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Answers to Some FAQs
Contributor: Yvette McBride Thomas
1. What happens if a patient has no progress for a long time?
Sometimes when a patient goes along time with no progress it can be one or a combination of several things: 1) The patient has become comfortable with the progress made up to that point and could possibly be afraid to move on; 2) sometimes patients sabotage their own progress because they are not use to having any success in their lives; 3) the relationship with the counselor may be the only positive relationship in their lives and they don’t want it to end. This list is not limited; it will be up to the counselor to help the client discover why they are not progressing further. This is where the stages of change will be very helpful and ASAM dimension 4. Treatment acceptance/resistance (Process of change). It is sometimes helpful to walk the client through each stage and help them discover where they are in their recovery and why they are stuck. Being stuck is a setup for relapse and if the client is unaware of their relapse triggers they may return to using and sometimes they will relapse to stay in treatment.
2. Will treatment be stopped?
Treatment usually will not be stopped until all avenues have been explored. Using the ASAM guidelines will help identify the possible challenges facing the client. They may not know what the challenge may be or if they do they do not know how to put it into words. If the client is really resistant to treatment and is not ready to make the necessary change or do the required work they will discontinue treatment on their own.
ASAM Dimension 4. Treatment acceptance/resistance/stages of changes:
a. Denial
b. Surrender and compliance
c. Process of recovery
d. Treatment issues
e. 12-step philosopy
f. Attitudes in recovery and addiction
g. Patient in need of information on treatment and program tools
3. Or would treatment be changed to something else?
The treatment goals can change based on the new information discovered. This may also be an opportunity to introduce the client to a new person via referral and explain to the client that based on the treatment changes it maybe beyond your scope of expertise (except when the client states that there has been some physical/sexual abuse) You can also suggest that the client attend a 12step support meeting for a specific area (i.e. ACOA or Coda)
5. Counseling – Part III Family and Significant Others Counseling
This is third component of the 5th practice domain: Counseling. (check out Part I Individual Counseling and Part II Group Counseling)
Addictions affect the person who has them and also her/his family members and significant others. Counseling addicted families should be required, and offered, as part of every treatment service. Unfortunately, some treatment agencies can only afford treating the person with the addiction, and due to lack of resources and funding they cannot get the family and significant others involved.
Regardless for this situation, substance abuse counselors can offer a competent practice when they have the following knowledge:
- Systems theory and dynamics.
- Dynamics associated with substance use, abuse, dependence, and recovery in families and significant others.
- Interaction patterns on substance abuse behaviors.
- Cultural factors associated with family dynamics and substance abuse disorders.
- Signs and patterns of domestic violence.
Although it is difficult to accept sometimes, the truth is that family members contribute in different ways to the substance abuse behavior. It is not about putting the blame on someone, but inevitably each member of a family plays a specific role in a family’s issue; understanding family dynamics helps us understand why addiction is called a family disease.
As I mentioned in a previous post, in family counseling the client is the family as a whole, always considering individual differences. The required experience an addictions counselor must have in this area includes:
- Models of diagnosis for families
- Intervention strategies appropriate for different stages of the problem.
- Intervention strategies for violence within the family.
- Laws and resources regarding violence within the family.
- Methods for engaging family members and significant others in the treatment and recovery processes.
- Confidentiality and regulations regarding family counseling.
Our goals in family counseling are:
- To help families and significant others understand the effect of their interactions on substance use.
- To assist them in identifying and stopping harmful patterns of interaction.
- To help them learn healthy strategies and behaviors that maintain recovery and promote healthy relationships.
- To assist them with referral to appropriate support resources.
5. Counseling – Part II Group Counseling
This is the second part of the 5th practice domain, counseling (go to Part I Individual Counseling).
During group counseling, our client is the group as a whole, just as in couples counseling the client is the couple and not the individual members. However, we still have to consider individual differences when forming a group. Things to consider are:
- Group type
- Purpose of the group
- Group size
- Member selection criteria
- Group goals
- Behavioral ground rules for participating
- Outcomes
- Criteria and methods for termination or graduation from group
Group counseling is an important part of treatment. It is very common that a counselor will facilitate in a group where some of her/his clients from individual counseling will participate. A competent counselor must know:
- Group methods appropriate to help the client achieve objectives.
