As is true with all human service agencies, an intensive outpatient
treatment (IOT) program for treating alcohol and other drug (AOD) disorders is
only as good as its staff. A program operated by a staff that is uncoordinated
and fragmented, uncooperative and independent, unsupportive and unsupported, and
lacking in optimism, inspiration, and trust will foster client treatment
experiences that have the same qualities. Programs that have these
characteristics are unable to provide quality care.
In contrast, an AOD treatment program that is operated by a staff that is
coordinated and unified, cooperative and interdependent, mutually supportive and
effective at communication, and grounded in optimism, inspiration, and trust
will help foster a treatment environment that is conducive to patients'
biopsychosocial health. A staff and treatment program with these
characteristics can typically provide exceptional treatment services.
Since AOD treatment is intrinsically demanding and stressful work, it is
critical that treatment programs provide active and vigorous support for staff
members. It is always the quality of the therapeutic alliance that influences
patient experience and outcome. Therefore, programs must support staff in a way
that allows staff to establish and maintain effective therapeutic bonds with
clients.
With regard to staffing issues, intensive outpatient treatment programs have
several characteristics that distinguish them from traditional outpatient
treatment and medically managed inpatient programs. For example, IOT programs
provide treatment to many patients who have left the heavily supervised and
restricted environment of an inpatient setting for the less restricted
environment of an IOT program. Potent medical, psychiatric, emotional, and
social crises may have only recently occurred, and may yet be unresolved. There
is not the benefit of shift staff to manage patient care, a problem that creates
a great deal of pressure on IOT staff to handle extraordinary patient care
issues.
IOT programs often provide services during evening and weekend hours.
During periods of limited staffing, supervisors and staff must be flexible and
responsive. IOT programs often have part-time staff and contract personnel,
demanding special supervision to ensure continuity of services. Because of the
nature of IOT programs, it is essential that staff members communicate
effectively with one another. They must be able to adapt easily to changing
situations.
Staff Member Roles
IOT treatment staff assignments and responsibilities vary according to the
size of the individual program. In larger programs, some clinical services may
be provided by specialists. In smaller programs, it is likely that some staff
members will need sufficient training to provide comprehensive services.
IOT programs offering distinctive treatment components such as medically
managed detoxification, family therapy, and recreation and leisure activities
may require specialists such as physicians, family therapists, and certified
recreation therapists.
Programs also have different sources from which to draw staff. A
hospital-affiliated program, for example, can draw from the hospital's medical,
nursing, social work, and other personnel. But many programs are freestanding,
or affiliated with an institution without the broad range of services that a
hospital can offer.
Personnel in an IOT program can be categorized into three groups:
Core clinical staff provide direct client treatment
services such as assessment, counseling, case management, medical examinations,
crisis interventions, and nursing care, as well as clinical supervision.
Administrative, clerical, and support staff perform administrative
functions such as program planning, financial management, logistical support,
recordkeeping, contracts management, and management of regulatory compliance.
Consultant and auxiliary personnel are often outside consultants
who provide a range of specialized services including vocational counseling
neuropsychological testing, pastoral counseling, and HIV/AIDS education.
The professionals listed below may constitute the core clinical staff. The
skills of many of these providers may overlap. For example, nurses and social
workers may also serve as addiction counselors. As the AOD field progresses,
less attention will be given to training orientation and membership in a
particular discipline, and more to overall competency in addictions treatment.
All of these staff have a vital role in the functioning of an IOT program on a
full- or part-time basis:
Medical staff include physicians such as psychiatrists, family or
internal medicine specialists, addiction medicine specialists, and general
practitioners; and nurses, nurse practitioners, physician assistants, and other
"physician extenders" who provide medical and nursing assessments, examinations,
evaluations, pharmacotherapeutic services, and clinical supervision.
Addiction counselors provide assessments, individual and group counseling,
education, case management, and transition and discharge planning.
Social workers and other licensed professional counselors provide
assessments; individual, group, and multifamily counseling and therapy;
education; case management; and transition and discharge planning; they
facilitate and make community linkages and provide clinical supervision.
