Recent developments in the field of alcohol and other drug (AOD) abuse
treatment, along with a prevalent interest in and awareness of the effectiveness
of the intensive outpatient treatment (IOT) level of care, have promoted the
growth of IOT programs. This chapter primarily addresses services that are
considered essential to any IOT program, as well as services that can be
described as optimal. The chapter includes a review of the salient clinical
issues and characteristics of IOT. A framework for considering IOT programs,
rather than an exhaustive clinical explication, is presented. Although the
needs of special groups (such as clients with dual disorders, pregnant women,
elderly people, and gay men and lesbians) are not specifically addressed in this
section (see Chapter 5), the services described here can
be adapted for programs that specialize in meeting the needs of these and other
groups.
Rationale
Traditional outpatient treatment generally consists of individual or group
counseling. This approach is not sufficiently intensive to meet the needs of
patients with moderate to severe AOD disorders, since clients engage in therapy
sessions only once or twice a week. Traditional outpatient treatment usually
offers fewer types of treatment services than IOT and is generally not organized
to address the multidimensional needs of AOD-dependent patients.
At the other end of the spectrum of treatment intensity is inpatient
treatment: medically managed intensive inpatient treatment and medically
monitored intensive inpatient treatment. These two levels of care involve an
organized service of around-the-clock evaluation, care, and treatment in an
inpatient setting. In this setting, patients who have severe withdrawal, and/or
medical, emotional, or behavioral problems can receive primary medical and
nursing services.
IOT represents an approach to addiction treatment at a level of intensity
that is intermediate between intensive inpatient treatment and traditional
outpatient treatment. Chapter 2 includes a discussion of
the levels of care. When clients are appropriately placed, IOT provides a level
of effectiveness at significantly less expense that is equivalent to the
effectiveness of inpatient programs. IOT has significant advantages as a level
of care organized to treat clients with moderate to severe AOD disorders. These
advantages can be recognized in terms of cost, attractiveness to patients, and
clinical efficacy.
Advantages
Financial and Cost Benefits
AOD abuse has been shown to have a tremendous economic impact on society.
The Institute of Medicine estimates that the annual total cost to society of
alcohol problems is $117 billion. However, less than $10 billion is spent
annually on total treatment costs for alcohol problems (Institute of Medicine,
1990), a negligible amount when compared with the costs to society. However, in
an era of health care reform, the AOD treatment field has the same commitment as
other health care fields to cost-efficient quality care. Within the context of
a continuum of care, IOT is an example of innovative change contributing to the
attainment of the national objective of reducing the costs of health care.
The bulk of AOD abuse costs relate to morbidity, mortality, and crime.
Additional costs are for support services and treatment for fetal alcohol
syndrome, acquired immunodeficiency syndrome (AIDS), and other medical
comorbidity, as well as services to persons living with someone who has an AOD
disorder.
One of the only clear and consistent indicators of positive AOD treatment
outcome is the length of time an individual is involved with AOD treatment
services. Treatment in an intensive outpatient setting can be provided for many
more weeks than in an inpatient setting, and at significantly less cost.
Further, studies in which traditional 28-day inpatient treatment programs for
AOD abuse have been compared with IOT have demonstrated comparable clinical
outcomes (Fink et al., 1985).
Cost savings are also realized in IOT programs in terms of continued
productivity of clients who remain able to work and those who have fewer days
lost from school or employment. In addition, clients are able to continue
functioning in such important roles as parents and homemakers.
Additional and substantial cost savings can occur when an integrated
treatment plan is used to link various service providers, including primary
health care providers. Early intervention and preventive services can lead to
the type of savings associated with preventive medicine. AOD intervention
offered in coordination with health care networking may ensure less complicated
medical treatment and reduced comorbidity. IOT programs can easily be organized
as a component of care within a health care system.
Consumer Benefits
In contrast to traditional inpatient treatment, IOT allows services to be
provided at times that are convenient to clients. The flexible program design
of IOT also allows the provider to tailor services in response to regional
variations and the needs of special groups, both in terms of core elements of
the program and the special services that may be added to existing programs.
The special accommodations that can be provided to patients make IOT an
attractive option, especially in situations requiring flexibility.
Clients may view confidentiality as less of an issue in IOT settings,
because unlike in inpatient settings, clients are not separated from their daily
milieu -- thus avoiding protracted absences from work or family. Furthermore,
an IOT approach avoids the disincentive to seek treatment that is often
experienced by patients when the only AOD treatment choice is hospitalization.
Flexibility, reduced barriers to seeking treatment, and enhanced confidentiality
all serve to increase self-referral and utilization of this level of care.
Clinical Benefits
Increased duration of treatment. Among the many advantages of IOT
is the increased duration of treatment. This allows for a prolonged opportunity
to engage and treat clients while they remain in their home community. IOT
provides for an increased opportunity for patients to practice newly learned
behaviors. Clients in IOT are given sufficient time to incorporate new
identities as recovering people with extended support, such as enhanced
opportunities to become part of a fellowship of recovering people. IOT sets the
stage for continuing outpatient care, which further increases the likelihood of
successful recovery; the longer patients remain in treatment, the better the
prognosis for full recovery.
Flexible levels of care. The severity of addiction and the
intensity of symptoms vary among patients and vary over time for each patient.
Generally, people require more intense treatment initially, followed by
progressively less intense care. However, problems such as relapse, medical and
social crises, and the emergence of psychiatric or subacute withdrawal symptoms
demand a temporary increase in treatment intensity and/or level of care. IOT
provides significant clinical flexibility that can be used to respond to
clients' individual treatment needs -- especially when these needs change over
time. Thus, as a client's treatment needs become more or less intense, the IOT
program can likewise increase or decrease the intensity of treatment for that
individual.
