the use of confrontational tactics, they do not take a laissez-faire,
anything-goes attitude toward the client’s progress in treatment. Limit setting and constructive
feedback are essential features of the approach used to enhance a client's motivation for change.
9.6 Counselor's Response to Relapse Behaviors
A relapse to alcohol and/or other drug use during treatment is viewed and managed as a clinical
issue. Every effort is made to retain clients in treatment, providing the level of care that is most
appropriate to their changing needs.
Relapsing behaviors are treated as avoidable mistakes and manifestations of ambivalence. The
thoughts, feelings, circumstances, and chain of setup behaviors leading up to the relapse are
carefully reviewed. The first goal of this debriefing is to help the client recognize and accept the role
of personal choice and responsibility in determining drug-using behavior. To decrease the likelihood
of further use, a relapse prevention plan is formulated that incorporates specific decision-making,
problem solving, and behavioral avoidance strategies.
9.7 Counselor's Response To Client Violence
Violence is defined as a broad range of offensive behavior with varying degrees of severity. Client
violence is managed on a case-by-case basis, using a range of standardized consequences.
9.8 Counselor's Response To Client Sexual Relations At Treatment Facilities
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Sexual relations between consenting adult clients while they are at a treatment site can become an
issue for the treatment provider and represents a barrier to recovery for the clients. Treatment
providers manage this behavior as a clinical issue.
9.9 Counselor's Response To Client Homicidality/Suicidality
A client’s threat to harm self or others is addressed in the standard, clinically appropriate manner.
All applicable laws related to mandatory reporting will be followed.
9.10 Clinical Documentation
Progress notes describe the process of change and movement toward the completion of treatment
plan goals. They provide a record that documents the counselor’s interventions on the issues and
concerns the client presented as well as the client’s response toward the type of help that was
provided. Each entry of the progress notes should have some statements within the following 4
areas:
1. Identifies the issue(s) from treatment plan
2. Describes the type of intervention the counselor used
3. Describes any follow-up from previous issues
4. Identifies any new problems (may require a treatment plan update)
10. OUTCOMES MEASUREMENT
Evidence Based Practices (EBP) include more than just the use of specific empirically approved
treatments or theories. The “…ongoing monitoring of patient progress and adjustment of treatment
as needed are essential to EBPP.” (APA Presidential Task Force on Evidence-Based Practice, 2005)
This ongoing (concurrent) monitoring is one form of the practice that is referred to as Outcomes
Measurement.
Traditionally, outcomes measurement has been information collected at intake and then again at
discharge. The resulting differences in data are used to make changes to treatment protocols, policies
and programs. Also, data collected before the application of a specific intervention or treatment
model and then again after the application typically is used for making determinations about the
relative effectiveness of a treatment to a particular population.
One of the newly emerging aspects of EBP is the use of outcomes data for informing clinical
decisions in real time practice. DADS has chosen to engage in the use of concurrent outcomes
measurements to support treatment decisions as they occur. This use of outcomes data is often
referred to as Practice Based Evidence; meaning that the outcomes data being collected is from the
actual practice of the treatment in real life conditions and is directly relevant to the specific clinical
work at hand. The advantages of having this type of outcome data available during the course of
treatment lies primarily in the opportunities for the clinician to match and adapt treatment
approaches and interventions specifically to the client’s needs as they evolve through a treatment
episode.
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The use of such outcome data provides the client with an ongoing record of their work as the
treatment episode evolves. It provides the clinician with useful data on certain variables known to
effect eventual outcomes (such as the quality of the treatment alliance), that aren’t typically
accounted for in the research that establishes the effectiveness of specific treatments. Clinicians are
also able to assess specific trends in a client’s outcome data that may indicate treatment relevant
conditions, e.g. the possibility of early treatment drop out, time to change intensity, level of care, or
frequency of treatment.
DADS use of concurrent outcomes measurement currently involves the use of the Outcome Rating
Scale (ORS) and the Session Rating Scale (SRS). The ORS measures functionality in four different
domains of client functioning. It is primarily a measure of the client’s perceived level of distress.
The SRS measures the treatment alliance. It is primarily a measure of the client’s perception of the
treatment relationship. These two tools are used regularly during a treatment episode (typically once
a week) to provide both the client and the counselor on-going data regarding the treatment process.
This data is entered into the ASIST that is a computerized storage and interpretation tool for the
ORS and SRS data. The ASIST produces various statistical measures along with storing and tracking
the client’s progress. It also identifies clients that are at risk for treatment failure thus alerting staff to
cases that require clinical supervision.
11. COMMUNICATION
11.1 Inter-agency Referral
Treatment Providers communicate and collaborate with referring agencies about their mutual clients
using appropriate consent releases.