Psychologists provide individual and group therapy, psychological testing,
neuropsychological testing, other assessments, and clinical supervision.
Core staff are often able to provide certain specialized services that may
enhance the IOT program. Similarly, auxiliary or consulting staff can be used
for program enhancement and may include the following:
Vocational rehabilitation counselors
Recreational therapists
Art, speech, dance, and music therapists
Nutritionists and dieticians
HIV and AIDS specialists
Clergy and pastoral counselors
Literacy and general equivalency diploma (GED)instructors
Patient advocates.
Clerical staff members have very important roles in an IOT program.
Clerical and support staff are often the first individuals to have contact with
potential clients. The nature of this interaction can often lead to successful
client placement. Additionally, administrative staff ensure the effective
logistical operation of the program. Without their participation, there would
be no program. Such staff are also responsible for communicating information
about the IOT program to potential patients or referral sources. These
individuals should not be taken for granted and should be viewed as members of
the team. It is important that they receive education and training regarding
AOD abuse, the nature of the IOT program, and confidentiality regulations. They
must receive appropriate levels of supervision and support.
In addition, interns and trainees can fulfill several clinical and
nonclinical functions. These include physicians and medical students who are
participating in an addiction medicine internship; undergraduate and graduate
students in clinical psychology, counseling, social work, and addiction studies;
and nurses who are participating in an addiction setting placement for a nursing
specialty in addiction. Trainees and interns cannot be expected to replace paid
staff or provide services that they are not qualified to provide. However, they
can be valuable adjuncts to the program and should be incorporated into staff
planning. Programs should have written policies and procedures for notifying
patients that their care may in part be provided by interns and trainees.
Shared Knowledge and Beliefs
In addition to specific clinical skills and specialty training, all AOD
treatment personnel should share common beliefs and philosophical orientations.
First, they should recognize that AOD addiction is a disorder, not a problem
caused by moral corruption, emotional deficits, failed willpower, or ignorance.
Second, they should recognize that AOD addiction is a biopsychosocial and
spiritual disorder not treated effectively or exclusively by any one discipline
or orientation, but best treated by a multidisciplinary team of professionals.
Third, staff should share the conviction that addiction is a treatable disorder,
and that together they can successfully treat people with AOD addiction. Also,
staff should share the belief that self-help groups such as the 12-step
programs are vital aspects of AOD treatment and recovery.
AOD treatment staff members should be flexible and emotionally mature. They
should demonstrate self-awareness, the capacity to relate effectively to others,
the capacity to confront and resolve one's own difficulties, self-respect and
respect for others, and the willingness to learn about and understand people
with backgrounds different from their own.
AOD treatment staff should be willing to listen and understand and have a
desire to learn. They should be willing to utilize supervision and mentorship
and have an openness to new approaches and orientations. They should be eager
to examine their own prejudices and able to avoid overidentification with
clients.
Counselors and all professional IOT staff members should be familiar with
the following 12 core functions of the AOD counselor:
Screening
Intake
Orientation
Assessment
Treatment planning
Counseling
Therapy
Case management
Crisis intervention
Patient education
Referral and coordination
Reporting and recordkeeping
Consultation with other professionals with regard to patient treatment and
services.
Clinical Competency Guidelines
The clinical competencies required are somewhat dependent on the specific
program, and vary from program to program. In large, heavily staffed programs,
not every staff member will have to possess an entire range of skills and
competencies.
However, because of the complex needs of clients treated in an IOT program,
staff often must be skilled in more than one area of therapeutic intervention.
In smaller programs, it is particularly critical that staff members have
comprehensive skills and experiences.
Evaluation and Diagnostic Skills
Staff members should have a clear understanding of the diagnostic signs and
symptoms and criteria associated with AOD use disorders. They should be able to
conduct a thorough psychosocial evaluation and understand that a diagnosis is
not merely a label placed on a patient but a set of hypotheses about the
patient's condition. They should understand that the diagnostic process is a
framework for determining the problems clients have -- a framework that dictates
what treatment is provided.
Staff need to be thoroughly familiar with the current version of the
Diagnostic and Statistical Manual of Mental Disorders, (American
Psychiatric Association, 1994), which continues to be the professional guide
to making diagnoses and treatment decisions, and which is the standard reference
for reimbursers and other professionals.
