Participant Curriculum 02

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THE COLOMBO PLAN
The Colombo Plan Asian Centre for Certication and Education
of Addiction Professionals Training Series
Participant Manual
Treatment for Substance
Use DisordersThe
Continuum of Care for
Addiction Professionals
ii
Curriculum 2: Treatment for Substance Use Disorders
Acknowledgments
Curriculum 2: Treatment for Substance Use DisordersThe Continuum of Care for
Addiction Professionals is part of a nine-volume training series developed for the U.S.
Department of States Bureau of International Narcotics and Law Enforcement Affairs
(INL). The publication was developed under contract number SAQMPD07D0116,
Demand Reduction Support Services, between INL and Alvarez & Associates, with JBS
International, Inc. (JBS), serving as subcontractor.
Special thanks go to Thomas Browne, Deputy Director, Ofce of Anticrime Programs,
and Gregory R. Stanton, Program Ofcer, for their guidance and leadership throughout
the projects development. Suzanne Hughes, M.A., CASAC, Alvarez & Associates, served
as Project Director, and Sara Lee, M.S.W., LICSW, Alvarez & Associates, served as Senior
Demand Reduction Coordinator. From JBS, Candace L. Baker, M.S.W., CSAC, MAC, served
as Project Director and Lead Curriculum Developer, and Larry W. Mens, M.Div., served
as Curriculum Developer. Other JBS staff members include Wendy Caron, Senior Editor;
Frances Nebesky, M.A., Associate Editor; and Claire Macdonald, Senior Graphic Designer.
Staff members of NAADAC, The Association for Addiction Professionals, contributed
signicantly to development of this publication. We would like to thank Cynthia Moreno
Tuohy, NCAC II, CCDC III, SAP, Executive Director; Shirley Beckett Mikell, NCAC II, CAC
II, SAP, Director of Certication and Education and Certication Commission Staff Liaison;
Donovan Kuehn, Director of Operations and Outreach; and Misti Storie, M.A., Education
& Training Consultant. Other contributors included Suzanne Hall-Westcott, M.S., Director
of Program Development, Daytop International; Diane Williams Hymons, M.S.W.,
LCSW-C, LICSW, Principal, Counseling-Consulting-Training-Services; Phyllis Mayo, Ph.D.,
Psychologist; and Donna Ruscavage, M.S.W., Ruscavage Consulting.
Some material in this curriculum was previously developed by JBS for Family Health
International (Hanoi, Vietnam) under a contract supported by the U.S. Agency for
International Development.
Special thanks are extended to the international consultants and pilot-test group members
(see Appendix C) who provided invaluable input. Their enthusiastic participation and
creativity contributed greatly to the nished product.
Public Domain Notice
All materials appearing in this curriculum except for those taken directly from copyrighted
sources are in the public domain and may be reproduced or copied without permission
from the U.S. Department of States INL or the authors. Citation of the source is
appreciated. However, this publication may not be reproduced or distributed for a fee
without specic, written authorization from INL.
Disclaimer
The substance use disorder treatment interventions described or referred to herein do not
necessarily reect the ofcial position of INL or the U.S. Department of State. The guidelines
in this document should not be considered substitutes for individualized client care.
Published 2011
iii
CONTENTS
Part IParticipant Orientation
Participant Orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Part IITraining Modules
Module 1Training Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Module 2Recovery and Recovery Management . . . . . . . . . . . . . . . . . . 31
Module 3Factors Affecting Treatment Outcomes . . . . . . . . . . . . . . . . . 57
Module 4Introduction to Motivation and Stages of Change . . . . . . . . . 83
Module 5Treatment: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Module 6Components of Treatment: The Continuum of Care . . . . . . 125
Module 7Evidence-Based Practices for Treatment Intervention . . . . . 233
Module 8Integrating Learning Into Treatment . . . . . . . . . . . . . . . . . . 397
Part IIIAppendices
Appendix AGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Appendix BResources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Appendix CSpecial Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . 409
1
PARTICIPANT ORIENTATION
Introduction
Welcome! This training will provide you with a comprehensive overview of the nature of
change and an understanding of the process and elements of treatment for substance
use disorders (SUDs).
Addiction Professionals is part of a training series developed through funding from the
U.S. Department of State to The Colombo Plan for the Asian Centre for Certication
and Education of Addiction Professionals (ACCE). More information on the Colombo
Plan and ACCE can be found at http://www.colombo-plan.org.
The overall goal of the training series is to reduce the signicant health, social, and
economic problems associated with SUDs by building international treatment capacity
through training, professionalizing, and expanding the global treatment workforce. The
training prepares counselors for professional certication at the entry level by providing
the latest information about SUDs and their treatment and facilitating hands-on
activities to develop skills, condence, and competence.
Congratulations for taking the time to learn more about your work!
The Training
The eight modules in this training curriculum may be delivered over 5 consecutive
days or may be offered over the course of several weeks or months. Your trainers have
provided you with a specic agenda.
The learning approach for this training includes:
Trainer-led presentations and discussions;
Frequent use of creative learner-directed activities, such as small-group and partner-
to-partner exercises and presentations;
Reective writing exercises;
Periodic reviews to enhance learning retention; and
Learning assessment exercises.