12. CONFIDENTIALITY
Treatment providers adhere to all federal and state confidentiality laws and regulations governing
client alcohol and substance abuse treatment records.
13. CLIENT RIGHTS
A list of client rights are posted in a public area at each treatment site and clients are informed of
their rights during the intake process. All clients have rights, which include, but are not limited to
the following:
1.
2.
3.
4.
To be accorded dignity in their personal relationships with program staff and other persons.
To not be discriminated against on the basis of sex, race, color, creed, religion, or national origin.
To be assured of privacy and confidentiality.
To be informed of the procedure for protecting confidentiality and for registering complaints,
including but not limited to, the name, address, and telephone number of the Client Rights
Advocate.
5. To be afforded an appeal of placement, transfer, discharge and Fair Hearing decisions.
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ATTACHMENT 1
Research-Based Principles of Drug Addiction Treatment
1. Addiction is a complex but treatable disease that affects brain function and behavior.
Drugs of abuse alter the brain's structure and function, resulting in changes that persist long
after drug use has ceased. This may explain why drug abusers are at risk for relapse even
after long periods of abstinence and despite the potentially devastating consequences.
2. No single treatment is appropriate for everyone. Matching treatment settings,
interventions, and services to an individual's particular problems and needs is critical to his or
her ultimate success in returning to productive functioning in the family, workplace, and
society.
3. Treatment needs to be readily available. Because drug-addicted individuals may be
uncertain about entering treatment, taking advantage of available services the moment people
are ready for treatment is critical. Potential patients can be lost if treatment is not
immediately available or readily accessible. As with other chronic diseases, the earlier
treatment is offered in the disease process, the greater the likelihood of positive outcomes.
4. Effective treatment attends to multiple needs of the individual, not just his or her drug
abuse. To be effective, treatment must address the individual's drug abuse and any associated
medical, psychological, social, vocational, and legal problems. It is also important that
treatment be appropriate to the individual's age, gender, ethnicity, and culture.
5. Remaining in treatment for an adequate period of time is critical. The appropriate
duration for an individual depends on the type and degree of his or her problems and needs.
Research indicates that most addicted individuals need at least 3 months in treatment to
significantly reduce or stop their drug use and that the best outcomes occur with longer
durations of treatment. Recovery from drug addiction is a longterm process and frequently
requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug
abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because
individuals often leave treatment prematurely, programs should include strategies to engage
and keep patients in treatment.
6. Counseling—individual and/or group—and other behavioral therapies are the most
commonly used forms of drug abuse treatment. Behavioral therapies vary in their focus
and may involve addressing a patient's motivation to change, providing incentives for
abstinence, building skills to resist drug use, replacing drug-using activities with constructive
and rewarding activities, improving problemsolving skills, and facilitating better
interpersonal relationships. Also, participation in group therapy and other peer support
programs during and following treatment can help maintain abstinence.
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7. Medications are an important element of treatment for many patients, especially when
combined with counseling and other behavioral therapies. For example, methadone and
buprenorphine are effective in helping individuals addicted to heroin or other opioids
stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective
medication for some opioid-addicted individuals and some patients with alcohol dependence.
Other medications for alcohol dependence include acamprosate, disulfiram, and topiramate.
For persons addicted to nicotine, a nicotine replacement product (such as patches, gum, or
lozenges) or an oral medication (such as bupropion or varenicline) can be an effective
component of treatment when part of a comprehensive behavioral treatment program.
8. An individual's treatment and services plan must be assessed continually and modified
as necessary to ensure that it meets his or her changing needs. A patient may require
varying combinations of services and treatment components during the course of treatment
and recovery. In addition to counseling or psychotherapy, a patient may require medication,
medical services, family therapy, parenting instruction, vocational rehabilitation, and/or
social and legal services. For many patients, a continuing care approach provides the best
results, with the treatment intensity varying according to a person's changing needs.
9. Many drug-addicted individuals also have other mental disorders. Because drug abuse
and addiction—both of which are mental disorders—often co-occur with other mental
illnesses, patients presenting with one condition should be assessed for the other(s). And
when these problems co-occur, treatment should address both (or all), including the use of
medications as appropriate.
10. Medically assisted detoxification is only the first stage of addiction treatment and by
itself does little to change long-term drug abuse. Although medically assisted
detoxification can safely manage the acute physical symptoms of withdrawal and, for some,
can pave the way for effective long-term addiction treatment, detoxification alone is rarely
sufficient to help addicted individuals achieve long-term abstinence. Thus, patients should be
encouraged to continue drug treatment following detoxification. Motivational enhancement
and incentive strategies, begun at initial patient intake, can improve treatment engagement.
