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ASAM Dimension 1 – Acute Alcohol and/or Drug Intoxication
Contributor: Yvette McBride Thomas
Dimension 1: Acute Alcohol and/or Drug Intoxication
Problems: (need)
- Patient presents with opiate withdrawal symptoms
- Patient reports continued opiate dependency for ____ years and urine toxicology confirms opiates in system
- Patient reports pattern of acute cocaine intoxication
- Patient reports/evidence episodic alcohol intoxication
- Patient reports pattern of THC abuse or dependency
- Patient is opiate dependent and in need of continued outpatient methadone treatment
- Patient has been maintained in OMT and patient in consult with staff have determined he/she is ready for therapeutic detoxification
- Patient shows signs of continued opiate use on current methadone dosage
GOALS (I will)
- Stabilize on methadone maintain dosage
- Cease use of illicit opiates as evidence by urine screen results
- Cease use of alcohol
- Cease use of non-narcotic illicit drugs as evidence by urine results
- Successful therapeutic detoxification from methadone/methadone
- Continued stability o OMT
INTERVENTION (objective)
- Medical review of history and physical by MD: target date within 72 hours of admission
- Begin induction of methadose and monitor for needed dose adjustments. Patient to be observed at dosing 6x per week initially and patient to report any symptoms of intoxication or withdrawal to medical personnel: target date for dose stabilization: three weeks and monitoring ongoing
- Patient to be randomly breathalyzer for monitoring due to history of ETOH abuse: target randomly breathalyzer throughout the course of treatment
- Patient to have a urine toxicology screen within six (6) weeks of treatment to monitor for evidence of illicit drug use/pattern of intoxication and random urine screens per FDA regulations throughout treatment
- Counselor and medical team to consult MD to order appropriate therapeutic detox plan
- Patient to monitor self during therapeutic detox and report any symptoms to staff for MD review
- Counselor to discuss possible need for increase in meth dose with patient and document on medical review
- MD to review patient urine screens and symptoms for possible meth dose change per medical review
DIAGONOSTIC SUGGESTIONS (taken from DSM-IV codes associated with presenting problems)
- AXIS 1
303.90 Alcohol Dependency
305.00 Alcohol Abuse
304.30 Cannabis Abuse
304.20 Cocaine Dependence
305.60 Cocaine Abuse
304.80 Polysubstance Dependence
BEHAVIORAL DEFINITIONS
- Consistent use of alcohol or other mood-altering drugs until high, intoxicated, or passed out
- Inability to stop or cut down use of mood altering drug once started, despite the verbalized desire to do and the negative consequences continued use brings
- Denial that chemical dependence is a problem despite direct feed-back from spouse, relatives, friends and employers that the use of the substance is negatively affecting them and others
- Amnesiac blackouts have occurred when using alcohol
- Increase tolerance for the drug as there is the need to use more to become intoxicated or to attain the desired affect
- Continued alcohol/drug use despite experiencing persistent or reoccurring physical, legal, vocational, social, or relationship problems that are directly caused by the use of drugs/alcohol
LONG TERM GOALS
- Accept chemical dependency and begin to actively participate in a recovery/support program
- Establish a sustained recovery, free from the use of all mood-altering substances.
- Establish and maintain total abstinence while increasing knowledge of the disease and the process of recovery
- Acquire the necessary skills to maintain long-term sobriety from all mood-altering chemicals
- Withdraw from mood-altering substance, stabilize physically and emotionally, and then establish a supportive recovery plan
THERAPEUTIC INTERVENTIONS
- List recreational and social activities and places that will replace substance abuse related activities
- Assist client in developing insight into life changes needed in order to maintain long term sobriety
- Assist client in planning social and recreational activities that are FREE from association with substance abuse
- Write a good-bye letter to drug of choice telling it why it must go
- Direct patient to write a good-bye letter to drug of choice; read it and process related feelings with counselor/therapist.