Documentation Skills
Patients' charts are legal documents and serve several important training
functions. The records identify patient issues and serve as the official log to
track changes, progress, and case planning. As such, they serve as a vehicle
for communication among treatment providers. This is especially critical when
the care of a patient is transferred to another provider.
Records are the basis for utilization review, quality assurance, program
assessment, and licensure -- to ensure the continued status of the program and
the ongoing care of patients. Good recordkeeping is more than a "bureaucratic
obligation." It ensures that good care is being provided and records the
specific impact of interventions.
For these reasons, chart documentation is a fundamental part of the
responsibilities of treatment staff. Training regarding the proper and timely
documentation of assessments, interventions, treatment, transition, and
discharge is essential for staff at all levels of IOT programs.
Fundamental Counseling Skills
Certain fundamental and generic counseling skills are needed in all types of
therapeutic interventions. These include establishing rapport and the ability
to engage and align with the client. Staff and other clinicians should be
genuine and nonjudgmental and should treat clients with respect. They should
not be threatening and must be able to deal with clients' ambivalence about
abstinence. Staff should have the characteristics and skills that relate to
empathy, genuineness, respect, self-disclosure, warmth, immediacy, concreteness,
confrontation, and change.
Staff should also have the ability to recognize if counseling and other
therapeutic interventions are working or not, and should have an awareness of
the client's reaction to the therapeutic process and of their reaction to the
client. They should know when it is necessary to seek help from other
professionals.
IOT patients are often newly recovering AOD abusers. It is particularly
important for the staff to be able to confront them in a nonjudgmental way.
Staff must be able to provide information and education despite patients'
tendency to deflect information.
Staff must be aware that many therapeutic issues will not be addressed
during IOT and that some issues will be addressed partially and incompletely.
There may be a lack of time within a specific therapeutic intervention or within
the schedule of the IOT program to address some issues fully. Also, many
clients will have several problems, such as mental health needs, that require
clinical attention. However, addressing some problems should be temporarily
postponed until clients are stable with regard to their AOD use disorders.
Thus, staff will often need to orchestrate the level of intensity of therapeutic
interventions and allow sufficient time for individual clients to reach closure
on an issue (even if temporary) before the clients leave the premises.
Staff should also have the ability to integrate therapy with events
occurring in their clients' lives. Staff should be comfortable becoming
involved with the clients' family, employer, and community.
Staff should be able to work with a team and be willing to assume and
relinquish authority when necessary. They should have appropriate training for
working with people from different ethnic and cultural groups. Staff must have
a commitment to using community resources, and to active networking and
relationship building to develop a community network of treatment and social
services.
Staff members who are recovering from AOD addiction should be trained to
serve as AOD professionals. They should be educated about not overidentifying
with patients. Recovering staff members should not expect a patient to respond
to treatment in the same manner as they did. They need to be comfortable with a
patient's developing a different set of recovery skills and resources than their
own.
Individual Counseling Skills
Competencies needed for individual counseling include general listening,
reflecting, paraphrasing, and solution-oriented, problem-solving skills. Staff
also need the ability to establish rapport, to regulate the intensity of the
session, and to manage the therapeutic boundaries of the relationship. Staff
should also have the competence to recognize and resolve transference and
countertransference issues and to confront denial and resistance. Staff should
seek regular consultation on these issues from their supervisor.
Group Therapy Skills
Staff involved in group therapy must know the difference between group
therapy and group support. They must understand the purpose of "here-and-now"
group therapy and group process dynamics. They should be able to use the group
to facilitate confrontation when necessary and to move the group from a
psychoeducational to an interactional mode and back again when necessary.
Flexibility is especially important in facilitating the interactive process.
Staff members must have the ability to structure and actively facilitate the
early recovery group, until the group demonstrates the capacity to organize
itself. Staff members should be able to use the group to advance the overall
goals of treatment such as achieving abstinence, solving problems, improving
social skills, resolving conflicts, effectively expressing emotions, developing
trust, and cooperating with others.