11. Treatment does not need to be voluntary to be effective. Sanctions or enticements from
family, employment settings, and/or the criminal justice system can significantly increase
treatment entry, retention rates, and the ultimate success of drug treatment interventions.
12. Drug use during treatment must be monitored continuously, as lapses during treatment
do occur. Knowing their drug use is being monitored can be a powerful incentive for patients
and can help them withstand urges to use drugs. Monitoring also provides an early indication
of a return to drug use, signaling a possible need to adjust an individual's treatment plan to
better meet his or her needs.
13. Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B
and C, tuberculosis, and other infectious diseases as well as provide targeted riskreduction counseling to help patients modify or change behaviors that place them at
risk of contracting or spreading infectious diseases. Typically, drug abuse treatment
addresses some of the drug-related behaviors that put people at risk of infectious diseases.
Targeted counseling specifically focused on reducing infectious disease risk can help patients
further reduce or avoid substance-related and other high-risk behaviors. Counseling can also
help those who are already infected to manage their illness. Moreover, engaging in substance
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abuse treatment can facilitate adherence to other medical treatments. Patients may be
reluctant to accept screening for HIV (and other infectious diseases); therefore, it is
incumbent upon treatment providers to encourage and support HIV screening and inform
patients that highly active antiretroviral therapy (HAART) has proven effective in combating
HIV, including among drug abusing populations.
Source: Principles of Drug Addiction Treatment: A Research-based Guide (NIDA. 2009).
You can download the full document at www.nida.nih.gov/PODAT
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ATTACHMENT 2
Principles of Drug Abuse Treatment for Criminal Justice Populations: A
Research-Based Guide
1. Drug addiction is a brain disease that affects behavior. Drug addiction has well-recognized
cognitive, behavioral, and physiological characteristics that contribute to continued use of drugs
despite the harmful consequences. Scientists have also found that chronic drug abuse alters the
brain’s anatomy and chemistry and that these changes can last for months or years after the
individual has stopped using drugs. This transformation may help explain why addicts are at a high
risk of relapse to drug abuse even after long periods of abstinence and why they persist in seeking
drugs despite deleterious consequences.
2. Recovery from drug addiction requires effective treatment, followed by management of the
problem over time. Drug addiction is a serious problem that can be treated and managed
throughout its course. Effective drug abuse treatment engages participants in a therapeutic process,
retains them in treatment for an appropriate length of time, and helps them learn to maintain
abstinence over time. Multiple episodes of treatment may be required. Outcomes for drug abusing
offenders in the community can be improved by monitoring drug use and by encouraging continued
participation in treatment.
3. Treatment must last long enough to produce stable behavioral changes. In treatment, the
drug abuser is taught to break old patterns of thinking and behaving and to learn new skills for
avoiding drug use and criminal behavior. Individuals with severe drug problems and co-occurring
disorders typically need longer treatment (e.g., a minimum of 3 months) and more comprehensive
services. Early in treatment, the drug abuser begins a therapeutic process of change. In later stages,
he or she addresses other problems related to drug abuse and learns how to manage the problem.
4. Assessment is the first step in treatment. A history of drug or alcohol use may suggest the need
to conduct a comprehensive assessment to determine the nature and extent of an individual’s drug
problems, establish whether problems exist in other areas that may affect recovery. and enable the
formulation of an appropriate treatment plan. Personality disorders and other mental health problems
are prevalent in offender populations; therefore, comprehensive assessments should include mental
health evaluations with treatment planning for these problems.
5. Tailoring services to fit the needs of the individual is an important part of effective drug
abuse treatment for criminal justice populations. Individuals differ in terms of age, gender,
ethnicity and culture, problem severity, recovery stage, and level of supervision needed. Individuals
also respond differently to different treatment approaches and treatment providers. In general, drug
treatment should address issues of motivation, problem solving, and skill-building for resisting drug
use and criminal behavior. Lessons aimed at supplanting drug use and criminal activities with
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constructive activities, and understanding the consequences of one’s behavior are also important to
include. Treatment interventions can facilitate the development of healthy interpersonal relationships
and improve the participant’s ability to interact with family, peers, and others in the community.
6. Drug use during treatment should be carefully monitored. Individuals trying to recover from
drug addiction may experience a relapse, or return, to drug use. Triggers for drug relapse are varied;
common ones include mental stress and associations with peers and social situations linked to drug
use. An undetected relapse can progress to serious drug abuse, but detected use can present
opportunities for therapeutic intervention. Monitoring drug use through urinalysis or other objective
methods, as part of treatment or criminal justice supervision, provides a basis for assessing and
providing feedback on the participant’s treatment progress. It also provides opportunities to
intervene to change unconstructive behavior—determining rewards and sanctions to facilitate
change, and modifying treatment plans according to progress.
