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2. Treatment Planning
This topic is important. It is part of both the 12 Core Functions and the 8 Practice Domains. I briefly mentioned it in a previous post, so you will find a lot of similarities. Here I go into more detail.
Treatment planning is a written document developed by the counselor and the client. They collaborate with each other to identify and prioritize problems needing resolution. Treatment planning involves determining important treatment goals; it describes measurable steps toward achieving those goals; and it represents an agreement between the counselor and the client.
A treatment plan is not a one-size-fits-all but an individualized document. It must address the identified substance use disorder, potential mental conditions, employment, education, spirituality, health, social, and legal issues as well as issues related to the progress of the treatment.
As I mentioned in previous posts, counselors need to be familiar with the stages of change and readiness for treatment, and be able to establish treatment priorities based on information from the assessment process.
During treatment planning, we should be able to:
- Explain assessment results to the client in an understandable manner.
- Identify and prioritize problems based on client’s needs.
- Formulate immediate and long-term goals using behavioral terms (book recommendation: Martin, Garry. “Behavior Modification: What it is and how to do it.” 9th ed.)
- Identify the treatment methods and resources to be used as appropriate for each client.
- Develop with the client a mutually acceptable treatment plan and method for monitoring and evaluating progress.
One of the main goals during treatment planning is to collaborate with the client and his/her significant others in order to establish a trusting relationship with them.
Assessment
While screening is used to determine whether a client is eligible for admission into a particular program, assessment is an ongoing process to evaluate the treatment plan the client’s progress in treatment.
There are different assessment tools and we must select the one that is more appropriate, based on age, gender, racial and ethnic background, and disabilities.
Assessment tools include:
- History of alcohol and drug use
- Physical and mental health
- Addiction treatment histories
- Family issues
- Work issues
- History of criminality
- Psychological and emotional issues
- Current physical and mental health, and substance use/abuse issues
- Education and basic life skills
- Socioeconomic situation and lifestyle
- Current legal status
- Use of community resources
- Level of readiness for treatment
- Level of cognitive and behavioral functioning
When selecting and administering assessment instruments, we need to know which are the current validated instruments and protocols (remember validity and reliability); we also need to take into consideration the limitations of both the assessment instruments and the counselor’s training and education. Our responsibility is to use these instruments appropriately, so we must recognized when we need assistance from a supervisor (remember: consultation with other professionals).
Extra training, and therefore commitment, is required in order to learn how to analyze and interpret assessment results. In order to determine treatment recommendations, treatment plan modifications, and whether somethings are working better that others, we must be knowledgeable about:
- Scoring methods for assessment instruments
- How to analyze and interpret results
- Available treatment options
Remember that we want that our client participates actively in the treatment process, so we must introduce and explain the purpose of ongoing evaluations.
Finally, we need to keep in mind our agency’s protocols and procedures; appropriate terminology and abbreviations (avoid jargon!); legal implications of actions and documentation; and how to maintain client’s confidentiality (always important in everything we do).
I. Clinical Evaluation
In order to provide a competent practice, addiction counselors need to learn and understand the 8 Practice Dimensions and the knowledge, skills, and attitudes associated with each of them.
Clinical Evaluation
Clinical evaluation is a systematic approach to recognizing and diagnosing substance abuse problems, including the potential for co-occurring mental disorders.
There are two elements included in the clinical evaluation process:
- Screening
- Assessment
Screening
Screening allows us to review the client’s current situation, including symptoms and other information, in order to determine the most appropriate course of action, taking into consideration the needs and characteristics of the client and the resources available within the community.
This is basically the first interaction between the client and significant others, and the counselor. It is very important how this first interaction is conducted.
Our goal is to establish rapport with our client and her/his significant others. We need to know:
- Why it is important to build rapport.
- The purpose of building rapport.
- The range of human emotions and feelings.
- What constitutes a crisis.
- How to prevent and manage a crisis situation.
- How to identify situations and conditions when additional professional assistance is necessary.
- Sources of assistance available.
The way in which we interact with our client is very important. The client may be experiencing anxiety, anger, fear, going through withdrawals, etc. Here is what we need to do:
- Demonstrate effective verbal and nonverbal communication.
- Identify the client’s beliefs.
- Reflect the client’s feelings and message –Active listening.
- Recognize dangerous situations.
- Treat the client with empathy, respect, and genuineness – Unconditional positive regard.
Gathering Information
Screening is a data-gathering process. Data is gathered from the client and other sources such as family, friends, employer, and coworkers. There are different screening instruments and we must select the ones that are sensitive to age, developmental level, culture, and gender. The data we will gather should include a history of current and past substance use/abuse and substance abuse treatment; physical and mental health; mental and functional statuses; and current socio-economic and environmental problems.
A competent substance abuse counselor must have knowledge in the following:
- Validated screening instruments for substance abuse and mental status.
- Purpose, application, and limitations of those instruments.