Group counselors must understand the dynamics of addiction, especially the
generally potent defense mechanisms that prompt clients to avoid rather than
confront issues. Staff should be familiar with denial, minimization,
resistance, projection, and other manifestations of an addicted person's defense
mechanisms, and should develop ways to address these defenses using the group
process.
In contrast to other settings, IOT group facilitators should be more active,
directive, and responsive to client resistance. The group must be client
centered, but with the counselor playing an active role, especially early in the
group's development.
The ability to manage clinically difficult patients is an important
attribute. Staff are likely to encounter patients who are still using AODs,
patients who are withdrawn, patients trying to take over the group, cognitively
impaired patients, and patients with active psychiatric illness.
Staff should understand that change takes time. They should also know that
facilitating a seemingly unproductive group session does not mean that the
process is ineffective. It is also important for staff to be able to work with
a cofacilitator, which involves planning and responding to the group process.
Ideally, cofacilitators meet before and after group sessions to discuss the
day's group experience. Because of the special advantages of two-therapist
groups, cofacilitators are recommended for all outpatient groups.
Family Therapy Knowledge
Staff members who participate in family therapy sessions or multifamily
therapy sessions should have knowledge of and supervised experience with
systems-based family therapy methods and techniques. Family interventions are
key to outpatient work. Thus, it is recommended that all IOT counselors have
some contact with family work.
A traditional family therapist may work with a family once a week. In IOT,
the family therapist needs to go beyond traditional frameworks of family therapy
and be able to engage in a variety of other activities related to adaptive
family responses to the AOD use that exists in the family. These additional
interventions may include multifamily therapy, family educational services,
psychodrama, or extended day family treatment services. Family therapists in
the IOT setting should be trained and skilled in a variety of intervention
techniques. Family specialists working with AOD clients should have a thorough
knowledge of adjunct family supports such as Al-Anon and Naranon.
Case Management and Teamwork
IOT program staff members work with many other people in order to accomplish
their goals. Thus, communication skills are vital. Open and regular
communication among team members is crucial. There must also be communication
between program staff and the other community resources that serve clients.
Staff must be able to relate to medical and psychiatric staff so that they can
work in concert.
The two primary functions of case management are to ensure that patients
receive the services that they need -- when they need them -- and to ensure that
they experience a continuity of treatment despite changes in treatment programs,
changing needs for medical and social services, and other changes in their
lives.
IOT staff members involved in case management must serve as liaisons among
treatment providers, third-party reimbursement sources, social services, and
community resources. They must have a thorough knowledge of available medical,
psychological, addiction, religious, spiritual, and social services.
Multidisciplinary Teams
Because of the biopsychosocial and spiritual nature of addiction treatment
and recovery, and because of the diversity of client needs, multidisciplinary
teams are essential in the IOT setting. No single profession incorporates the
breadth and depth of resources and skills needed to adequately address the wide
range of issues of IOT clients and their families.
Staffing should be based on an appreciation of the philosophy of the
multidisciplinary team approach and a respect for all disciplines and their
contribution to the treatment process. The size of teams varies according to
the facility, but the following services should be included in some way:
Medical services
Counseling
Case management
Social and family services
Psychological services
Psychiatric services
Other ancillary services.
Decisionmaking in the treatment of the IOT patient should be a group
endeavor, where input from the various disciplines is considered in assessing
progress in recovery. The team is the unit that will assess and chart progress
and do treatment planning. The team should function cooperatively, with open
communication, with the best interests of clients always being the focus.
The team should have regularly scheduled meetings. Also, ongoing
communication among team members outside of formal meetings is critical,
especially since some patients' problems require immediate or rapid resolution.
Working Knowledge of Self-Help Programs
Staff in IOT programs should understand the philosophy of 12-step and other
self-help programs, how these programs work, and how they relate to IOT
treatment services and any other treatment in which the client may become
involved. Besides understanding the philosophy, purpose, and function of
self-help programs, they must understand several practical issues. These
include:
The common resistances that people have to participation in
12-step and other groups
A knowledge of local meetings so that patients can be referred to groups
that meet their individual needs
The function and importance of sponsorship and how to incorporate
sponsorship-seeking in the treatment plan
The differences among 12-step group meetings, such as open and closed
meetings, speaker and step meetings, nonsmoking meetings, and meetings for
people from special groups, such as men, women, gay men, lesbians, and youth.