7. Treatment should target factors that are associated with criminal behavior. “Criminal
thinking” is a combination of attitudes and beliefs that support a criminal lifestyle and criminal
behavior. These can include feeling entitled to have things one’s own way. feeling that one’s
criminal behavior is justified, failing to be responsible for one’s actions, and consistently failing to
anticipate or appreciate the consequences of one’s behavior. This pattern of thinking often
contributes to drug use and criminal behavior. Treatment that provides specific cognitive skills
training to help individuals recognize errors in judgment that lead to drug abuse and criminal
behavior may improve outcomes.
8. Criminal justice supervision should incorporate treatment planning for drug abusing
offenders, and treatment providers should be aware of correctional supervision requirements.
Coordination of drug abuse treatment with correctional planning can encourage participation in drug
abuse treatment and can help treatment providers incorporate correctional requirements as treatment
goals. Treatment providers should collaborate with criminal justice staff to evaluate each
individual’s treatment plan and ensure that it meets correctional supervision requirements, as well as
that person’s changing needs, which may include housing and childcare; medical, psychiatric, and
social support services; and vocational and employment assistance. For offenders with drug abuse
problems, planning should incorporate the transition to community-based treatment and links to
appropriate post-release services to improve the success of drug treatment and re-entry. Abstinence
requirements may necessitate a rapid clinical response, such as more counseling, targeted
intervention, or increased medication, to prevent relapse. Ongoing coordination between treatment
providers and courts or parole and probation officers is important in addressing the complex needs of
these re-entering individuals.
9. Continuity of care is essential for drug abusers re-entering the community. Those who
complete prison-based treatment and continue with treatment in the community have the best
outcomes. Continuing drug abuse treatment helps the recently released offender deal with problems
that become relevant only at re-entry, such as learning to handle situations that could lead to relapse,
learning how to live drug-free in the community, and developing a drug-free peer support network.
Treatment in prison or jail can begin a process of therapeutic change, resulting in reduced drug use
and criminal behavior postincarceration. Continuing drug treatment in the community is essential to
sustaining these gains.
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10. A balance of rewards and sanctions encourages prosocial behavior and treatment
participation. When providing correctional supervision of individuals participating in drug abuse
treatment, it is important to reinforce positive behavior. Nonmonetary “social reinforcers” such as
recognition for progress or sincere effort can be effective, as can graduated sanctions that are
consistent, predictable, and clear responses to noncompliant behavior. Generally, less punitive
responses are used for early and less serious noncompliance, with increasingly severe sanctions
issuing from continued problem behavior. Rewards and sanctions are most likely to have the desired
effect when they are perceived as fair and when they swiftly follow the targeted behavior.
11. Offenders with co-occurring drug abuse and mental health problems often require an
integrated treatment approach. High rates of mental health problems are found both in offender
populations and in those with substance abuse problems. Drug abuse treatment can sometimes
address depression, anxiety, and other mental health problems. Personality, cognitive, and other
serious mental disorders can be difficult to treat and may disrupt drug treatment. The presence of cooccurring disorders may require an integrated approach that combines drug abuse treatment with
psychiatric treatment, including the use of medication. Individuals with either a substance abuse or
mental health problem should be assessed for the presence of the other.
12. Medications are an important part of treatment for many drug abusing offenders.
Medicines such as methadone and buprenorphine for heroin addiction have been shown to help
normalize brain function and should be made available to individuals who could benefit from them.
Effective use of medications can also be instrumental in enabling people with co-occurring mental
health problems to function successfully in society. Behavioral strategies can increase adherence to
medication regimens.
13. Treatment planning for drug abusing offenders who are living in or re-entering the
community should include strategies to prevent and treat serious, chronic medical conditions,
such as HIV/AIDS, hepatitis B and C, and tuberculosis. The rates of infectious diseases, such as
hepatitis, tuberculosis, and HIV/AIDS, are higher in drug abusers, incarcerated offenders, and
offenders under community supervision than in the general population. Infectious diseases affect not
just the offender, but also the criminal justice system and the wider community. Consistent with
Federal and State laws, drug-involved offenders should be offered testing for infectious diseases and
receive counseling on their health status and on ways to modify risk behaviors. Probation and parole
officers who monitor offenders with serious medical conditions should link them with appropriate
healthcare services, encourage compliance with medical treatment, and re-establish their eligibility
for public health services (e.g., Medicaid, county health departments) before release from prison or
jail.
Source: Principles of Drug Abuse Treatment for Criminal Justice Populations. NIDA. 2007.
You can download the full document at www.nida.nih.gov/PDF/PODAT_CJ/PODAT_CJ.pdf
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