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Center for Substance Abuse Treatment. Substance Abuse: Clinical Issues in Intensive Outpatient Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2006. (Treatment Improvement Protocol (TIP) Series, No. 47.)

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Substance Abuse: Clinical Issues in Intensive Outpatient Treatment.

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Chapter 3. Intensive Outpatient Treatment and the Continuum of Care

Overview of a Continuum of Care

“Continuum of care” refers to a treatment system in which clients enter treatment at a level appropriate to their needs and then step up to more intense treatment or down to less intense treatment as needed. As outlined by Mee-Lee and Shulman (2003), an effective continuum of care features successful transfer of the client between levels of care, similar treatment philosophy across levels of care, and efficient transfer of client records. The American Society of Addiction Medicine (ASAM) has established five main levels in a continuum of care for substance abuse treatment:

  • Level 0.5: Early intervention services
  • Level I: Outpatient services
  • Level II: Intensive outpatient/Partial hospitalization services (Level II is subdivided into levels II.1 and II.5)
  • Level III: Residential/Inpatient services (Level III is subdivided into levels III.1, III.3, III.5, and III.7)
  • Level IV: Medically managed intensive inpatient services

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.

In addition to the levels of care described by ASAM, outpatient treatment can be broken down into four sequential stages that clients work through, regardless of the level of care at which they enter treatment:

  • Stage 1—Treatment engagement
  • Stage 2—Early recovery
  • Stage 3—Maintenance
  • Stage 4—Community support

These stages are discussed later in the chapter in the context of IOT and outpatient treatment.

Conceiving of a Continuum of Care

To reinforce the idea of a continuum of care, Mee-Lee and Shulman (2003) suggest that clinicians and administrators “envision admitting the client into the continuum through their program rather than admitting the client to their program” (p. 456). This early focus on moving the client along the continuum also prompts clinicians to look ahead to the next step in a client's treatment. This, in turn, helps clinicians engage in the treatment planning that is integral not only to the client's ongoing care but also to the transition from one level of treatment to the next.

IOT Programs and the Continuum of Care

IOT programs are diverse and flexible with respect to the spectrum, intensity, and duration of services and the settings in which services are delivered. They are, therefore, well suited to meet the varied needs of persons with substance use disorders. Conceptually, IOT is an intermediate level of ambulatory care that serves the following functions:

  • An entry point into substance abuse treatment. The client comes to the IOT program, an assessment reveals that the client would benefit from IOT (see chapter 5 of this TIP for placement criteria), a treatment plan is developed, and services are begun.
  • A stepdown level of care. The client is transitioned to the IOT program from an inpatient or residential facility. In this case, the client may have been stabilized in a hospital facility or residential treatment program and now needs intensive treatment services to achieve or maintain abstinence as well as address other problems.
  • A step-up level of care. The client is referred to the IOT program if he or she has been unsuccessful in outpatient treatment or continuing community care and is assessed as needing an intensive and structured level of care to regain abstinence, work on relapse prevention skills, and address other issues.

Assisting the Client Along the Continuum

IOT is part of a seamless continuum of levels of care. Moving the client along the continuum may require the IOT provider to refer the client to another treatment organization or may be the result of an internal transfer to another component of a comprehensive IOT program.

Any change of setting, staff, or peers interjects a risk of the client's dropping out of treatment. Experience suggests that the administrative paperwork and approvals needed to transfer a client between levels of care within the same organization can be accomplished with less disruption for the client than a referral to a new provider organization. Consequently, when referrals are made to a nonaffiliated provider organization, coordination and case management needs increase.

Key Aspects of IOT (Level II)

After considering IOT from the broad perspective of the continuum of care, it is necessary to look within Level II to understand IOT's particular goals, intensity, duration, settings, and stages.

IOT Goals

Goals of IOT programs vary based on such factors as the treatment population, program comprehensiveness, and the program's philosophy. Although programs differ, all IOT programs attempt to address the following general goals:

  • To achieve abstinence
  • To foster behavioral changes that support abstinence and a new lifestyle
  • To facilitate active participation in community-based support systems (e.g., 12-Step fellowship)
  • To assist clients in identifying and addressing a wide range of psychosocial problems (e.g., housing, employment, adherence to probation requirements)
  • To assist clients in developing a positive support network
  • To improve clients' problemsolving skills and coping strategies

Intensity of Treatment

Relative to traditional outpatient treatment, IOT provides an increased frequency of contact and services that respond to the chronicity and severity of substance use disorders and other problems experienced by clients. The actual number of hours and days per week that clients participate in IOT varies depending on individual client needs. State licensure bodies may require 9 treatment hours; ASAM defines IOT as 9 hours of treatment per week for adults (Mee-Lee et al. 2001). Although IOT programs generally provide structured programming for 9 hours or more per week spread over 3 to 5 days, some IOT programs provide fewer hours. The consensus panel recommends that the number of programming hours be 6 to 30 hours, based on client needs. Some clinicians find that more frequent, shorter visits are of greater benefit to the client than less frequent but longer sessions. However, some clients require longer treatment sessions, similar in intensity to partial hospitalization. More research is needed on optimal treatment intensity and factors to be considered in increasing or decreasing treatment intensity.