- Ask client to make a list of the ways substance abuse has negatively impacted his/her life and process it with therapist
PROGRESS NOTE
Note: each note is in the order of the therapeutic intervention
Consistent abuse of alcohol/drug
- The patient described a history of alcohol abuse on a frequent basis and, often, until intoxicated or passed out
- Family members confirmed a pattern of chronic abuse by the patient
- The patient acknowledges that his/her alcohol abuse began in adolescence and continued into adulthood
- The patient has committed him/herself to a plan of abstinence from alcohol/drugs and to participate in a recovery/support program
- The patient has maintained total abstinence, which is confirmed by his/her family
Inability to reduce alcohol/drug abuse
- The patient acknowledges that he/she frequently has attempted to terminate or reduce usage of the mood/mind altering substance, but has found that once use has begun, he/she is unable to follow through.
- The patient acknowledges that in spite of negative consequences and a desire to reduce or terminate the use of drugs/alcohol he/she is unable to do so.
- As the patient has participated in a total recovery program, he/she has been unable to maintain abstinence.
Denial
- The patient presented with denial regarding the negative consequences of his/her substance abuse, inspite of direct feedback from others about its negative impact
- The patient’s denial is beginning to breakdown as he/she is acknowledging that substance abuse has created problems in his/or life
- The patient now openly admits to the severe negative consequences in which substance abuse has resulted
Amnesiac blackouts
- The patient has experienced blackouts during alcohol abuse, which have resulted in memory loss for periods of time in which the patient was still functional
- The patient stated that his/her first blackout occurred at a young age and that he/she has experienced many of them over the years of his/her alcohol abuse
- The patient acknowledged only one or two incidents of amnesiac blackouts
- The patient has not had any recent experiences of blackouts, as he/she has been able to maintain sobriety
Increase tolerance
- The patient described a pattern of increasing tolerance for the mood-altering substance as he/she needed to use more of it to obtain the desired affect
- The patient described the steady increase in the amount and frequency of the substance abuse as his/her tolerance for it increased
Continued alcohol/drug use
- The patient has continued to abuse alcohol/drugs in spite of recurring physical, legal, vocational, social, or relationship problems that were directly caused by the substance use
- The patient has denied that the many problems in his/her life are directly caused by alcohol/drug abuse
- The patient acknowledged that alcohol or drug abuse has been the cause of multiple problems in his/her life and verbalized a strong desire to maintain a life free from using all mood-altering substances
- The patient is now able to face resolution of significant problems in his/her life as he/she has begun to establish sobriety
- As the patient has maintained sobriety, some of the direct negative consequences of substance abuse have diminished
REFERENCE USED: Jongsma, A.E. Jr and Peterson, L. Mark The Complete Adult Psychotherapy Treatment Planner 2nd edition
SUGGESTED READING
Alcoholics Anonymous (1975). Living Sober. New York: A.A. World Services
Alcoholics Anonymous (1976). Alcoholics Anonymous: The Big Book. New York: A.A. World Services
Carnes, P. (1989). A Gentle Path Through the Twelve Steps. Minneapolis, MN: CompCare.
Nuckals, C. (1989) Cocaine: From Dependency to Recovery. Blue Ridge Summit, PA: TAB Books
Diagnosis
Contributor: Yvette McBride Thomas
Diagnosis— the meaning or interpretation that is derived from assessment information and is usually translated in the form of some type of classification system.
- A description of a person’s condition and not a judgment of a person’s worth
- A common misconception is that a classification of mental disorders classifies people, when actually what are being classified are mental disorders that people have. For this reason, the text of DSM-IV…avoids the use of such expressions as ‘a schizophrenic’ or ‘an alcoholic’ and instead uses the more accurate, but admittedly more cumbersome, ‘an individual with schizophrenia’ or ‘an individual with alcohol dependence’” (DSM IV-TR, APA, p. xxxi).