Increased patient caseload levels and improved patient retention.
When staffed appropriately, IOT programs can usually treat a high volume of
patients. A larger patient population makes it easier to create groups devoted
to special issues such as incest, sexuality, anger management, and relapse. The
IOT structure, which relies on a team approach and a therapeutic milieu, may
result in a higher retention rate than low-intensity outpatient treatment. This
means that staff can spend more time on effective caseload management. The
flexible nature of the IOT setting also permits the ability to modify the
structure and character of special issues groups.
Daily application of learning. IOT promotes the daily application
of what is learned in treatment. Clients can put into immediate practice the
coping strategies needed to adapt to living without AODs. They learn to
confront daily challenges -- indeed, they must do so. New behaviors are learned
within the context of the client's normal existence and environment, rather than
according to prescribed strategies that are learned within a sheltered
environment and only later, after discharge, put into practice. Changes can be
made and supported incrementally and on a daily basis, thus providing an
increased likelihood for permanency. Rather than having a hiatus from life in
the "real world," the client in an IOT system must face the daily challenges
posed by recovery. Changes thus become internalized, applied components of the
client's life.
Community-centered support. Because IOT programs promote treatment
that is patient-driven and centered on the whole person, they can assertively
address problems related to family and work and to social, psychological, and
emotional well-being. Psychosocial supports from family, employer, and
community can be readily established or reestablished with an outpatient
treatment experience. Clients are in a good position to confront challenges
because not only have they learned new behavioral and cognitive responses to
cravings, and have had real-life opportunities to practice relapse prevention
techniques, but they also have an established community-based support network,
including family and employer involvement with the IOT program.
Relapse management support. Because of the daily contact with
patients afforded by IOT as opposed to traditional outpatient treatment,
relapses can be addressed during early stages, often before actual AOD use. The
approach of most IOT programs is to view relapses less as failures and more as
evidence that changes are needed in the patient's treatment goals, lifestyle,
and/or social systems. In IOT, clients can usually identify relapse triggers
and issues with ease since they have real-world experiences to draw upon. When
relapses do occur and when they are framed as potentially positive learning
experiences rather than as stigmatizing episodes, the likelihood of patients
remaining in treatment is heightened. Clinical assessment of the severity and
duration of the relapse is essential.
Patient responsibility. Since clients are responsible for their
participation, passive participation is difficult in IOT programs. IOT tends to
empower clients, who must develop incentives to keep returning to treatment. In
IOT, clients are less able to be reluctant or resistant observers. Personal
responsibility is thus placed squarely on clients' shoulders.
Enhanced self-help participation. Self-help resources such as
Alcoholics Anonymous and Narcotics Anonymous (AA and NA) are often essential to
patient recovery during and beyond the IOT level of care. A special advantage
of IOT is that clients can establish relationships to the community self-help
support programs that they will likely rely on for extended support. Rather
than identifying local groups after the completion of inpatient treatment,
patients can be settled into an appropriate community-based resource prior to
their completion of intensive treatment.
Enhanced therapeutic milieu. IOT programs offer patients the
opportunity to develop relationships with other clients that can be readily
fostered and maintained throughout and beyond the treatment experience. Clients
can relate to one another outside of the parameters of the program. Since they
likely live close to one another, they can continue mutual support once IOT is
completed.
Problems and Challenges
IOT is a level of care that exists within the broader continuum of care. As
such, IOT has limitations, disadvantages, and potential problems. Chief among
these challenges are problems associated with the retention of patients,
reimbursement and related financial concerns, and the management of acute
crises.
It is possible for an element of IOT that generally provides significant
strength to occasionally become a disadvantage. For example, participation in
treatment while living in one's normal environment provides daily opportunities
to practice relapse prevention and drug refusal skills. However, this
arrangement also provides daily opportunities to encounter numerous social,
environmental, and emotional triggers for drug craving and relapse. Like all
other medical and psychological interventions, IOT involves both benefits and
risks. Thus, patient placement in IOT must be considered in terms of costs and
benefits.
One of the challenges of IOT relates to client retention and completion of
treatment. The potential for encounters with drug craving cues and triggers,
the potential for exposure and access to AODs, the lack of insulation from
family and social crises, and the absence of supervision during nontreatment
hours may contribute to retention problems.
While physical health is often the last aspect of health to deteriorate
because of AOD addiction, it is often the first aspect to return to normal.
Many patients equate restoration of physical health with being "cured." Thus,
as some patients begin feeling better physically, they may feel that no further
treatment is necessary.
Thus, clients in an IOT program should be exposed to assertive education and
training about triggers, drug refusal techniques, handling social and emotional
crises, feeling "cured," and after-hour peer-support and self-help programs.
Reimbursement Issues
The financial challenges inherent in IOT stem from the fact that it remains
a relatively new approach. Problems in this area are related to definition,
reimbursement, standardization, resistance within the AOD field, and competition
with inpatient programs. The introduction of IOT comes at a time when payers
are skeptical of providers and when there is an increased demand for reduction
of health care costs. Overall, there is less experience with program and fiscal
management of IOT programs, and third-party reimbursement for IOT services can
be difficult to secure. The use of nonuniform admission and placement criteria
further complicates the reimbursement issue. Additional difficulties may be
posed by the relatively low profit margin experienced by many IOT programs, and
the constant demand for a stable and high census. In some cases, a minimum
number of days are required for reimbursement. Reimbursement may be lost for
the whole week if a patient misses a certain number of days.