There are important distinctions between professional AOD treatment and
nonprofessional adjuncts to treatment such as the self-help groups.
Professional staff must be able to understand them and to explain these
differences to a client.
Crisis Management
Crisis management is one of the core functions of AOD counselors, a function
that is particularly pertinent to the special needs of patients in an IOT
program. It can be approached in two ways: staff members can have the crisis
response skills necessary to handle a crisis themselves or they can develop the
necessary community relations to rapidly obtain the appropriate resources as
soon as a crisis develops or seems imminent. Both approaches should be a part
of IOT staff training in crisis management.
The ability to manage a crisis should be considered when hiring personnel
for the IOT setting. Necessary skills include sound judgment; the ability to
think, assess, and respond appropriately; and the ability to assess and
stabilize a psychological, social, or medical crisis. Sometimes the skill
required is as simple as knowing when to call 911. Other important traits are
knowing how to stay out of dangerous situations, knowing when to let go of an
issue if a potential crisis is escalating, and understanding one's personal
limitations.
Programs should have an explicit written protocol about handling crisis
situations. All staff members should be familiar with the protocol.
Ethical Guidelines
Adherence to professional ethics is important for staff members of all
intensive outpatient treatment programs. Personnel working in IOT settings
should have a demonstrated commitment to the ethical standards of their
profession.
Each individual profession represented in IOT has its own professional code
of ethics, and these form the basis for identifying and managing ethical issues.
Within the complex IOT context, it is important that counselors and other
professionals not go beyond the bounds of their training and experience in the
services they provide. Another important point to emphasize is that staff are
expected to adhere to ethical standards regarding contact with clients. There
should be clear program guidelines on staff contact with patients outside the
program since it is inevitable that staff will see clients away from the
program. This may be particularly likely for staff who participate in community
self-help groups.
Because of the open and unstructured nature of IOT, and the necessity to
sometimes work in isolated settings, counselors may be particularly susceptible
to charges of misconduct. The program must have clearly stated ethical
standards of staff-patient relationships. Whenever possible, at least two staff
members should be on site whenever patients are present.
The program must have a protocol for reviewing untoward incidents or
complaints and for documenting reports. These incidents must be handled
immediately after they happen.
Staffing Level Guidelines
Because IOT programs vary widely, it is impractical to state specific
guidelines for staffing levels or patient-to-staff ratios. However, it is
equally important to emphasize that staff in an effective IOT program must be
capable of providing intensive, high-level, and responsive services. IOT needs
clearly differ from those of other programs with respect to staffing levels.
AOD patients have traditionally been served in inpatient facilities, with
24-hour coverage and the support staff associated with an inpatient setting.
Although IOT programs require lower staff-patient ratios than outpatient
programs that are less group oriented and less structured, there should be
sufficient staffing to ensure that no client will go unnoticed and unattended.
This is especially critical with respect to the particular challenges cited in
Chapter 3. This consideration to patient care should be
given within the context of what staff can reasonably accomplish within the
parameters of the paid work schedule. For example, a 20-hour part-time employee
should not be given caseload responsibilities requiring 40 hours.
A number of variables should be considered in establishing counselor
caseloads, including the type of care provided and the availability of auxiliary
services. Some States may have regulations governing staff-to-client ratios.
These issues must be addressed on a program-by-program basis.
A program should establish clear standards associated with clinical care
time to support task rates. A proposed ratio for primary therapists is 50-50:
50 percent of their time engaged in clinical patient contact, and the other 50
percent doing support work related to patient services, such as recordkeeping
and community networking. This ratio should be applied to clinical work only,
not to supervision or other work clinicians might sometimes perform.
Establishing an ideal time-use ratio is recommended for staff well-being and
burnout prevention. However, considering the intense needs of IOT clients, this
is an ideal that frequently cannot be met because considerable time is often
spent in direct patient care. The size of the IOT program staff, the clinical
needs of patients, and the availability of backup services must all be factored
into this formula.