- Diagnoses are important for:
- Insurance company reimbursement
- Developing a proper treatment plan
- To be able to communicate with other professionals, counselors must be able to speak about, understand, or report a client diagnosis
- Diagnostic decisions are an evolving process and not a static event.
- Diagnosis and treatment planning are now such standard components of counseling practice that a failure to diagnose on some level or a lack of professional diagnostic training may be construed as unethical (p. 335).
Nota bene:
- Dual diagnosis—a substance abuse diagnosis with a co-occurring mental health diagnosis in the same individual.
- Substance abuse counselors (e.g. LCDCs, ADCs) do not diagnose mental health disorders. We can only diagnose alcohol/drug addiction problems.
Resource: Gladding, S.T. (2011). Counseling: A comprehensive profession (7th ed.). Upper Saddle, NJ: Pearson-Merrill.
8. Professional and Ethical Responsibilities
Professional and ethical responsibilities are the obligations of an addiction counselor to adopt ethical and behavioral standards of conduct and continuing professional development. Our competencies in this area, are:
1. To adhere to established professional codes of ethics that define the professional context within which the counselor works to maintain professional standards and protect the client.
Knowledge, skills, and attitudes:
- Federal, State, agency, and professional codes of ethics.
- Clients’ rights and responsibilities.
- Professional standards and scope of practice.
- Boundary issues between client and counselor.
- Difference between the role of the professional counselor and that of a peer
- counselor or sponsor.
- Consequences of violating codes of ethics.
- Means for addressing alleged ethical violations.
- Nondiscriminatory practices.
- Mandatory reporting requirements.
- Openness to changing personal behaviors and attitudes that may conflict with ethical guidelines.
- Willingness to participate in self, peer, and supervisory assessment of clinical skills and practice.
- Respect for professional standards.
2. To adhere to Federal and State laws and agency regulations regarding the treatment of substance use disorders.
Knowledge, skills, and attitudes:
- Federal, State, and agency regulations that apply to addiction counseling.
- Confidentiality rules and regulations.
- Clients’ rights and responsibilities.
- Legal ramifications of noncompliance with confidentiality rules and regulations.
- Legal ramifications of violating clients’ rights.
- Grievance processes.
3. To interpret and apply information from current counseling and psychoactive substance use research literature to improve client care and enhance professional growth.
Knowledge, skills, and attitudes:
- Professional literature on substance use disorders.
- Information on current trends in addiction and related fields.
- Professional associations.
- Resources to promote professional growth and competency.
- Read and interpret current professional and research-based literature.
- Apply professional knowledge to client-specific situations.
- Apply research findings to clinical practice.
- Apply new skills in clinically appropriate ways.
- Commitment to life-long learning and professional growth and development.
- Willingness to adjust clinical practice to reflect advances in the field.
4. To recognize the importance of individual differences that influence client behavior, and apply this understanding to clinical practice.
Knowledge, skills, and attitudes:
- Differences found in diverse populations.
- How individual differences affect assessment and response to treatment.
- Personality, culture, lifestyle, and other factors influencing client behavior.
- Culturally sensitive counseling methods.
- Dynamics of family systems in diverse cultures and lifestyles.
- Client advocacy needs specific to diverse cultures and lifestyles.
- Signs, symptoms, and patterns of violence against persons.
- Risk factors that relate to potential harm to self or others.
- Hierarchy of needs and motivation.
- Assess and interpret culturally specific client behaviors and lifestyles.
- Convey respect for cultural and lifestyle diversity in the therapeutic process.
- Adapt therapeutic strategies to client needs.
- Willingness to appreciate the life experiences of individuals.
- Appreciation for diverse populations and lifestyles.
- Recognition of one’s biases toward other cultures and lifestyles.
5. To use a range of supervisory options to process personal feelings and concerns about clients.
Knowledge, skills, and attitudes:
- The role of supervision.
- Models of supervision.
- Potential barriers in the counselor–client relationship.
- Transference and countertransference.
