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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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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 broadening 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.

Defining Substance Abuse Treatment and IOT

For most of the 20th century, substance abuse was considered an acute disorder. Viewing substance abuse more like pneumonia than like chronic diseases such as hypertension or diabetes had shaped the expectations and treatment choices of clinicians. As McLellan and colleagues (2000) point out, regarding substance abuse as a chronic disorder means realigning treatment and outcome expectations so that they resemble those for other chronic disorders. Today, many IOT programs are involved in treatment beyond the traditional 4 to 12 weeks. Increasingly, IOT programs focus on ongoing care that addresses many areas of clients' lives through case management and the involvement of other service providers and families and communities.

A parallel development has been the frequent application of research findings into practice in the field of substance abuse treatment. Research has yielded new understanding about the complexity of substance use disorders that takes into account biochemical processes, learning, spirituality, and environment. IOT programs are integral to the process of translating scientific findings into clinically effective treatments. The collaboration between research and practice has moved some treatments out of research centers and into IOT programs. Cognitive-behavioral interventions, relapse prevention training, motivational enhancement, and case management are used in community-based treatment settings as a result of the cross-fertilization of research and treatment.

One result of the convergence of research and practice is the development of evidence-based principles that shape and guide substance abuse treatment. The consensus panel recommends 14 principles for IOT programs. These principles lay a theoretical foundation for discussions of IOT services, clinical challenges, and treatment approaches and adaptations. In their focus on client engagement and retention, individualizing treatment, using the entire continuum of care, and reaching out to families, employers, and the community, the 14 principles help define the IOT program's contemporary role.

Continuum of Care and IOT Services

An IOT program is most effective at helping its clients if it is part of a continuum of care. The American Society of Addiction Medicine has established five levels of care: medically managed intensive inpatient, residential, intensive outpatient, outpatient, and early intervention. In addition, continuing community care (e.g., 12-Step support groups), which a client participates in after the conclusion of formal treatment, is another important level of service. A continuum of care ensures that clients can enter substance abuse treatment at a level appropriate to their needs and step up or down to a different intensity of treatment based on their responses. Clinicians enhance the capabilities of their programs when they are informed about and willing to refer clients to other treatment providers. Close monitoring of clients' progress toward treatment goals is key to determining when they are ready for the next appropriate level of care. Any transition in treatment increases the likelihood that a client will drop out. A step-up or stepdown in treatment intensity in the same program or a referral to a nonaffiliated provider can be disruptive for the client. Mee-Lee and Shulman (2003) recommend that a continuum of care feature seamless transfer between levels, congruence in treatment philosophy, and efficient transfer of records. Clinicians need to be thoroughly familiar with local treatment options, including support groups, so that they can orient clients as the clients transition to new treatment situations.

Services integral to all IOT programs are core services. The consensus panel believes that these core services, such as group and individual counseling, psychoeducational programming, monitoring of drug use, medication management, case management, medical and psychiatric examinations, crisis intervention coverage, and orientation to community-based support groups, are indispensable and should be available through all IOT programs. Additional services that are offered at the program site or through links with partner organizations are enhanced services. This concept is flexible, and what might be considered enhanced services for some programs may be essential services for a program with a different client population. (Clients whose first language is not English might need language classes to find work and participate in mutual-help groups, whereas a program that primarily serves native speakers would have little call for such a service.) Enhanced services include adult education classes, recreational activities, adjunctive therapies (e.g., biofeedback, acupuncture, meditation), child care, nicotine cessation treatment, housing, transportation, and food.

Entry, Engagement, and Treatment Issues

Many clients who enter substance abuse treatment drop out in the early stages (Claus and Kindleberger 2002). Entry and engagement are crucial processes; how an IOT program addresses them can influence strongly whether clients remain in treatment. Client intake and engagement can involve contradictory processes such as collecting intake information from clients while initiating a caring, empathic relationship. Balancing administrative tasks and therapeutic intervention is a challenge clinicians face during a client's first hours in an IOT program. To help clinicians achieve that balance, the consensus panel recommends assessing potential clients' readiness for change and using strategies that motivate them to enter and continue treatment. Clinicians should begin to establish a therapeutic relationship as soon as clients present themselves for treatment. Any barriers to treatment must be addressed. Based on screening and assessments, clients should be matched with the best treatment modality and setting to support their recovery. An individualized treatment plan should be developed with the cooperation of the client to address the client's needs.