Duration of Treatment

The recommended minimum duration of the IOT phase often is cited as 90 days. Low-intensity outpatient treatment over a longer period may be a cost-effective means to enhance treatment outcomes because this approach is associated with less substance use and better social functioning in clients (Moos et al. 2001). Duration of treatment should be increased or decreased based on the client's clinical needs, support system, and psychiatric status, among other factors. Longer duration of care is related to better treatment outcomes (Moos and Moos 2003).

Treatment Settings

IOT can be provided in any setting that meets State licensure or certification criteria (Mee-Lee et al. 2001). Programs offering IOT only and comprehensive programs offering several levels of care may differ in structures and services provided. IOT programs that are part of a large hospital setting can provide medical detoxification services, pharmacotherapy, and treatment for other medical and psychiatric conditions. IOT programs located in prison facilities treat offenders with alcohol and drug problems and successfully link offenders with stepdown services in the community on release. Other IOT programs may be located near vocational training sites so that welfare recipients and others easily can attend both treatment and training sessions in homeless shelters and in modified therapeutic community programs.

Stages of Treatment

Within IOT or Level II care, treatment often is delivered in sequential stages, with service intensity and structure lessening as clients progress. As IOT services taper in intensity, the client assumes increasing responsibility and is provided less structure and supervision from treatment staff. IOT programs should have the flexibility to increase the intensity of services if the client's lack of progress indicates such a need.

Sequenced IOT can motivate clients, help them succeed in reaching recovery milestones and in meeting the criteria for completing a treatment stage, and provide an incentive for clients to grow and progress. Marking the passage from one IOT stage to the next with a celebration or ceremony also motivates clients. Sequenced stages allow complex information to be broken into small units that can be modified and made appropriate for each client's cognitive and psychological functioning and stage of readiness.

IOT may be conceptualized as having two core stages, which correspond with the client's progress in treatment: stage 1—treatment engagement and stage 2—early recovery. Definitions of IOT, such as those adopted by some States or health insurers, may include additional or fewer stages or may blend similar goals and services within different stages.

Stage 1—Treatment engagement

Goals and durationOne of the most critical tasks for the counselor and clinic is encouraging the client to remain in treatment. Many clients drop out of treatment after attending only a few sessions. During this initial stage, the counselor determines the client's presenting problems with respect to substance abuse; physical, psychological, and social functioning; and social support network. Also, the counselor explains program rules and expectations and works to stabilize any crises. Exhibit 3-1 presents the goals, duration, counselor activities, and completion criteria of this stage of IOT.

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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 (more...)

Stage 2—Early recovery

Goals and durationThis stage is highly structured with educational activities, group involvement, and new behaviors to help the client develop recovery skills, address lapses, and build a substance-free lifestyle. Exhibit 3-2 presents the goals, duration, counselor activities, and completion criteria of this stage of treatment.

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

Transition to Outpatient Treatment

Effective treatment in a continuum of care includes ongoing, less intensive, and tapered contact with treatment systems, much as with other chronic health conditions (McLellan et al. 2000). The client and counselor must prepare for the transition to less intensive treatment, a juncture that presents a high dropout risk. This stepdown level of care sometimes is provided as part of a comprehensive IOT program by the same staff and in the same facility. In other cases, clients are transferred through formal linkages to outpatient treatment delivered by a separate community-based program, often referred to as standard, traditional, or—in this TIP—simply outpatient treatment.

Compatible models of care

The consensus panel believes that, whenever possible, the client should be referred to an outpatient treatment program with a treatment model (e.g., 12-Step, cognitive-behavioral, combined) that is compatible with that offered by the IOT program to ensure that the client is not confronted with significantly different treatment goals, approaches, and philosophies. If a client is to be transferred to a program with a different philosophy, the client should be oriented to the differences so that the transition is not confusing and the client can benefit from the new program.

Transition planning

An individual transition plan helps the client transition from one level of care to another and provides an important link between his or her current treatment provider and the next. To prepare an effective transition plan, the IOT counselor can

  • Engage the client as an active participant in developing the plan early in IOT, including setting goals, establishing criteria for measuring progress, and identifying activities that will be part of ongoing treatment.
  • Maintain a working knowledge of the services and resources that are available in the community.
  • Develop strong working relationships with staff of key agencies (e.g., justice organizations, employers) to facilitate the transition, make special arrangements as needed, and eliminate unnecessary barriers for the client during transition.
  • Obtain the client's written consent and arrange for the smooth and timely transfer of clinical information or documents to the new treatment program.