- Resources for exploration of professional concerns.
- Problem-solving methods.
- Conflict resolution.
- The process and effect of client reassignment.
- The process and effect of termination of the counseling relationship.
- Phases of treatment and client responses.
- Willingness to accept feedback.
- Acceptance of responsibility for personal and professional growth.
- Awareness that one’s personal recovery issues have an effect on job performance and interactions with clients.
6. To conduct self-evaluations of professional performance applying ethical, legal, and professional standards to enhance self-awareness and performance.
Knowledge, skills, and attitudes:
- Personal and professional strengths and limitations.
- Legal, ethical, and professional standards affecting addiction counseling.
- Consequences of failure to comply with professional standards.
- Self-evaluation methods.
- Regulatory guidelines and restrictions.
7. To develop and use strategies to maintain one’s physical and mental health.
Knowledge, skills, and attitudes;
- Rationale for periodic self-assessment regarding physical health, mental health, and recovery from substance use disorders.
- Available resources for maintaining physical health, mental health, and recovery from substance use disorders.
- Consequences of failing to maintain physical health, mental health, and recovery from substance use disorders.
- Relationship between physical health and mental health.
- Health promotion strategies.
- Carry out regular self-assessment with regard to physical health, mental health, and recovery from substance use disorders.
- Use prevention measures to guard against burnout.
- Employ stress-reduction strategies.
- Locate and access resources to achieve physical health, mental health, and recovery from substance use disorders.
- Model self-care as an effective treatment tool.
- Recognition that counselors serve as role models.
- Appreciation that maintaining a healthy lifestyle enhances the counselor’s effectiveness.
Assessment (Part II)
Contributor: Yvette McBride Thomas
Assessment—the procedures and processes of collecting information and measures of human behavior outside of test data .
- Can be obtained “through a variety of formal and informal techniques including standardized tests, diagnostic interviews, projective personality measures, questionnaires, mental status examinations, checklists, behavioral observation, and reports by significant others (medical, educational, social, legal, etc.)”
- The concept of assessment emphasizes the humanness of counseling…a total picture of the person being evaluated.
- “The term assessment is being used increasingly to refer to the intensive study of an individual, leading to recommendations for action in solving a particular problem.”
- The goal of the assessment process is a comprehensive evaluation of individuals, usually in the present.
- Often it includes a formulation of a treatment plan that will result in positive and predictable outcomes.
- Ways to conduct assessments include:
- Structured clinical interviews
- DSM-IV-TR (2000)—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, published by the American Psychiatric Association (APA)
- Mental Status Exam (MSE) is being “increasingly used by counselors in work settings requiring assessment, diagnosis, and treatment of mental disorders”
- Overall, assessment is crucial because it allows counselors not only to determine what a client’s problem is but to learn the client’s orientation to problem solving.
Resource: Gladding, S.T. (2011). Counseling: A comprehensive profession (7th ed.). Upper Saddle, NJ: Pearson-Merrill.
7. Documentation
Documentation involves the recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data.
The competencies in this area, are:
1. Demonstrate knowledge of accepted principles of client record management.
- Regulations pertaining to client records.
- The essential components of client records, including release forms, assessments, treatment plans, progress notes, and discharge summaries and plans.
- Composing timely, clear, complete, and concise records that comply with regulations.
- Documenting information in an objective manner.
- Writing legibly.
- Using new technologies in the production of client records.
2. Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties. Our knowledge and skills in this area, are:
- Federal, State, and program confidentiality rules and regulations.
- The application of confidentiality rules and regulations.
- Confidentiality rules and regulations regarding infectious diseases.
- Apply infectious disease regulations as they relate to addictions treatment.
- The legal nature of records.
- Request, prepare, and complete release of information when appropriate.
- Protect and communicate clients’ rights.
- Explain regulations to clients and third parties.
- Provide security for clinical records.
- Willingness to seek and accept supervision regarding confidentiality rules and regulations.