Staff Stressors
IOT work and the nature of the population being treated can cause
significant stress among staff. This stress can sometimes be an impediment to
running the program successfully. Training front-line and supervisory staff
about these stressors can help diminish some problems and help staff prevent or
effectively address other problems as they arise.
Staff in different programs will face different dilemmas, and each program
must develop its own way of dealing with stressors. In all but the smallest
programs, regular meetings to process the concerns of staff members are
recommended. Regular meetings should also be held to address the problems of
support personnel, who may face different stressors -- sometimes because of the
pressures placed on clinical staff. Problems should be addressed as early as
possible.
For example, holding a meeting at the end of a stressful day allows staff
members to communicate their feelings and express problems and complaints before
another work day begins. Staff members should be encouraged to ask for such
meetings whenever there is a need.
Some significant stressors that should be anticipated include:
Long hours and inconsistent work schedule. The demands of
clinical coverage in IOT programs often involve evening and weekend hours for
virtually all staff members, which can result in staff members feeling isolated
from colleagues and support services. Sometimes staff members are required to
work broken day shifts, which, like evening and weekend schedules, can interfere
with family life.
Demands of an AOD treatment population. The acute manifestations
of AOD abuse and the stress faced by clients, their high risk for crises and
sometimes unpredictable behavior, and the intense nature of the treatment
environment can create significant stress for counselors and other staff
members. The infrequent opportunities for staff members to share their
experiences with other peers can lead to isolation, frustration, anger, fatigue,
and a sometimes overwhelming sense of responsibility and feelings of
helplessness.
Large caseloads. IOT programs often require a lower
staff-to-patient ratio than other outpatient programs. High caseloads can be
detrimental to the program. Having smaller caseloads can prevent staff members
from being overwhelmed by the demands of the job. This is especially critical
in many programs that have to operate with smaller staffs than they actually
need.
Time involvement. Extensive case management time and effort are
needed because of the complex issues and needs of AOD clients. These include
patient retention efforts and networking with other providers, including
employee assistance programs and employers, social service agencies, mental
health care providers, and the criminal justice
system. Issues such as relapse, patient employment problems, psychosocial
conflicts, after-hours crises, and family problems often complicate treatment
and must be handled by the treatment team.
Limited resources. Limited community resources and
supports further complicate treatment in some areas. Clinical staff are
required to make extra efforts for nontraditional AOD abuse treatment tasks,
which can include vocational placement, housing assistance, and transportation
assistance.
Coordination with managed care providers. Coordinating treatment
with managed care providers is a recent addition to some counselors' job
descriptions. This responsibility can be an additional stressor. Staff members
may feel that pressures from managed care providers conflict with efforts to
help patients, and reimbursement may be exhausted long before the counselor
feels the treatment process should be concluded.
Some of these stressors can be addressed by the team approach, which can
promote shared responsibility and personal support. It is imperative to have a
full spectrum of clinical support services available on short notice, and it is
also imperative that clinicians know when and whom to ask for help.
Stresses involved with IOT work are significant and should not be
underestimated. However, they can be resolved, and programs can develop a work
culture and personnel policies and procedures that enhance staff retention,
avoid burnout, and keep the program functioning at a level that provides
high-quality care.
It is important to note that a program should be committed to having as much
regard for its staff members as it does for its clients. Again, the most
essential and indispensable resource of a program is its staff.
Program Philosophy and Description
As discussed above, a fundamental aspect of an effective treatment program
is the establishment of a program philosophy and a description of the population
served and how the program serves it. The program philosophy and description
should incorporate a clear mission statement, congruent with the day-to-day
practice of the program.
This written document relates to staff performance and expectations because
it defines standards for effective and ethical treatment interventions, and it
defines the relationship between clinician and client. It provides boundaries
for counselors. The program philosophy should provide standards and guidelines
for the well-being of staff, and support the staff by giving them clear
guidelines and goals for acceptable and desired standards of care and defined
roles.
IOT is community-based treatment, and the program statement should address
professional relationships within the community, as well as the purpose of
treatment, expected outcomes, and strategies for accomplishing these objectives.
