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ASAM Dimension 3 – Emotional/Behavioral Conditions
Contributor: Yvette McBride Thomas
Dimension 3: Emotional/Behavioral Conditions
- Patient reports evidences of possible depressive symptoms
- Patient reports unresolved loss/grief issues due to deaths in immediate family
- Patient has a history of poor anger management
- Patient has a history of illicit behavior which has led to legal problems
- Patient reports difficulty coping with loss of child custody
- Patient exhibits very low frustration tolerance
- Patient’s current functioning affected by history of verbal/sexual/physical abuse
- Patient experiencing grief due to divorce/desperation
- Patient experiencing difficulty coping with loss of significant relationship
- Patient seems unable to keep schedule of structured recovery activities, showing erratic or irresponsible behavior.
Goal (I will)
- Patient to address unresolved loss issues
- Patient to increase frustration management skills
- Patient to increase anger management skills
- Patient to cease illegal behaviors
- Patient to develop alternative to illegal behavior
- Patient to increase communication skills
- Patent to address emotional needs of family
- Patient to increase responsible time/task management skills
- Patient to complete mental health symptoms questionnaire with counselor within ___ weeks
- Patient to examine situations precipitating frustration and anger and discuss nonaggressive responses to address and discuss in counseling sessions and monitor progress on anger/frustration.
- Patient to contact anger management group with in _______weeks and attend as scheduled, following up with primary counselor (pc)
- Patient to process the loss of loved one in counseling sessions and progress on grief management to be monitored with with grief support group within ______ of referral
- Patient to process feelings over possible loss of child custody
- Patient to explore ways to cope with emotional affects of serious illness
- Patient is to discuss progress on avoiding arrest and illicit activities
- History of explosive aggressive outburst out of proportion to any precipitating stressors leading to assaultive acts or destruction of property
- Overreaction of hostility to insignificant irritants
- Body language of tense muscles (clenched fist/jaw, glaring looks, or refusal to make eye contact)
- Consistent pattern of challenging or disrespectful treatment of authority figures using verbally abusive language
Long term goals
- Decrease overall intensity and frequency of angry feelings and increase ability to recognize and appropriately express angry feelings as they occur.
- Develop an awareness of current anger behaviors, clarifying origins of and alternatives to aggressive anger
- Come to an awareness and acceptance of angry feelings while developing better control and more serenity.
- Become capable of handling angry feelings in constructive ways that enhance daily functioning.
- Identify targets of and causes of anger
- Verbalize increased awareness of anger expression patterns
- Verbalize how influential people in growing up have modeled anger expressions
- Identify pain and hurt of past or current life that fuels anger
- Utilize relaxation techniques to cope with angry feelings
- Verbalize increased awareness of how past ways of handling angry feelings have had a negative impact
- Verbalize increased awareness of and ability to react to hot buttons or anger triggers in a nonaggressive manner
- Write an angry letter to target and process this letter with counselor/therapist
- Write a letter of forgiveness to perpetrator of past or present pain and process letter with therapist/counselor
- Assist patient in identifying ways key life figures have expressed angry feelings and how positively or negatively these experiences have influenced the way patient handles anger
- Assign patient to list the experiences of life that have hurt and led to anger
- Ask patient to list ways anger has negatively impacted his/her daily life. Process list in counseling session
- Ask patient to write an angry letter to parents, spouse, or whomever, focusing on the reason for his/her anger toward that person. Process letter in counseling session
- Ask patient to write a forgiveness letter to target anger as a step toward letting go of anger. Process letter in session.
Reference used: Jongsma, A.E. Jr and Peterson, L. Mark The Complete Adult Psychotherapy Treatment Planner 2nd edition
Roselline, G., and Worden, M (1986) Of Course You’re Angry. San Francisco: Harper Hazelden
Runin, T. I. (1969) The Angry Book. New York: Macmillan
Weisinger, H. (1985) Dr. Weisinger’s Anger Workout Book. New York: Quill.
Smedes, L. (1991). Forgive and Forget: Healing the Hurts We Don’t Deserve. San Franciso: Harper
Lerner, H. (1985) The Dance of Anger: a Woman’s guide to Changing the Patterns of Intimate Relationships. New York: harper Perennial
http://www.kap.samhsa.gov/products/manuals/pdfs/angermanagement_manual_0508.pdf – 2012-09-10
ASAM Dimension 2 – Biomedical Conditions and Complications
Contributor: Yvette McBride Thomas
Dimension 2: Biomedical Conditions and Complications
- Patient has a medical condition (e.g. high blood pressure, asthma, diabetes, etc.) and has not consistently participated in recommended medical care.
- Patient has a serious illness and needs to continue medical care with his/her primary care physician/specialist
- Patient is pregnant and needs to engage in regular high risk prenatal care
- Patient is in need of dental treatment
- Patient is in need of prophylactic for treatment /prevention of active TB
- Patient is in need of healthcare information on HIV/AIDS, TB, and Hep that include the effects of illicit drugs on the body.
- Patient is in need of CXR after positive PPD (TB)
- Patient is in need of HIV education as part of preventive care
- Patient needs to engage in regular preventive medical care
- Biomedical condition may be exacerbated by illicit drug/alcohol use.