- The effectiveness of various models and strategies for group counseling for populations with substance abuse problems and with members of multicultural backgrounds.
- How to accommodate individual needs within the group.
- How to apply confidentiality rules in group.
- Developmental processes affecting groups over time.
- Transition stages in therapeutic groups.
- How to effectively address resistant behaviors, transference issues, and countertransference issues within group.
- How to facilitate the entry on new members and the transition of exiting members.
Group counseling could be challenging at times, especially when the counselor does not have a clear idea of what her/his role is in group. In order to conduct group counseling effectively, without getting all our energy drained in the first 10 minutes of session, we must know:
- Leadership, facilitator, and counselor methods appropriate for each group type and therapeutic setting.
- Types and uses of power and authority in group counseling.
- When and how to use appropriate power.
Documentation is part of group counseling too. We must document measurable progress toward group and individual goals; know the concepts of process and content, in order to make appropriate process interventions.
We must be able to describe and summarize the client’s behavior within group. This will help us identify the client’s progress as well as issues and needs that may require a modification in the treatment plan.
5. Counseling – Part I Individual Counseling
Counseling is a set of methods adapted to individual clients, and designed to help that client progress toward mutually determined goals about her/his recovery.
A competent counselor understands and has the ability to apply the many different models of addiction counseling. Counseling includes:
- Individual counseling
- Group counseling
- Couples counseling
- Families counseling
Individual Counseling
Our main goal is to establish a helping relationship with our client. A helping relationship is non-judgmental, which creates an environment of warmth, respect, genuineness, and empathy in which our client can feel safe to talk about the most difficult issues in her/his life.
Counseling is not about just listening people talk about their problems. Being non-judgmental is not something we decide to do, but someone we learn how to be. To accomplish this, drug addictions counselors need to know:
- Approaches to counseling that are person-centered and have demonstrated effectiveness in the treatment of substance abuse disorders
- Meaning of warmth, respect, genuineness, concreteness, and empathy ( not your personal definition, but the meaning of these concepts as they apply to the helping relationship)
- Active listening
- Transference and countertransference
Counseling is all about getting our client engaged in her/his own treatment and recovery process. Addictions counseling is not about telling people what to do and how to live their lives, or imposing our morals and values on them. As I have mentioned before, counselors need to know:
- theories and research about client’s motivation
- counseling theories to promote client engagement
- stages of change
Our goals (as counselors) in counseling, are:
- To work with our client to establish realistic and achievable goals
- To promote our client’s knowledge, skills, and attitudes towards positive change, including the maintenance of health and prevention of HIV/AIDS, tubeculosis, STDs, hepatitis C, and other infectious diseases
- To work appropriately with our client to recognize and discourage all behaviors inconsistent with the progress in recovery
- To know when, how, and why to involve the client’s significant others
- To facilitate the development of basic life and social skills
- To make constructive therapeutic responses when the client’s behavior is inconsistent with the agreed recovery goals.
- To apply crisis prevention and crisis intervention skills
4. Service Coordination
Service coordination is the action that brings the client, treatment services, and community resources together in order to address issues and needs identified in the treatment plan. It includes case management and client advocacy; all of this to enable the client to achieve specified goals.
Services coordination includes these three main activities:
- Implementing the Treatment Plan
- Consulting
- Continuing Assessment and Treatment Planning
Implementing the Treatment Plan
Our goals in this area are:
- To initiate collaboration with the referral sources.
- To obtain, review, and interpret information from screening and assessment processes.
- To make sure that our client is eligible for admission into specific treatment.
- To assess readiness for treatment and change.
- To complete necessary administrative procedures for admission to treatment.
- To establish accurate treatment and recovery goals with the client, making sure the family is also involved. Things to discuss with our client and his/her family are:
- Nature of services
- Program goals
- Procedures
- Rules of conduct
- Schedule of treatment activities
- Cost of treatment
- Duration of care
- Client’s rights and responsibilities
- Effects of treatment and recovery on client and significant others
Consulting
Our main goal here is to continuously evaluate our client’s recovery process and the problems interfering with this progress, always considering the client’s background and treatment plan. This action will provide us, the counselors, with good feedback to adjust the treatment. Our main responsibilities are:
- To be familiar with methods for assessing the client’s past and present biopsychosocial status.
- To understand the terminology, procedures, and functions of other disciplines related to the treatment of substance abuse disorders.