It is difficult for IOT programs to operate at a cost-effective level of
utilization if too few clients are enrolled. In addition, the high flexibility
of IOT programs makes it difficult to project revenue. Chapter
6 describes problems that relate to reimbursement and managed care.
Crisis Management
While in treatment, patients often lack coping skills to adequately deal
with psychological, social, and medical crises. Given the complexity of AOD
patients and the emphasis on reduced costs of care, patients in IOT are often at
risk for complications. The IOT level of care provides less control over acute
patient management problems. An important example is the fact that clients
typically experience acute crises during after-hour periods. For this reason,
it is recommended that IOT programs provide 24-hour crisis intervention
services.
IOT programs for AOD abuse will differ with regard to the number, type, and
intensity of treatment services provided. Indeed, treatment services can be
categorized into core, optimal, and enhancing elements.
Core elements. All IOT programs should have certain core
or minimal treatment services. These include screening, assessment, treatment
planning, 24-hour crisis management, pharmacotherapy, individual and group
therapy, client and family education, case management, toxicology screening, and
program outcome evaluation.
Optimal elements. IOT programs that provide more than the basic or
minimal treatment services exist on a continuum that ranges from "complete" to
"enhanced." These optimal elements include family therapy, childcare and
transportation, recreation and leisure, continuing care, alumni activities, and
outreach efforts in the community.
Enhancing elements. Programs may provide treatment services that
can be described as adjunctive therapies. These optional elements include
psychodrama, stress reduction techniques, acupuncture, biofeedback, art therapy,
and other therapeutic services.
Core Elements
There are several minimal elements that are essential to the effective
operation of a basic IOT program. While inclusion of all of these elements will
not guarantee effectiveness, the implementation of these components ensures that
certain barriers to effective care are removed. Describing them as core
elements is based primarily on clinical experience. Vigorous research and
examination are required to determine which of these elements indeed makes a
difference in the experience and outcomes of clients treated in IOT. Although
individual program configurations and target client differences can restrict and
influence the way in which some treatment services are organized and provided,
the following treatment services should be considered critical for IOT programs.
Program Leadership
The management and administration of an IOT program should provide
leadership through the development and expression of a program mission,
philosophy, and development plan. Further, program management and
administration should ensure that the program has the financial and
philosophical support to successfully meet its mission, goals, and objectives.
An IOT program requires planning, coordination, and evaluation of service
delivery, including the maintenance of essential linkages with payers and
referral sources. Good program management fosters continuous quality
improvement and is required for financial planning and management. New
opportunities for program expansion and improvement must be continually
identified, as should changes in regional and national trends in AOD abuse and
treatment.
Program administration should be organized in such a way that the program
can proactively deal with the changes and challenges of the times. A key
responsibility of program management is to provide a working environment that
enhances staff productivity. Human resources support should be organized to
meet the needs of the work force in order to ensure a successful and healthy
operation (see Chapter 4 for discussion of staffing
issues).
Screening
Screening for AOD abuse and dependence is a treatment service that
identifies whether an individual is appropriate for an AOD abuse assessment. An
initial, brief screening of a potential patient may be done during the first
phone contact or through a scheduled or unscheduled walk-in. During this
initial screening, basic data are gathered and the individual is encouraged to
participate in an assessment if appropriate.
Some people can be screened out as inappropriate for IOT without their ever
coming in to the program. In these instances, clients should be referred to
appropriate resources. To the extent possible, medical emergencies should be
screened and the client should be given a brief overview of the services
provided by the program. The purpose of this initial screening is to determine
whether the individual is likely to be an appropriate candidate for the program
according to clear, previously determined admission criteria that include
guidelines on clinical and financial eligibility.
There are several purposes and reasons for providing AOD abuse screening.
They include:
Determining the need for an AOD assessment
Ensuring immediate placement in the appropriate level of care
Responding to communications from referral sources, self-referrals,
families, and others about the potential for AOD treatment
Engaging and involving the referral source with the treatment program and
the treatment process
Documenting information gained during crisis interventions and assisting
clients to reach other levels of care such as emergency room treatment
Scheduling appointments for assessment and preparing patients for the
assessment process.
It is recommended that clinical staff be involved in front-line AOD
screening. Nonclinical staff are appropriate for answering questions about the
program or for the registration of clients, but they should not be placed in a
situation that involves clinical judgment.
When initial contact is made with a potential client, staff members handling
the contact should realize that, although the call or visit may be routine for
them, this initial step has enormous implications for the client. He or she may
experience feelings of fear, anxiety, rage, apprehension, resentment, or
ambivalence. Staff should be sensitive to the highly charged emotional set that
is typical of many clients when they first contact a treatment site. It is
important to congratulate people who contact an AOD program (whether for
themselves or for others) for taking such an important step.
Assessment and Intake
Once a potential client has been screened, an assessment should be arranged
as soon as possible if the person seems to be an appropriate candidate for the
level of care provided by the treatment program. The goal of the assessment
process should be to determine the individual needs of each patient through the
completion of a diagnostic evaluation and to confirm the appropriateness of
participation according to the program's admission criteria. The initial
assessment should provide a complete psychosocial profile of each person,
including all problem areas such as AOD use; psychological, physical, legal, and
vocational problems and issues; and family and other social relationships.
An alliance should be successfully reached with the client prior to
completing the assessment interview. Also, clients should be informed about
confidentiality regulations and other informed consent issues. Both of these
will help to promote a trusting relationship between the client and the program
staff.