- Reliability and validity.
- How to administer and score screening instruments.
- Interpretation of results.
- How to communicate effectively during emotionally charged situations.
- How to write accurately, concisely, and legibly.
The screening process includes determining whether a client is appropriate and eligible for admission into a particular program, so we need to be familiar with:
- Symptoms of intoxication, withdrawal, and toxicity for all psychoactive substances, alone and in combination with others.
- The physical pharmacological, and psychological effects of substance use.
- Acute and Chronic effects.
- Available resources for help with drug reactions, withdrawal, and violent behavior.
- Options, limitations, and legal implications of toxicity screening.
- Meaning of toxicology reports.
- Toxicology language.
- Relationship between psychoactive substance use and violence.
- Diagnostic criteria for suicide risk and danger to others.
- Mental and physical conditions that overlap symptoms of drug intoxication and withdrawal.
Working with the client during the screening process includes helping the client identify the effects of substance use or abuse on her/his current life problems. A very useful tool is Motivational Interviewing (MI). MI will help us assess the client’s readiness to address substance abuse issues; interpret the client’s perception of her/his experiences; and assess the client’s stage of change.
Substance abuse counselor must be familiar with:
- Denial and other defense mechanisms.
- Stages of readiness.
- Stages of change
- Treatment options and their philosophies.
- The client’s needs and preferences.
- Available resources for admission and referral.
Assessment
Professional Readiness
Professional readiness is an ongoing process. It should not be understood as something you get done one time and you don’t look at it again. Professional readiness is directly linked to continuing education.
Understanding Diverse Cultures
A competent substance abuse counselor is constantly learning about:
- Information and resources in regards to diverse cultures, lifestyles, gender and age.
- Information and resources to provide quality care to people with special needs and disabilities.
- How culture, lifestyle, gender, etc. influence behavior.
- How culture, lifestyle, and values influence substance use.
- Assessment and intervention methods that are appropriate to culture and gender.
- Counseling methods that match the needs of people from multicultural backgrounds, and people with disabilities.
- Legislation related to human, civil, and client’s rights.
Self-awareness is Important
If we want to become competent substance abuse counselors, we must be open to evaluation, supervision, and change. In order to grow both personally and professionally, we need to:
- Be aware of our personal and professional strengths and limitations.
- Be aware of cultural, ethnic, and gender biases.
- Look for resources available for continuing education.
- Make a commitment to continuing professional education.
- Know the benefits of self-assessment, clinical supervision, and consultation with other professionals.
- Find ways to enhance our personal and professional growth.
Substance Abuse Prevention
Addictions professionals are not only involved with treatment and recovery. We also have the obligation to participate in prevention programs.
Substance abuse treatment and substance abuse prevention are two different fields. Research shows that for every dollar spent on prevention, 7 to 18 dollars are saved on treatment and recovery.
What we need to learn about substance abuse prevention includes:
- Research-based prevention models and strategies.
- The relationship between prevention and treatment.
- Environmental strategies and prevention campaigns.
- Benefits of working with community coalitions.
I recommend this book Substance Abuse Prevention: The Intersection of Science and Practice, by Julie Hogan et al. I am currently reading this book for my class on substance abuse prevention.
Setting-specific Policies and Procedures
It is our responsibility to learn, understand, and apply our agency’s (the place in which we are currently working) policies and procedures to handle crisis and dangerous situations, such as safety measures for clients and self.
Application to Practice
Diagnostic Criteria
As substance abuse counselors, we must understand the established diagnostic criteria included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) standards and in the most current International Classification of Diseases (ICD) standards. This knowledge will help us establish client’s placement criteria, and will allow us to identify the strengths and limitations of both the diagnostic criteria and the placement criteria.
Note: I did not know what TAP 21 meant by placement criteria, so I went online and found this website American Society of Addiction Medicine (ASAM) and I read the table of contents of their placement criteria publication. Placement criteria refers to the type of treatment the client will be placed into, depending on the diagnosis. Types of treatment could be: early intervention, intensive outpatient (IOP), or Opiod Maintenance Therapy (OMT).
Supplemental readings about placement criteria and diagnosis:
- ASAM Dimension 1
- ASAM Dimension 2
- ASAM Dimension 3
- ASAM Dimension 4
- Assessment
- Diagnosis
Variety of Help
Because substance abuse treatment is not a one-size-fits-all, substance abuse counselor must be familiar with all the options out there in regards to helping strategies. The following list mentions some of them, just to give you an idea:
- Methods and tools used to evaluate the substance abuse problem.
- Interventions that match the client’s stage/level of dependence, change, and recovery.
- The use of motivational interviewing (MI).
- Ways to get the family and social network involved in the recovery process.
- Support groups and self-help groups.
- Court-ordered and voluntary care models.
- Brief therapy interventions
- Long-term therapy interventions.