- To collaborate as part of a multidisciplinary treatment team.
- To maintain confidentiality and respect regulations.
- To establish and maintain nonjudgmental relationships with clients and service providers.
Continuing Assessment and Treatment Planning
We are responsible for maintaining an ongoing contact with client and involved significant other to make sure they are following the treatment as planned. Although we cannot make the client do anything, including staying in treatment, we can still try to engage the client and significant others in the treatment process. Therefore, we need to:
- Understand the stages of change
- Assess treatment and recovery progress in consultation with our client and significant others
- Make appropriate modifications to the treatment plan
- Describe and document the treatment process, progress, and outcomes accurately
- Engage the client and significant others with continuing care
- Help the client develop a relapse prevention plan
- Address confrontation, conflict resolution, and problem-solving with the client
- Discuss discharge planning with the client and significant others.
3. Referral
Referral is the process through which the counselor helps the client find available support systems and community resources to meet the needs identified in the clinical evaluation and treatment planning. As competent counselors, we must be familiar with the mission, function, resources, and quality of services of:
- civic groups, community groups, and neighborhood organizations
- health and allied healthcare systems (managed care)
- employment and vocational services
- cultural enhancement organizations
- faith-based organizations
- governmental entities
- criminal justice systems
- child welfare agencies
- housing administrations
- childcare facilities
- crisis intervention programs
- abused persons programs
- self-help groups
- advocacy groups
We must be familiar with the criteria to be eligible to receive community services, including fee and funding structures; how to access community agencies and service providers; and community resources for both affected children and other members of the family.
Since some of the resources in the community might end or be closed down, we need to continuously evaluate the available resources and make sure they are appropriate for our client. We also need to evaluate the motivation and ability of our client to make use of the referrals.
Remember, it is not enough with being a counselor and making the referral; how we do it, is also very important. The skills we need in this area, are:
- Professional oral and written communication for successful referrals
- Use of appropriate technology to access, collect, and deliver necessary documentation
- Document the referral process accurately
Just as with everything mentioned in previous topics, we want to explain to our client, in clear and specific language, the necessity for referral and process of it. If our client understands this step, there is an increased likelihood the she/he will follow through.
Finally, we want to evaluate the outcome of the referral. We must know the methods and procedures used to assess the client’s progress toward treatment goals.
ASAM Placement Criteria
Contributor: Yvette McBride Thomas
American Society of Addiction Medicine (ASAM) dimensional treatment plan categories.
The following are taken from the six dimensions of the ASAM patient placement criteria. The universal problem areas will be used to formulate treatment plans
Problem areas:
1. Acute alcohol and/or drug intoxication
2. Biomedical conditions and complications
3. Emotional/behavioral conditions
4. Treatment acceptance/resistance
5. Relapse potential
6. Recovery environment
Each of these problems is broad enough to encompass a variety of sub-categories
- Acute alcohol and/or drug intoxication
a. Disease concept
b. Post-acute withdrawal
c. Effects of alcohol and/or drugs
d. Eating disorders
e. Any other signature medical issues - Biomedical condition and complications
a. Client in need of information about std’s and hiv
b. Client is in need of nutrition information
c. High risk pregnancy
d. Any other significant medical issues - Emotional/behavioral conditions
a. Anti-social behavioral parents
b. Criminal behavior
c. Dual diagnosis
d. Co-dependency
e. Sexuality
f. Family conflicts/roles
g. Self-esteem
h. Spirituality
i. Communication/socialization skills
j. Parenting skills
k. Resentment/anger
l. Process of change
m. Obsessive/compulsive
n. Dysfunctional/relationships
o. Illiteracy
p. Feelings (gratitude, loss & grief, shame & guilt) - Treatment acceptance/resistance’s/stages of changes
a. Denial
b. Surrender and compliance
c. Process of recovery
d. Treatment issues
e. 12-step philosopy
f. Attitudes in recovery and addiction
g. Patient in need of information on treatment and program tools - Relapse potential
a. Relapse prevention plan
b. Understanding effects of people, places, and things on addiction and recovery
c. Signs and symptoms of relapse - Recovery environment
a. Self-help meetings
b. Aftercare plan
c. Halfway house/recovery home
d. Alcohol and/or drug free work place
e. Constructive use of leisure time
f. Budgeting
g. Occupational counseling
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