There should be a mechanism for immediate, same-day involvement in the
program so that clients can be placed in treatment at the earliest opportunity.
Encouragement and positive reinforcement for clients' participation are required
throughout this process. Those for whom medical stability is in question should
be examined by a physician prior to admission. It is advised that patients
receive a physical examination within the first days of treatment when possible.
This will ensure that medical issues are appropriately addressed in the
treatment plan. If the assessment reveals that a client is inappropriate for
participation in the IOT program, the program is responsible for linking the
client with an appropriate level of care.
Procedures for registering clients should be developed to ensure their
appropriate transition from the assessment to the assigned level of care. It is
useful to collect financial information prior to the assignment, to ensure
availability of services and appropriate placement.
Intake and registration procedures should include patient education
regarding program policies and procedures, rules and regulations, expectations
and rights, program schedules, the consequences of noncompliance, the use of
AODs during treatment, the role of toxicology screening results, and the extent
and limits of confidentiality.
Assessment within AOD treatment is a comprehensive, multidimensional
process. Readers are referred to related TIPs for further clarification of the
assessment of AOD abuse disorders. These TIPs are Screening and Assessment
of Alcohol- and Other Drug-Abusing Adolescents; Assessment and Treatment of
Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse; and
Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the
Criminal Justice System.
Toxicology Screening
Routine and random drug testing of body fluids for AOD use is essential to
any IOT program. Screening should be performed randomly and perhaps as often as
once a week, especially at the beginning of treatment. In some cases, asking
clients to submit to screening more than weekly may prove beneficial.
Toxicology screening benefits patients by providing additional structure in
terms of relapse prevention and fosters honesty about relapses by reducing
patients' ability to manipulate the IOT staff, their employers, and other people
in their lives. Screenings can help to reduce clients' ability to minimize or
deny AOD use. All clients must be taught that the purpose of toxicology testing
is to enhance accountability, to help maintain a drug-free environment, and to
help achieve treatment goals. Screening also serves as a measure of client
progress with respect to abstinence. Toxicology screening has other functions
that relate to counseling issues -- such as confronting clients who claim to be
abstinent with urine tests that are positive for AOD use.
Patients must provide written informed consent regarding who, outside of the
program staff, may have access to or be informed of toxicology screen results.
The measures taken to address positive screening results should not be punitive,
but at the same time, patients should understand that some consequences may be
outside the control of the program or the therapist.
If the results of toxicology screening are to be used for other than
strictly internal purposes, the method used must meet requirements for
certification by the National Institute of Drug Abuse and the Clinical
Laboratory Improvement Act. When providing urine samples for analysis, clients
should always be supervised ("observed urines") to reduce the opportunities for
falsification. This is particularly critical when urine samples are used for
legal or employment purposes. Appropriate procedures should be developed
regarding the safe collection, handling, storage, and testing of urine samples.
Treatment Planning
There is nothing unique about treatment planning in an IOT program. Rather,
treatment planning should follow the standard of care for AOD treatment in
general. Based on the findings of the assessment, goals are established for an
individualized master treatment plan that describes specific goals and actions
to be taken. The treatment plan is a comprehensive and evolving record of
treatment goals reflecting the client's cognitive, emotional, social, physical,
and behavioral changes.
The treatment plan should be based on the patient's expressed objectives and
on findings from the initial assessment, medical examination, toxicology
screenings, and the biopsychosocial assessment. Specific, measurable goals that
the patient agrees to accomplish during the course of treatment should be
identified in the master treatment plan. The treatment plan should be developed
by the treatment team and the patient together; it should be updated and
reviewed regularly to ensure that it reflects the patient's progress toward
established treatment goals and to identify new problems that require treatment.
The treatment plan should serve as a "road map" for the treatment providers and
the client, so that everyone understands "where the client intends to go and how
the client will get there."
A treatment contract can be a part of the master treatment plan. It is a
useful tool to address problems that arise throughout the course of treatment.
A treatment contract consists of specific behavioral commitments to which the
patient agrees. It can provide structure and support to the patient.
24-Hour Crisis Management Services
Because clients' problems do not typically conform to the working hours of
the IOT service, arrangements must be made for clients to have access to
emergency services and counseling support on a 24-hour basis. In smaller
programs, this may be accomplished by agreements with existing services such as
hotlines, crisis intervention services, and hospital emergency rooms. Larger
programs that offer comprehensive addiction services may provide crisis
intervention services through on-call specialists connected to an answering
service and/or a paging system, or through the utilization of staff members who
work in residential programs.
Pharmacotherapy Services
Pharmacotherapy services include the medical management of withdrawal,
pharmacologic interventions such as methadone and naltrexone, treatment of
psychiatric disorders, and treatment of medical problems including HIV and AIDS.
Pharmacotherapy should not be a stand-alone service, but should be integrated
with other treatment services.
Pharmacotherapy should be available for patients who require support through
ambulatory detoxification, anti-craving and anti-addiction medications, and
psychotropic medications to manage psychiatric disorders, as well as for
HIV-positive clients who require antiretroviral therapy and other medications.
Although some programs may elect not to use anti-craving and anti-addiction
medications, it is essential that patients with major mental illness be
maintained on appropriate psychotropic medications.
Ideally, the outpatient use of prescribed psychoactive substances will be
carefully monitored on site, or possibly by other arrangements such as regular
visits to the patient's physician or a mental health clinic. The coordination
of such services is critical, and prescribing physicians should be integral or
extended members of the treatment team.