- A positive test for HIV/AIDS
- Patient has a history of neglecting his/her physical and medical health
Goal (I will)
- Secure medical care
- Engage in regular medical care for management of chronic medical condition
- Continue specialized treatment for serious medical condition
- Secure high risk prenatal care
- Secure dental care
- Receive screening and/or treatment for prevention of active TB
- Learn effects of illicit use on medical condition
- Participate in regular prevention medical care
- Ensure coordination of care including primary medical provider and treatment provider
- Medically stabilize physical condition
- Accept chronic medical condition with proper medical attention given to it
- Take responsibility for maintain physical health and well being
- Establish chemical dependency recovery that leads to improved physical health
- Patient to secure medical appointment with primary care physician to follow up on abnormal labs within one month or earliest available appointment
- Patient to discuss in counseling session the benefits of complying with recommended medical care; monitor on going medical compliance
- Patient to verify available coverage and report back to staff: verify medical coverage as needed and offer patient appropriate referrals based on source of coverage.
- Patient to become aware of negative effects of illicit drug use on biomedical condition after reviewing in counseling: address ongoing through course of treatment.
- Patient to register all prescription medication and update prescription verification throughout course of treatment
- Patient to use referral list and call for dental appointment: target date one month or first available appointment
- Patient to bring verification of attendance at high risk prenatal clinic: monthly throughout the course of pregnancy
- Patient to be able to name benefits of regular prenatal care: address in counseling throughout period of pregnancy
- Patient to become aware of illicit drug/alcohol abuse/use on pregnancy: address in counseling session throughout period of pregnancy
- Patient to receive HIV/AIDS as well as TB risk reduction education: target date within six(6) weeks of entering treatment and update as needed throughout the course of treatment
- Patient to attend post-partum medical appointment within eight (8) weeks of delivery or first available appointment
- Treatment staff to consult with patient primary medical doctor as needed to ensure ongoing appropriate care
- Patient to discuss importance of preventive medical care for self and family
- Patient to bring in verification of TB screen (PPD)
- Patient to bring verification of prophylactic treatment for prevention or treatment of active TB
Diagnostic Suggestions (taken from DSM-IV codes associated with presenting problems)
- Axis 1
303.90 Alcohol Dependence
304.20 Cocaine Dependence
304.80 Polysubstance Dependence
- A positive test for HIV/AIDS
- History of neglecting his/her physical and medical health
- Medical complications secondary to chemical dependence
Long Term Goals
- Accept chronic medical conditions with proper medical attention given to it
- Take responsibility for maintaining physical health and well-being
- Establish chemical dependence recovery that leads to improved physical health
- Make any necessary arrangements required for patient to obtain the medical services needed
- Refer patient to physician for complete physical
- Help patient understand his/her medical problem and the need to cooperate with doctor’s recommendations
- Monitor treatment effectiveness and document patient’s follow-through on doctor’s orders; redirect when patient is failing to comply
- Consult with physician and review doctor’s orders with patient
- Provide patient with any appropriate literature that will increase his/her understanding of medical condition
- Arrange for consultation with dietitian to explain proper nutrition that will enhance medical recovery
- Explore and assess the role of chemical abuse/dependency has on medical condition
- Refer patient to public health of physician for STD and/or HIV testing, education and/or treatment
- Help patient identify and express his/her feelings connected with medical condition
- Assign patient to make a list of things he/she could do to help maintain physical health; process list
Note: each note ins is the order of the therapeutic intervention
- The patient presented with serious medical problems that are having a negative impact on his/her daily living
- The patient has pursued/refused treatment for his/her medical condition
- The patient has not sought treatment for his/her medical condition because of a lack of insurance and financial resources
- The patient’s serious medical condition has been under treatment and is showing signs of improvement
- The patient reports that he/she has tested positive for HIV/AIDS
- Patient has been HIV positive for several months but has had no serious deterioration in his/her condition
- The patient is obtaining consistent medical care for his/her HIV status
- The patient has refused medical care for his/her HIV-positive status and tends to be in denial about seriousness of this situation
- The patient’s HIV-positive status has resulted in the development of AIDS
- Because of the patient’s chronic chemical dependency history, he/she has developed medical complications
- The patient has accepted that he/she has deteriorated medically because of his/her chemical dependency pattern and has terminated substance abuse
- The patient is in denial about the effects of his/her substance abuse and continues this self-destructive pattern
- The patient’s medical condition has improved subsequent to termination of substance abuse
- The patient described a history of neglecting his/her physical and medical problems
- The patient continues to refuse medical evaluation and treatment for physical problems
- The patient agrees to seek medical treatment and has followed through on this recommendation
- After receiving medical treatment, the patient’s physical and medical condition has improved significantly.
Reference: Jongsma, A.E. Jr and Peterson, L. Mark The Complete Adult Psychotherapy Treatment Planner 2nd edition
Substance Abuse Treatment for Persons with HIV/AIDS. Treatment Improvement Protocol (TIP) Series, No. 37.
The National AIDS Treatment Information Project – http://www.natip.org/index.html
The Measurement Group – www.themeasurementgroup.com
JAMA HIV-AIDS information center – http://www.ama-assn.org/special/ hiv/hivhome.htm
Critical Path AIDS Project – http://www.critpath.org/critpath.htm
HIV/AIDS Treatment Information Service (ATIS) – http://www.hivatis.org
AIDS Clinical Trial Information Service (ATCTIS) – http://www.actis.org
Centers for Disease Control and Prevention (CDC) – http://www.cdc.gov
ASAM Dimension 1 – Acute Alcohol and/or Drug Intoxication
Contributor: Yvette McBride Thomas
Dimension 1: Acute Alcohol and/or Drug Intoxication
- 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
- 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
- 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
- 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
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.
- 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
- 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
- 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
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
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:
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)
Application to Practice
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
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.