Services Appropriate to Cultural Background
A competent substance abuse counselor must be aware of and respect the diversity within and among cultures. For example:
- Diverse cultural norms, values, beliefs, and behaviors.
- Differences in verbal and nonverbal communication.
As substance abuse counselors dealing with clients from multicultural backgrounds, we need to find the resources to develop individualized treatment plans. We need to know the strengths and limitations of the available treatment options, how to have access to them and make referrals.
Medical and Pharmacological Resources
We must be familiar with:
- Current literature related to medical and pharmacological interventions.
- Potential risks and benefits of medical and pharmacological interventions.
- Health practitioners in the community who have training in and knowledge about addiction and addiction treatment.
Service Coverage Options
Some substance abuse counselors might not like this part of the job, and even try to avoid it, but it is very important and necessary to do it and do it well. We must be familiar with:
- The variety of public and private payment plans.
- Methods of gaining access to available payment plans.
- Policies and procedures used by available payment plans.
Our goal is to cooperate with payment providers in order to promote the most cost-effective, high-quality care for our clients.
Prepare for a Crisis
Features of crisis:
- Family disruption
- Social and legal problems
- Physical and psychological
- Panic states
- Physical dysfunction
How to respond and follow through in crisis situations?
- Perform substance use screening and assessment.
- Use of prevention and intervention principles and methods.
- Use of principles of crisis case management.
- Be familiar with posttraumatic stress symptoms.
- Methods of debriefing after critical events.
- Know the available resources for assistance in the management of crisis situations.
Treatment Knowledge
Models of Treatment
The substance abuse counselor must be familiar with the most accepted and scientifically supported models of substance abuse prevention, treatment, recovery, relapse prevention, and continuing care. Knowledge in this area also includes:
- Philosophies, practices, policies, and outcomes of the most accepted therapeutic models.
- Pharmacotherapy
- Support groups and self-help groups
- Behavioral self-control training
- Mental health
- Psychotherapy
A competent substance abuse counselor must be open to new, evidence-based treatment approaches, including pharmacological interventions.
Family, Friends, and Community
Substance abuse counselors must also recognize the importance of family, social networks, and community systems in the client’s environment, since they could be either sources of strength or obstacles during treatment and recovery processes.
It is important to learn ways to incorporate family and social networks in treatment and recovery, and appreciate the many ways in which they could enhance these processes.
Research, Outcomes, and Applications
Knowledge in the following areas is necessary:
- Research methods in the behavioral and social sciences.
- Research literature related to the prevention and treatment of addiction.
- Research on epidemiology, etiology, and treatment efficacy.
- Benefits and limitations of research.
Interdisciplinary Approach
Knowledge in this area includes:
- How multiple disciplines contribute to treatment efficacy.
- Familiarity with terminology and concepts in order to communicate effectively across disciplines.
The substance abuse counselor must show a desire to collaborate with others, respect for the contributions of multiple disciplines, and commitment to professionalism.
Understanding Addiction
A competent substance abuse counselor must have a basic understanding of addiction. She/he must have knowledge about:
- the terms and concepts related to theory, etiology, research, and practice,
- criteria and methods used to evaluate models and theories (we should always question what we learn),
- how to apply those theories and models appropriately,
- how to access literature on addiction-related topics, i.e, research skills.
While doing this, the substance abuse counselor must possess certain attitudes, such as:
- being open to information that may differ from personal beliefs,
- appreciate the complexity in understanding addiction,
- value diverse ways of thinking expressed in theories and models,
- flexibility to form personal concepts through critical thinking.
The substance abuse counselor must be able to recognize the social, political, economic, and cultural context surrounding addiction and substance abuse. This is important because different living environments create the conditions for people to have both risk and protective factors that may lead to or prevent substance abuse and addiction. Knowledge in this area includes:
- Concepts of social, political, economic, and cultural systems and their impact on drug use/abuse.
- The history of licit and illicit drugs.
- Risk and protective factors for substance use/abuse.
- Statistical information about substance abuse disorders in the general population.
Substance abuse counselors must be able to describe the behavioral, psychological, physiological, and social effects of all psychoactive drugs on the person using and significant others. Knowledge in the following areas is necessary:
- Pharmacology of addiction.
- Initiation, intoxication, harmful use, abuse, dependence, withdrawal, craving, relapse, and recovery.
- The relationship of substance use and infectious diseases.
- The relationship between substance use and mental disorders.
Substance abuse counselors must be able to recognize overlapping symptoms for substance abuse, medical conditions, and mental disorders, also known as co-occurring/comorbid disorders, or dual diagnosis. Knowledge is required in:
- Normal and abnormal human growth and development.
- Methods from differentiating substance use disorders from medical conditions or mental disorders.
It is important that the substance abuse counselor does not jump into conclusions before all the assessments and clinical evaluations are completed. Whenever a client’s case is outside of the counselor’s expertise, she/he must be willing to refer the client to the most appropriate care.
LCDC Exam Review 