The philosophy gives the program a clear sense of what it is supposed to do and
expresses its reason for being.
The philosophy and program statement should be a dynamic document and should
be regularly reviewed and discussed, since a program is constantly developing,
changing, and adding new staff. It should be flexible enough to be open to new
input at any time, and all staff members should be encouraged to contribute to
it on an ongoing basis.
Job Description
It is important that all permanent and auxiliary clinical and administrative
staff members have a clear and complete job description that includes job
expectations, responsibilities, and specific functions. Job descriptions should
be the basis for performance evaluations, with clearly defined expectations and
performance levels. These performance indicators should be measurable and
should change as the responsibilities of the program and the capabilities of the
staff change.
Shared Ownership
Shared ownership of the program is an important concept that empowers staff
members by having them share accountability for the program. This means that
all staff feel credited when the program succeeds and that everyone participates
in its development and operation. Management in such a setting is participatory
rather than hierarchical. Shared ownership protects the integrity of the
program.
Situational methods such as program retreats or planning sessions should be
established to allow staff to have responsibility for input into program design
and development. Support to the staff can be further realized by extending the
ownership of the program to the patients it serves by offering a strong
therapeutic involvement (e.g., the use of multifamily therapy groups). Strong
patient involvement enhances clinical responsiveness while reducing patient
reliance on staff.
Appropriate Recognition
Another important staff support is appropriate recognition, which should
occur at all levels. Good management means acknowledging successes as well as
shortcomings. This is a skill that every supervisor should have, to avoid being
solely problem centered. IOT supervisors should be skilled at recognizing staff
effort and accomplishments outside of the normal appraisal process. The
supervisor should acknowledge work well done at times other than performance
review time.
Promotion
Another form of recognition is promotion. Managers should be encouraged to
promote from within whenever possible. They should actively encourage employees
to continue their education and should facilitate these efforts by posting
information about educational programs and events and providing a reasonable
subsidy for participation in them. Staff should be made aware of the potential
for advancement within the program or in other settings if exceptional
opportunities exist. Employees should be valued for their potential as well as
their actual contribution to a program.
Appropriate Compensation
Fair and competitive compensation for a job is an appreciated means of staff
support from the employee point of view. Even though there may currently be a
larger pool of human resources than positions in the field, it is important that
people be paid an adequate and reasonable wage that is commensurate with their
experience and qualifications.
Establishing commensurate levels of compensation cannot be adequately
addressed in this document. Pay scales vary widely from region to region across
the country. A program has the responsibility to hire someone who is adequately
trained, and compensate that person appropriately, consistent with the
competitive context of the position and the compensation available for similar
positions in other programs. Such actions are not only in the interest of the
employee, but also in the long-term interest of the clients and the program.
A certain level of salary does not guarantee a competent staff or effective
treatment, but if people are paid below community and professional standards, or
are exploited, they will not likely remain with the program. Frequent employee
turnover is a sign of poor personnel practices.
Flexible Work Schedules
In an IOT setting, the commitment to flexible work schedules is critical to
recruiting and retaining good staff. Flexible work schedules can help staff
members accommodate their personal needs and make stronger commitments to the
demands of the job. Whenever possible, schedules should be open to change and
negotiation. Supervisors should be sensitive to the difficulties of single
parents and other family issues and to other personal considerations that make a
difference in staff morale. Larger programs may be better equipped than smaller
ones to offer flexibility and rotating responsibilities. Flexible schedules are
also particularly relevant to IOT programs that use part-time and/or contractual
help. The nature of IOT work, which requires evening and weekend staff
coverage, can add to the flexibility of scheduling that a staff member may find
personally helpful. For example, some employees with children may prefer
evening and weekend work, so that they can share child care responsibilities
with a spouse who has a conventional work schedule.
This flexibility, of course, must be balanced with the needs of the program.
But often what works best for the individual employee works best for the
program.
Ongoing Supervision and Training
Ongoing supervision and training are also recommended staff supports.
Supervision must be consistent and regular, on both individual and group levels.