The panel recommends that the responsibility for client care be transferred clearly before a provider relinquishes clinical responsibility.

Key Aspects of Outpatient Treatment (Level I)

For clients who are stepped down from IOT, outpatient treatment offers the support they need to continue developing relapse prevention skills and resolving the personal, relationship, employment, legal, and other problems often associated with early recovery.

Outpatient Treatment Goals

The goals, strategies for treatment engagement, and recovery services of outpatient treatment are similar to those of IOT. However, the intensity and duration of the services differ from those provided in IOT.

Comparison of IOT and Outpatient Treatment

A study by McLellan and colleagues (1997) compared several components of 6 IOT programs and 10 outpatient treatment programs. Both types of programs provided group and individual abstinence counseling, relapse prevention programming, and drug and alcohol education. The IOT programs' treatment duration ranged from 30 to 90 days, and they provided 3 to 5 sessions per week. Hours per session ranged from 3 to 6. The outpatient programs' treatment duration ranged from 45 to 60 days, and they provided 1 to 2 sessions per week. Hours per session ranged from 1 to 2. Whereas the IOT programs provided more substance abuse counseling than the outpatient treatment programs, the outpatient treatment programs were more likely than IOT programs to offer medical appointments, family therapy sessions, psychotherapy, and employment counseling (McLellan et al. 1997).

Although outpatient treatment duration is typically 60 days, it is suggested strongly that clients be scheduled for periodic followup sessions on a long-term basis. The best outcomes from treatment of substance use disorders have been seen in clients who participate in continuing care, such as methadone maintenance or Alcoholics Anonymous-style support programs (McLellan et al. 2000). Because the availability of funding for followup appointments varies, outpatient treatment programs might consider strategies for establishing a service model that supports the delivery of followup sessions.

Stepdown Treatment

Clients who have completed stages 1 and 2 of their treatment at the IOT level of care can step down to outpatient treatment programs and enter stage 3—maintenance, having demonstrated a commitment to change, been stabilized, become abstinent, and developed relapse prevention skills.

Stage 3—Maintenance

Goals and durationStage 3—maintenance helps the client build on gains made during stages 1 and 2. The goals, duration, counselor activities, and completion criteria of this stage of treatment are presented in Exhibit 3-3.

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

Transfer to Continuing Community Care

Having completed stage 3 of their treatment, clients are discharged from formal treatment to continuing community care. Clients who remain within a system of ongoing care relevant to their needs are more likely to maintain their gains in abstinence and overall lifestyle changes. Participation in continuing community care is related to an increase in positive outcomes (Miller et al. 1997; Ritsher et al. 2002). Continuing care planning is therefore a central task for IOT program staff whose clients remain in stepdown care within the program. IOT programs that refer clients to separate programs for a stepdown level of care must ensure, through their referral agreements and procedures, that the outpatient treatment program agrees to engage in continuing care planning.

Continuing community care in the form of 12-Step support groups, faith fellowship, or other community-based organizations is sometimes neglected by treatment providers because of the difficulties of remaining engaged with clients after formal treatment is completed. Still, the benefits of carefully planning for transferring clients into community support groups are such that added attention should be given to these tasks. To ensure client access to a full continuum of care, treatment programs need to be aware of support groups and other community resources and introduce this information to clients early in the treatment process. Other key responsibilities for providers include ensuring transition of case management responsibilities, supporting clients' early engagement in continuing community care, contributing to the expansion of community services, and encouraging clients who drop out to reengage with treatment.

Continuing Community Care

Continuing community care following IOT and stepdown care is essential for all IOT clients, especially for those who may have other long-term psychiatric, social, or medical issues. The process of rebuilding a healthy, productive, and stable life takes years, and maintaining gains made over time may require continuous support for some individuals.

Once the client maintains abstinence and has begun to address other serious problems that could threaten recovery, the client can be discharged into continuing community care. Stage 4—community support consists of the client's participating in 12-Step or other mutual-help groups and meeting with psychologists, case managers, or staff from community-based agencies, with limited support and involvement from the treatment program.

Services in Continuing Community Care

As part of continuing care services, programs can sponsor alumni meetings and provide booster or checkup counseling sessions at the IOT or outpatient treatment facility. Periodic telephone contact also may be valuable (McKay et al. 2005). Other aspects of continuing care include involvement with selected community resources as needed, such as vocational training, recreational therapy, family therapy, or medical care.

Stage 4—Community support

Goals and durationThis stage is based on a detailed and individualized discharge plan for continuing recovery in the community using available resources. Exhibit 3-4 presents the goals, duration, counselor activities, and completion criteria of this stage.

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 Continuing Community Care

The duration of continuing community care varies for each individual. The chronic relapsing nature of substance use disorders often means that individuals may remain in this level of care for many months or years, relapse, return to outpatient treatment or IOT care, regain abstinence, and return to continuing community care.

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