Client retention is a priority throughout treatment. The consensus panel draws on research and the experience of practiced clinicians to address the issues of engagement and retention. Clients can become distracted from recovery if family members continue to use substances, boundaries between clients and staff are not established clearly, work conflicts with treatment, or they receive incompatible recommendations from different service systems. Clinicians need to know how to ensure the privacy of their clients and the safety and security of the program facility while maintaining open and productive therapeutic relationships with their clients. Clinicians also need to be familiar with common issues that can derail clients in group therapy such as intermittent attendance and other clients who are disruptive, ambivalent, or withdrawn. When clinicians understand and prepare for these problems, their clients have a better chance of being retained in and benefiting from treatment. A major factor in client retention is the quality of the relationship between client and counselor. The client is more likely to do well in treatment if a strong therapeutic alliance exists.

Treatment Approaches Used in IOT

IOT is compatible with different treatment approaches. Involving clients' families in their recovery is an effective strategy. Substance-using behavior may be rooted in part in a client's family history—whether family of origin or family of choice. Families can play a crucial role in a client's recovery. Providers should prepare for family involvement, education, and other services so that family members can support recovery. Family involvement in treatment has been linked to positive outcomes for clients in substance abuse treatment (Rowe and Liddle 2003). For IOT providers, adopting a family systems approach means including family members in every stage of treatment: the intake interview, counseling sessions, family dinners or weekends, and graduation celebrations. If family members are to support a client's recovery, they must be disabused of unrealistic expectations and learn about relapse prevention. IOT providers should consider offering family education groups, multifamily groups, and family support groups. If family therapy (which in most States requires a licensed, master's-level clinician) is warranted and an IOT clinic cannot offer it, referral relationships can be developed with an organization that provides individual family therapy, couples therapy, and child-focused therapy.

Providers should be familiar with the strengths and challenges of different treatment approaches so they can serve their clients better by modifying and blending approaches as necessary. The 12-Step facilitation approach is common in the treatment environment. Twelve-Step-oriented treatment helps clients achieve abstinence and understand the principles of Alcoholics Anonymous and other 12-Step groups through group counseling, homework assignments, and psychoeducation. The 12-Step approach emphasizes cognitive, behavioral, spiritual, and health aspects of recovery and is effective with many different types of clients.

Cognitive-behavioral therapy focuses on teaching clients skills that will help them understand and reduce their relapse risks and maintain abstinence. Clients must be motivated and counselors must be trained extensively for cognitive-behavioral therapy to succeed.

Motivational approaches, such as motivational interviewing and motivational enhancement therapy, also rely on extensive staff training and high levels of client self-awareness. Through empathic listening, counselors explore clients' attitudes toward substance abuse and treatment, supporting past successes and encouraging problemsolving strategies. These approaches are client centered and goal driven and encourage client self-sufficiency.

Therapeutic community approaches are used most often in residential settings but have been adapted for IOT. In therapeutic community approaches, a structured community of clients and staff members is the main therapeutic agent—peers and counselors are role models, the work at the facility is used as therapy, and group sessions focus on self-awareness and behavioral change. The intensity of the treatment calls for extensive staff training and can result in high client dropout. However, therapeutic communities have proved successful with difficult clients (e.g., those with long histories of substance use and those who have served time in prison).

The Matrix model integrates a number of other treatment approaches, including mutual-help, cognitive-behavioral, and motivational interviewing. A strong therapeutic relationship between client and counselor is the centerpiece of the Matrix approach. Other features are learning about withdrawal and cravings, practicing relapse prevention and coping techniques, and submitting to drug screens.