For in-depth discussions of issues related to pharmacotherapy in addiction
treatment, the reader is encouraged to read the TIP on State Methadone
Treatment Guidelines. Also, the TIPs Meeting Patient Needs in Opioid
Substitution Therapy: Matching Patients to Treatment Services and
Detoxification from Alcohol and Other Drugs are scheduled for publication in
1994.
Individual Counseling
In the past, counseling has often been distinguished from therapy in that
individual psychotherapy generally refers to a therapeutic attempt to help
clients identify self-defeating patterns of behavior and unconscious motivations
for specific behaviors. Psychotherapy often was organized toward the resolution
of long-standing conscious and unconscious conflicts. Counseling in an AOD
setting generally describes a therapeutic attempt to help patients solve
specific acute problems that are barriers to complying with or benefitting from
AOD treatment. Although extended examination of developmental and unconscious
issues are not discouraged, brief interventions are seen as preferable to
long-term individual work because of cost considerations. Particularly during
the early stages of treatment, individual and group counseling sessions are
valuable tools. Individual counseling can help:
Maintain clients' participation in the treatment process by
continual review and clarification of treatment goals and objectives
Reassure clients about fears and anxieties that are an expected part of the
behavioral change process
Enhance retention of clients in the program by strengthening the
client-counselor relationship
Identify new and healthy responses and solutions to stressful and difficult
situations.
Individual counseling provides the basis for a clinical relationship that
will be sustained throughout the course of treatment. Multiple sessions of
individual counseling, even if brief, are important in developing a solid
therapeutic relationship between the patient and the counselor.
Individual sessions can be used to address routine issues that do not
benefit either the client or group members by discussion in a group setting.
Conversely, in individual sessions, clients often disclose certain issues --
particularly those around which guilt or shame is experienced -- that could be
beneficially addressed in a group setting. Clients should be gently and
sensitively encouraged to present such issues in a group setting, thereby
defusing the emotional power of the issues and helping clients gain reassurance
from peers.
Group Therapy
Group therapy is a standard component of addiction treatment and should be
provided by a qualified clinician utilizing group processes and dynamics to
facilitate the treatment process. Certain patients may not be immediately
prepared to tolerate or work effectively within a group. Appropriateness for
group therapy should be considered by the treatment team before patients are
admitted to group therapy situations. Before participating in group therapy,
clients should be oriented regarding appropriate behavior in the group, and
other group rules should be explained, such as those associated with attendance,
participation, honesty, feedback to others, and confidentiality.
People who are addicted to AODs tend to isolate themselves and grow
alienated from others. Group therapy serves to break down isolating tendencies
and gives clients a reference point from which to explore the fears and
anxieties they experience as they contemplate a drug-free lifestyle. The
dynamic of peer confrontation and support can be fully experienced only in a
group setting.
Often the more experienced members of a group can anticipate and identify
the pitfalls and experiences that may be expected during the recovery process
for less experienced clients. Also, group norms help establish healthy recovery
patterns (Yalom, 1985). Further, the quality and strength
of the therapeutic milieu usually reflect the work clients do in group therapy.
Some group sessions should focus on here-and-now issues such as the desire
to use AODs, recent relapses, struggles with potent emotions, or conflicts with
other group members or family members. Other examples of special group topics
commonly addressed in IOT programs include incest and abuse, gender or cultural
issues, family relationships, and sexual orientation. Group sessions that are
more cognitively oriented or psychoeducational are different from group therapy.
Such education groups are another important component of IOT.
Ideally, therapy groups do not include more than 12 patients and are
facilitated by two therapists. Although not always feasible, IOT programs
should consider the advantages of dual-therapist groups, including role
modeling, coverage during the therapist's absence, and strategic facilitation.
Education Services
The didactic presentation of information on addiction and recovery is
considered an educational service. These educational programs, like those
offered in individual or group settings, are designed to address core issues of
human behavior and development associated with addiction and recovery. Some of
the topics covered in educational sessions include:
The dynamics of addiction and the addiction process
The role and process of treatment and recovery
Medical aspects of addiction
The importance of abstinence from alcohol and all other drugs
Appropriate use of prescribed and over-the-counter drugs
Powerlessness and unmanageability of AOD use
Maximizing the use of self-help and support groups
Spirituality and the development of an externalized source of support
The roles of nutrition, exercise, leisure, and recreation in recovery
Experiencing emotions and feelings without AODs
Relationship skills
Sex and sexuality and recovery
Conflict resolution and confrontation skills
Family dynamics of addiction
Healthy relationships and family functioning
Relapse management skills
AOD refusal skills
Avoiding and defusing triggers for craving and relapse
Minimizing risks for HIV, AIDS, and sexually transmitted diseases.
Generally, this information is effectively delivered through small-group,
highly interactive intimate discussions rather than in impersonal large-group
lectures. Adjunctive activities may include handouts or writing assignments.
Numerous videos and publications have been developed to support educational
efforts. It is important that patient responses to these sessions be discussed.
All educational programs should provide structure and time for productive
interactive discussion and processing of the information being learned.
Providers of educational services should have mastery of their subjects and
should avoid discussing subjects in which they are not well versed. Since
patients rely on the accuracy and relevance of these sessions, the quality of
these services is important. Consideration should be given to brevity.
Generally, the normal attention span is 20 minutes, and presentations should be
organized accordingly.
Family Education and Counseling
Family member participation is increasingly viewed as a critical area of AOD
treatment. Didactic and experiential sessions should be provided for family
members and significant others of patients enrolled in AOD treatment programs.