Clinical supervision for most staff should be scheduled at least once a week,
with a clinician with qualified clinical and supervisory experience, plus
additional sessions on an as-needed basis. Special attention should be paid to
the supervision of part-time staff, who depend on the supervisory process to
ensure continuity of services.
Staff development opportunities should be available as much as possible,
allowing professional personal leave days to participate in workshops, training
sessions, and other professional activities. Support for staff training should
be considered in the development of the program budget, and a reasonable
allocation should be given to professional development activities. The 1993
Substance Abuse Prevention and Treatment Block Grant requirements include
mandates requiring entities receiving funds to provide continuing education to
staff appropriate to the services that they provide. The focus of professional
development activities should be on learning new information and skills that
might lead to program enhancement and more broadly focused care and competency.
Given the nature of IOT, staff efforts to participate in activities such as
stress management workshops should be encouraged.
An important part of staff training is attention to culturally sensitive
issues. All programs should have a commitment to provide this training.
Culturally diverse groups and issues include:
Gender issues
Age issues
People from lower socioeconomic backgrounds, including homeless persons and
those with housing instability
Rural and urban populations
African Americans
Hispanic people
Native Americans
Asians and Pacific Islanders
Asian Americans
Gay men
Lesbians
Physically challenged people.
Exhibit 4-1 is a list of written materials and
sources for information about cultural sensitivity training.
Team Building
An organized approach to team building is another helpful way to support IOT
staff. It is helpful to have daily processing time for counselors to discuss
and analyze the clinical events of the day, particularly after any untoward
incident.
Regular retreat sessions are a valuable way of getting away from the stress
of the job and concentrating on planning and program evaluation. A retreat also
reinforces employees as stakeholders of the program, involved in participatory
management and decisionmaking.
Other planned events such as picnics, holiday parties, and structured
activities can boost employee morale. However, these social events do not
replace the need for ongoing communication and team building throughout the
year.
Peer Assistance
It is also helpful for intensive outpatient treatment programs to have a
peer assistance structure to deal with problems such as tragedies on the job.
Encouraging peer support, both formally through regular staff meetings to
discuss problems and issues and informally by creating a working team, is an
important element of an effective program. The promotion of staff wellness
should be a priority for IOT programs. In organizations that have them,
employee assistance programs can assist staff with the resolution of personal or
professional problems.
Certification and Credentialing
Every program should recognize a certifying body for professional staff, and
staff should have a professional development plan. This will ensure compliance
with internal privileging standards and those of credentialing bodies such as
the National Association of Alcohol and Drug Abuse Counselors, the American
Society of Addiction Medicine, and others.
It is also recommended that professionals who are working in the AOD field,
irrespective of their specific discipline or the amount of time in AOD treatment
settings, receive ongoing training in the treatment of AOD disorders. If the
IOT program is the primary setting in which they are working, staff
professionals need more than just a working knowledge of the field; they should
be able to formally demonstrate AOD treatment competency.
Recommendations
Regarding the critical issue of staffing IOT programs for AOD treatment, the
consensus panel offers the following recommendations:
Clinical staff should be knowledgeable about the full spectrum of
AOD abuse and addiction. Clinical staff should be certified or licensed, or
working toward certification or licensure in their discipline, with special
attention given to specific training in the addiction field.
The IOT program should be run by a core of clinical staff members who each
identify the program as his or her primary job. Although part-time employees
are part of many programs, an IOT program should not be run exclusively with
them unless it serves a very small or specialized population. The program
usually needs a core full-time staff that is responsible for maintaining the
continuity of care that the program provides.
Ongoing quality supervision that is responsive to the needs of the clinical
staff is an important part of the IOT program. Part-time personnel require
consistent supervision to ensure adequate support and guidance and consistency
of services.
Those charged with certain responsibilities should have the authority and
resources to successfully meet the expectations of their jobs.
Any consideration of IOT staffing must respect the unique stressors and
challenges faced by IOT staff, such as working odd hours, working in isolation,
and a lack of "third shift" support.
Quality IOT programming must be done within the context of
multidisciplinary teams.
The clinical staff should not be utilized in functions that limit or
detract from their ability to provide optimal care for their clients.
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