Contingency management and community reinforcement approaches encourage clients to change behavior; these approaches reinforce abstinence by rewarding some behaviors and punishing others. Programs select a goal that is reasonable, is attainable, and contributes to overall treatment objectives and then reward small steps the client makes toward that goal. Contingency management and community reinforcement approaches have been successful with clients who have chronic substance use disorders, when the costs for staff training and incentives can be addressed.

Treating Different Populations

Many of the approaches used in IOT programs were developed to treat substance use disorders in White, middle-class men. Adaptations to these approaches are necessary to treat a variety of clients such as those in the justice system, women, clients with co-occurring disorders, and adolescents.

Increasing numbers of people with substance use disorders are involved with the justice system. Justice agencies and treatment providers need to work closely with each other, communicating clearly and coordinating their efforts. Cooperation of a different kind must exist between clinicians and clients. Therapeutic alliance is especially important when working with clients in the justice system who may have difficulty trusting a clinician and forming meaningful relationships outside the criminal environment.

The number of treatment programs for women is increasing. These programs add enhanced services designed to address substance abuse in the context of pregnancy and parenting, self-esteem issues, and histories of physical, sexual, and emotional abuse. To treat women, clinicians often avoid confrontational techniques and focus on providing a safe and supportive environment with clearly established boundaries between client and counselor.

Many people with co-occurring mental and substance use disorders are not receiving appropriate care (Watkins et al. 2001) and find themselves shuttling between psychiatric and substance abuse treatment, caught between two systems (Drake et al. 2001). Integrated treatment attends to both disorders together, adapts standard interventions to allow for clients' cognitive limitations, and provides comprehensive services to care for both disorders. Programs that do not adopt an integrated approach are advised to coordinate services with mental health providers.

A comprehensive approach to services also is important for adolescents who are using substances. Adolescents experience incredible upheaval in their lives and often need habilitation rather than rehabilitation. Many are in treatment for the first time and need to be oriented to treatment culture. Because adolescents often are living at home, family involvement is crucial. A behavioral contract—stipulating desired behaviors and rewards—and case management—addressing medical, social, and psychological needs—are also beneficial treatment tools.

IOT programs are being called on to serve an increasingly diverse client population. Almost one-third of Americans belong to an ethnic or racial minority group, and more than 10 percent of the U.S. population was born outside the country (Schmidley 2003). Although there is widespread agreement that clinicians should be culturally competent, no consensus exists about what cultural competence means. As a starting point, clinicians should understand how to work with someone from outside their own culture and strive to understand the specific culture of the client being served. Whereas the ability to treat clients from outside one's culture is an extension of the skills of a good clinician, understanding the cultural context of individual clients is more demanding. Clinicians need to strike a balance between a broad cultural background and the specific cultural context of a client's life; an observation that is applicable to a large group may be misleading or harmful if applied to an individual.

For foreign-born clients, level of acculturation often is an issue. Most research shows that the more acculturated clients are, the more their substance use approximates U.S. norms. Programs that serve substantial numbers of foreign-born clients may consider offering language-specific programs and linking clients to language classes, job training, and employment services. Clients from other cultures may be averse to the emphasis on self-disclosure and self-sufficiency in substance abuse treatment. Counselors must be prepared to work within the client's value system, which may be at odds with values promoted by the treatment program.

Likewise, programs should ensure that program practices and materials do not pose a barrier to clients of non-Christian faiths. Many mutual-help programs have a strong Christian element; clients from other faiths should be informed of this orientation and provided with information about secular or religion-specific mutual-help groups.

Other general guidelines for programs that treat clients from other cultures include assessing policies and practices to spot potential barriers for diverse clients, training staff members in cultural competence, providing materials at an appropriate reading level or translating materials into clients' languages, and using outreach to promote awareness of the program.

The consensus panel offers an extensive list of resources for further research as well as demographic, substance use, and treatment information on members of racial and ethnic groups; persons with physical or cognitive disabilities; persons with HIV/AIDS; persons who are lesbian, gay, or bisexual; rural populations; and homeless populations. These resources are found in appendix 10-A.

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