These sessions help engage clients' families in treatment and enhance family
members' understanding of the treatment and recovery process. Topics that might
be covered in a family educational session include:
The dynamics of addiction, treatment, and recovery in the family
Relapse and relapse prevention
Family issues common in addicted families
Enabling and denial
Healthy family functioning
Healthy detachment and "tough love"
Communication and problem solving in the family
Management of family social functions
Introduction to Al-Anon, Alateen, and other relevant support systems for
family members.
One of the purposes of family counseling is to educate family members about
family dynamics and issues associated with addiction and recovery. Family
counseling should provide the structure to support stabilization in the family
and to assist the entire family in making changes that support the recovery of
the client and all members of the family.
Family education and counseling provide an opportunity for family members to
identify and address personal family dynamics and issues associated with the
identified patient's AOD use and to develop solution-oriented strategies for
change to support AOD recovery.
Self-Help and Support Group Orientation
Patients benefit from involvement with the 12-step programs and other
self-help resources both during and after intensive AOD treatment. Studies have
shown that those who participate in 12-step self-help groups such as Alcoholics
Anonymous have higher rates of abstinence than those who do not (Hoffman and Harrison, 1988). The rates of abstinence are higher still among
people who participate in aftercare plus Alcoholics Anonymous (Hoffman
and Harrison, 1988; 1988a; Hoffman
and Miller, 1992).
In many ways, self-help participation is the bridge between acute treatment
and long-term recovery. IOT programs provide a limited number of treatment
hours per week, and treatment continues for a limited time thereafter.
Participation in self-help and other support group activities is vital to
ensuring extended support beyond the treatment episode. The 12-step programs --
Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous -- are widely
known as the self-help resources that best support sobriety and recovery.
Patients should be informed that there is variability among 12-step group
meetings. For instance, some AA meetings are open to everyone, while some are
open only to people who have the desire to stop drinking. Some meetings are
open to a specific group of people. There are 12-step meetings attended only by
men, women, gay men, lesbians, the hearing impaired, Spanish-speaking people,
elderly people, people with AIDS, or nonsmokers. In many areas, there are
12-step meetings for impaired medical professionals and "double trouble" groups
for clients with dual disorders.
Some 12-step meetings are regular (discussion) meetings, while others focus
on the 12 steps ("step meetings"), and some feature people talking about their
experiences with AODs and recovery ("speaker meetings"). Clients should
understand the variety of options available in their community and know how to
gain access to them and what to expect during the meetings. Clients should
learn about the traditions and services associated with these programs, such as
concepts of sponsorship and service to others. Clients should be encouraged not
only to attend but to actively participate in the meetings. All clients should
be provided with a meeting directory of 12-step groups.
Staff members should receive training about the predictable resistances that
patients often have when introduced to self-help participation, especially
resistance regarding the spiritual focus of many of the 12-step programs. IOT
staff members should be sensitive to the need for matching individual patients
to a "home group" of people with similar backgrounds, culture, and experience.
A special advantage of IOT is that patients can identify and participate in
their home group before leaving treatment.
Although the 12-step programs are the most numerous and accessible self-help
resources available, they are not the only source of self-help support. While
some people will reject the 12-step programs as part of an overall rejection of
AOD treatment, some people will reject the 12-step programs in favor of
alternative self-help resources. AOD treatment staff should be willing to help
such clients explore reasonable alternatives that will genuinely help them
establish and maintain sobriety and promote emotional and spiritual growth. The
effectiveness of the self-help experience should be based on the client's
comfort level and assumed benefit rather than on the experience or traditional
outlook of the treatment provider.
AOD treatment staff should be familiar with alternatives to 12-step programs
that may be available in their area, such as Rational Recovery Systems, Secular
Organizations for Sobriety (Save Ourselves), and Women for Sobriety. There are
also self-help groups that have a specific religious orientation such as
Overcomers Outreach (for Christians) and the self-help group named Jewish
Alcoholics, Chemically Dependent Persons and Significant Others.
Case Management Services
IOT programs should have arrangements or agreements with other organizations
for delivery of support services not provided by the treatment program (such as
vocational rehabilitation, social services, and employment services). The case
manager links the client with these other services, manages the client's
treatment plan, and ensures the client's appropriate legal consent. Programs
treating individuals with children should also provide or have reliable linkages
to child care services.
For clients to benefit fully from IOT, issues identified in the
biopsychosocial assessment need to be addressed. Linkages should be provided to
services called for in the master treatment plan, such as primary health care,
job skills, child care, vocational and educational training, and transportation
to and from the treatment site. Case management functions include securing the
linkage and followup to ensure the provision of these services or of alternative
services and monitoring this process until the identified need has been
addressed. The absence of these critical services can create barriers to
effective treatment. For example, not having child care makes it impossible for
some parents to participate in treatment and family services. As the treatment
field advances in its effort to provide whole-person care, and as clients
continue to present with significant complications and special needs, case
management services will be increasingly important in the treatment of AOD
disorders.
Discharge and Transitional Service Planning
To ensure that the recovery process continues beyond the point of intensive
treatment, a continuing care plan should be developed by the patient and the
therapist. The objectives and goals identified during the initial phases of
treatment are carried forth in this written plan, which specifies the activities
and objectives that will enable the client to sustain abstinence and a
recovery-oriented lifestyle. Issues left unresolved should be addressed in the
continuing care treatment plan.
Transition planning consists of preparing the client for completion of
intensive treatment and developing plans for the client's ongoing support for
recovery. These plans should be established early in the treatment process and
may include outpatient services, group counseling, vocational training, ongoing
individual or family therapy, and/or self-help group participation.