- Respect for clients’ rights to privacy and confidentiality.
- Commitment to professionalism.
- Recognition of the absolute necessity of safeguarding records.
3. Prepare accurate and concise screening, intake, and assessment reports. Essential elements of screening, intake, and assessment reports, include:
- psychoactive substance use and abuse history
- physical health
- psychological information
- social information
- history of criminality
- spiritual information
- recreational information
- nutritional information
- educational or vocational information
- sexual information
- legal information
4. Record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.
- Current Federal, State, local, and program regulations.
- Regulations regarding informed consent.
5. Record progress of client in relation to treatment goals and objectives.
- Appropriate clinical terminology used to describe client’s response to intervention and progress made toward completing treatment goals and objectives.
- How to review and update records:
- Prepare clear and legible documents.
- Document changes in the treatment plan, client status, client response to and outcome of interventions, level of care provided, and discharge status.
- Use appropriate clinical terminology and standardized abbreviations.
- Note client’s strengths and limitations in achieving treatment goals.
- Record client’s response to and outcome of interventions.
- Record changes in client’s status, behavior, and level of functioning.
- Note limitations of treatment provided to client.
6. Prepare accurate and concise discharge summaries. The components of a discharge summary, include:
- client profile and demographics
- presenting symptoms
- diagnoses
- selected interventions
- critical incidents
- progress toward treatment goals
- outcome
- continuing care plan
- prognosis
- recommendations
6. Client, Family, and Community Education
Addiction counselors play an important role in providing clients, families, significant others, and community groups with information about the risks involved with alcohol, tobacco, and other drugs use, as well as available prevention, treatment and recovery resources.
Our competencies in this area are:
- To provide education both formal and informal about substance abuse prevention and treatment programs, and the recovery process. In order to help people from multicultural backgrounds, we need to keep in mind:
- Cultural differences among diverse communities.
- Cultural differences in substance use behaviors.
- Delivery of educational programs that are culturally relevant.
- Research and theory on prevention of substance abuse problems.
- Learning styles and teaching methods that we can adapt to our clients.
- How to facilitate discussions in a safe and respectful environment.
- How to preparing outlines and handout materials.
- How to make public presentations to deliver the information effectively.
- Cultural issues in planning prevention and treatment programs.
- Age and gender differences in substance use patterns.
- Culture, gender, and age-appropriate prevention, treatment, and recovery resources.
- Awareness of our own cultural biases.
- To describe the risk and protective factors that increase and decrease the likelihood for an individual, community, or group to develop a substance use disorder. Our knowledge in this area includes:
- Risk and protective factors for the onset of substance use disorders.
- How to present the issues from a non-judgmental perspective.
- To describe the warning signs, symptoms, and the course of substance use disorders. We must be familiar with:
- The continuum of use and abuse, including the warning signs and symptoms of a developing substance use disorder.
- The current Diagnostic and Statistical Manual of Mental Disorders (DSM) categories or other diagnostic standards associated with psychoactive substance use.
- To describe how substance use disorders affect families and significant others. We need to educate our client about:
- How psychoactive substance use by one family member affects other family members or significant others.
- The family’s influence on the development and continuation of a substance use disorder.
- The role of the family, couple, or significant others in treatment and recovery.
- To describe the continuum of care and resources available to the family and significant others. Our goals are:
- To present available treatment options, including local health, allied health, and behavioral health resources.
- To motivate both family members and the client to seek out resources and services from the full continuum of care.
- To describe different treatment modalities.
- To identify and make referrals to local health, allied health, and behavioral health resources.
- Although this may sounds easy to do, we need to keep in mind the difficulties families and significant others go through when seeking help. We must work from a strengths-based principle, which emphasizes client autonomy.
- We must be familiar with the models for substance abuse prevention and treatment, and recovery from substance use disorders.
- Awareness of our own biases when presenting the information.
- Delivering educational sessions.
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