Program and Outcome Evaluation
Evaluative studies are critical in determining an IOT program's
effectiveness as measured by factors such as completion rate, abstinence,
quality of life, employment and workplace stability, and reduction or cessation
of criminal behaviors. Outcome evaluations assist the program to identify its
rates of positive versus negative outcomes and to develop new and innovative
services. Outcome evaluations should not be used as a punitive tool, nor to
determine salary or pay scales. Rather, they can be used to point out
performance issues that require ongoing staff training and to identify those
intervention services that best help the addicted patient.
It is clear that the treatment of clients for AOD abuse is a difficult
business. Programs should be careful in developing standards of care to
identify fair and reasonable outcome indicators. Lifelong abstinence of
graduates, for example, would not only be too ambitious to study but would also
prove to be an unreasonable expectation. At the very least, it is recommended
that IOT programs track patient retention and completion rates and related
variables.
Optimal Elements
The planning, development, staffing, and allocation of resources for IOT
programs should be approached with the specific goal of meeting the treatment
needs of the target population. Therefore, it must be decided what treatment
needs patients are likely to have before decisions are made about the types of
treatment services that will be offered. All IOT programs should have the core
elements described in the previous section. Depending on the mission and scope
of specific IOT programs, many will require the elements described below as
optimal elements.
In other words, while certain AOD treatment services can be considered core
elements that constitute the minimal elements for an IOT program, and other
treatment services can be considered optimal elements that help to define an
enhanced IOT program, certain so-called optimal elements can be considered core
elements when they are required to meet the needs of the target population. For
example, an IOT program that primarily treats single gay men without children
who live in a specific neighborhood may not need child care or transportation
services. In contrast, a program that primarily treats working mothers who are
dispersed throughout a larger area may define child care and transportation
services as core elements. Although it may not be realistic or necessary for
all IOT programs to offer the complete array of core and optimal elements that
are recommended in this TIP, all programs are encouraged to consider these
services.
Outpatient Withdrawal Management
The medically supervised management of AOD withdrawal on an outpatient basis
can be a valuable service of an enhanced IOT program. There is increasing
evidence that withdrawal from AODs can be safely and cost-efficiently managed on
an outpatient basis. To support this function, IOT programs are advised to
secure or coordinate with appropriate medical resources to ensure that patients
are served in the least restrictive level of care. Daily or near-daily
withdrawal monitoring must be supported by an array of services, including
individual and group counseling as well as nursing and physician services. This
should not be a freestanding function, but must be linked with appropriate
support services.
Family, Marital, or Couples Therapy
Therapy with a client's family, spouse, or significant other may be provided
to address treatment and recovery issues as they relate to family dysfunction or
problems in relationships with these individuals. In some cases, additional
individual assessment and therapy with qualified professionals may also be
appropriate during intensive outpatient treatment to explore issues that surface
during treatment.
This type of assessment and subsequent treatment must be conducted by
professionals with appropriate levels of experience, training, and supervision
in family systems therapy. Such professionals should be well-grounded in
treating family dynamics that are distorted due to AOD use in the family.
Clients may require intensive family therapy to address long-term family
dysfunction or issues related to family of origin. For this aspect of
treatment, the family, in essence, becomes the patient.
Several treatment strategies can be helpful in addressing family issues,
including: family counseling with a primary therapist, family education groups,
and multifamily therapy groups.
Multifamily group therapy is a valuable treatment service for IOT programs.
Bringing families together to share common experiences and issues can provide a
tremendous opportunity for support and problem solving. Families that
participate in multifamily therapy may feel less isolated and alone in their
struggles. An extended milieu that includes family members can be established,
often leading to supportive relationships beyond the duration of the program.
Special services to children of AOD-abusing clients may have particular
benefit and should be considered if possible. It has long been known that the
children of AOD abusers are at risk for AOD abuse, depression, attention-deficit
disorder, and behavioral disorders.
Problems such as learning disabilities, sexual dysfunctions, or neurological
impairments may impede or truncate the treatment process if not addressed.
Parenting Skills Training
One of the goals of AOD treatment for women with children is to help women
keep their families intact -- unless they are abusing or neglecting their
children. Indeed, compared with inpatient treatment, IOT may be particularly
effective for stabilizing family relationships, since it allows patients to
continue to function in their family roles during the treatment process (Longabaugh et al., 1983). (When IOT staff become aware that child abuse or
neglect is occurring, child abuse and protection laws must be followed.)
Child Care and Transportation Services
In an optimal setting, access to child care is provided, either on site or
by arrangement. Similarly, the transportation needs of patients can be met
through bus, train, and subway passes or tokens, or staff drivers. State
licensure requirements and liability insurance are considerations in
implementing these services, as is having qualified staff to provide them.
Addressing these issues can have a significant impact on patient participation
and retention.
Organized Recreation and Leisure Activities
OT programs can be greatly enhanced by providing therapeutic recreation and
leisure activities. Optimally, programs can hire a certified recreation
therapist who has specific training in teaching recreation skills, leisure
activities, and stress reduction, and who can educate patients about the role of
such activities as an important aspect of recovery.
The value of recreational activities include: 1) learning social skills, 2)
learning cooperation and trust, 3) experiencing healthy competition and
teamwork, 4) bonding with other clients, and 5) learning to have fun without the
use of AODs. Recreational activities that involve physical exercise often
diminish agitation, stress, anxiety, and depression; increase appetite; and
enhance healthy sleep. Recreational activities include aerobic exercise,
organized sports and games, assorted arts and crafts endeavors, and therapeutic
participant games.
Leisure activities include taking quiet walks, reading books, engaging in
conversations, watching organized sports, and being passively entertained. In
an IOT program, leisure activities can teach clients that some passive
experiences can be therapeutic, healthy, relaxing, and enjoyable without the use
of AODs.
Transition and Continuing Care Services
IOT programs should provide extended treatment services that follow the
intensive phase of treatment.
Continuing care -- often called aftercare -- is the opportunity to address
treatment plan goals and objectives that were not met during the intensive
phase. Such services are designed to provide clients with continuing support
and opportunities for further growth and development. Continuing care is also a
transition from an intensive level of treatment to nontreatment phases of
recovery.
Continuing care services can include such outpatient services as case
management; individual, group, or family therapy; liaison and advocacy; and
monitoring and drug testing. Continuing care can also include various social
activities such as recreation and leisure events and field trips. The case
manager, counselor, therapist, or continuing-care-monitoring specialist can
provide valuable liaison services between the patient and the employer, union,
judge, or probation officer as required. Such IOT program staff can observe and
document participation and progress in treatment and provide evaluations to
appropriate individuals or agencies when required.
If an IOT program is not organized to offer these transitional services,
appropriate referral providers should be identified and used extensively. To
ensure effective continuing care, IOT programs should develop a close
relationship with those providers. Reimbursement for these services may be
problematic. Because of the proven value of extended treatment participation,
this matter should be carefully discussed with payers.
Alumni Activities
Activities that promote continued contact of former clients with the IOT
program can be of benefit to both current and former clients in the program.
Individuals who have completed treatment can serve as role models and peer
helpers by bringing new patients to group meetings and by organizing special
recreational activities such as picnics, parties, baseball games, and drug-free
outings and social activities. Alumni events can provide patients with the
sense of an extended or continuing therapeutic milieu and can offer important
structure and support.
Outreach
Engaging AOD patients in treatment can often be a difficult and challenging
process. IOT programs should consider providing a range of outreach services
designed to: 1) encourage potential clients to participate in screening and
assessment efforts, 2) minimize barriers to program intake, 3) provide education
and interventions to families, and 4) motivate patients to engage and
participate in treatment. Outreach services include satellite programs or
services provided in areas easily accessible to patients. Outreach services
also include visits by IOT staff or contractors to clients' homes, work sites,
detention centers, inpatient units, or jails to provide screenings and
assessments and other services.
Multiple contacts with the referral sources may be needed. Outreach
services may be needed for both clients and families -- including home visits
when possible -- to encourage clients to come to the treatment site, begin the
assessment process, and address their feelings of ambivalence and fear about
changing their lives.
When planning outreach services, IOT programs must be sensitive to
confidentiality issues. Under the Federal confidentiality regulations,
individuals who have applied for treatment services (whether followed through or
not) are considered patients. Representatives from an AOD program cannot go to
a patient's home or workplace without the patient's consent if the visit would
reveal to others the patient's status as an AOD abuser. AOD programs must
ensure that informed consent is obtained in instances when the patient's
relationship to the program can be identified. See Chapter 7
for a discussion of legal issues for IOT programs.
There are several therapeutic interventions that can be valuable components
of IOT programs -- as optional services that can enhance and supplement core
services. Examples include:
Structured cognitive and behavioral interventions
"Ropes" courses
Psychodrama
Acupuncture
Biofeedback
Art therapy
Dance and other movement therapies
Vocational and legal assistance.
The availability of these services may depend on the specific client groups
being treated, the geographic area, and funding considerations.
Clinical Challenges and Responses
While there are several advantages to IOT programs, there are specific
challenges that are distinctive to the IOT level of care. The more common
challenges are reviewed below and strategic responses are suggested.
Retention Problems and Relapse
Challenge. Unlike patients in residential treatment, those in IOT
must make the daily decision to return to treatment. Further, IOT patients
often live and work in environments in which substance abuse is prevalent and
access to AODs is unconstrained. As they leave the treatment site, they may
encounter environmental cues that trigger drug hunger and increase their risk
for relapse. Factors contributing to client dropout include:
Ambivalence about stopping use of the primary drug of choice
Lack of commitment to stop all AOD use
Crises regarding family and work responsibilities
Denial of AOD problems or severity of the problem
Denial that adverse consequences are caused by AOD use
Discomfort with identity as a recovering person
Inability to relate with others in a group setting
Lack of family support for treatment and recovery
Family sabotage through enabling behaviors
Work schedule conflicts.
Clinical response. Patient dropout and relapse problems should be
addressed through proactive interventions designed to engage and retain patients
in treatment. Since many patients experience similar types of problems that can
lead to relapse and dropout, programs should continually anticipate these
problems, develop educational and therapeutic strategies to prevent them from
occurring, and create specific plans to deal with them when they occur.
Many patients have been living in chaotic, high-stress, dysfunctional
environments that promote isolation and distrust and encourage people to ignore
their feelings and to medicate their emotions with AOD use. In contrast, IOT
programs should provide an environment that is orderly and free of unnecessary
stress, that encourages people to recognize and handle emotions without AOD use,
and that teaches and promotes trust and interdependence.
Programs should use several techniques that encourage patients to become
engaged in the treatment process and promote a sense of ownership of treatment
and recovery efforts. For example, rewards can be created for perfect or
excellent attendance in treatment, successful completion of treatment can be
marked with ceremonial graduation events, and important treatment and recovery
milestones can be acknowledged in client community meetings. Special events and
activities such as staff-client skits and games can be organized and regularly
scheduled. Such activities can help clients experience a sense of inclusion,
belonging, interdependence, trust, openness, and emotional self-awareness.
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