Your active participation is essential to making this a positive and productive learning
experience!
2
Goals and Objectives for Curriculum 2
Training goals
To provide participants with a comprehensive overview of the nature of change; and
To provide participants with an understanding of the process and elements of
treatment for SUDs.
Learning objectives
Participants who complete Curriculum 2 will be able to:
List and briey describe two overall goals of treatment;
Name the six stages of change and describe at least one characteristic of clients in
each stage;
Name at least eight of the U.S. National Institute on Drug Abuse principles of
treatment;
Describe the components of treatment;
Dene and provide examples of the continuum of care;
Briey describe nine counseling theories;
Briey describe ve evidence-based treatment interventions; and
Name at least ve factors that can affect a persons success in treatment.
Training materials
Training materials include:
This Participant Manual;
A notebook; and
A copy of Technical Assistance Publication (TAP) 21: Addiction Counseling
CompetenciesThe Knowledge, Skills, and Attitudes of Professional Practice.
Each module of your Participant Manual includes:
Training goals and learning objectives for the module;
A timeline;
PowerPoint slides printed three to a page with space for you to write notes;
Resource Pages containing additional information or exercise instructions and
materials; and
3
Participant Manual: Participant Orientation
A module summary.
The Participant Manual also has a glossary (Appendix A) and a list of resources
(Appendix B).
Your trainers will give you a notebook to use as your personal journal. You can use this
journal in a number of ways. You can note:
Topics you would like to read more about;
A principle you would like to think more about;
A technique you would like to try;
Ways you might be able to add some of the things youre learning to your practice; and
Possible barriers to using new knowledge.
Your trainers will also ask you to complete short writing assignments.
TAP 21 was developed in the United States to provide a common foundation on which
to base training and certication of addiction professionals. The publication addresses
these questions:
What professional standards should guide counselors working with people with SUDs?
What is an appropriate scope of practice for the eld of SUD counseling?
Which competencies are associated with positive treatment outcomes?
What knowledge, skills, and attitudes should all SUD treatment professionals have
in common?
TAP 21 can serve as a useful reference for you. Keep in mind, however, that it takes time
and experience to develop counseling competence. TAP 21 represents an ideal set of
goals, not a starting point. Dont get overwhelmed! Youll get there.
Getting the Most From Your Training Experience
To get the most from your training experience:
If you have a supervisor, speak to him or her before the training begins. Find out
what his or her expectations are for you.
Think about what you want to learn from each module.
Come to each session prepared; review the manual pages for the modules to be
presented.
Be an active participant. Participate in the exercises, ask questions, write in your
journal, and think about what additional information you want.
4
Speak to your supervisor (or co-workers, if you have no supervisor) after the training.
Talk about what you learned to be sure you understand how the information relates
to your job.
Discuss with your supervisor or co-workers ways that you can put your learning into
practice, and continue to follow up on your progress.
Have fun!
5
MODULE 1
TRAINING INTRODUCTION
Content and timeline ................................................................................... 7
Training goals and learning objectives ........................................................ 7
PowerPoint slides ........................................................................................ 8
Resource page ........................................................................................... 26
Summary .................................................................................................... 27
7
Participant Manual: Module 1Training Introduction
Module 1 Goals and Objectives
Training goals
To create a positive learning community and environment;
To give participants background information about why the training is being done;
To give participants a summary of the overall training goals, objectives, and learning
approach of the curriculum; and
To provide participants with a brief introduction to the concept of treatment for
substance use disorders (SUDs).
Learning objectives
Participants who complete Module 1 will be able to:
Explain the overall training goals and at least four objectives of the 5-day training;
State at least one personal learning goal; and
Briey describe the broad goal of treatment for SUDs.
Content and Timeline
Activity Time
Ceremonial welcome 20 minutes
Trainer welcome, housekeeping, and ground rules 10 minutes
Partner exercise: Introductions 60 minutes
Presentation: Training materials 15 minutes
Break 15 minutes
Presentation: Why this training? 15 minutes
Large-group exercise: Training expectations 15 minutes
Small-group exercise: What is recovery? 30 minutes
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Resource Page 1.1: The Colombo Plan Asian Centre for
Certication and Education of Addiction Professionals
Training Series
Curriculum 1: Physiology and Pharmacology for
Addiction Professionals
Curriculum 2: Treatment for Substance Use
DisordersThe Continuum of Care for
Addiction Professionals (this curriculum)
Curriculum 3: Mental and Medical Disorders That
Often Co-Occur With Substance Use
Disorders
Curriculum 4: Basic Counseling Skills for Addiction
Professionals
Curriculum 5: Screening, Assessment, and Treatment
Planning for Addiction Professionals
Curriculum 6: Case Management for Addiction
Professionals
Curriculum 7: Crisis Intervention for Addiction
Professionals
Curriculum 8: Ethics for Addiction Professionals
Curriculum 9: Working with Families in Substance Use
Disorder Treatment
27
1
UNODC. (2011). World drug report 2011. New York: United Nations.
2
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision).
Washington, DC: Author.
3
World Health Organization. (2007). International statistical classication of diseases and related health problems
(10th revision). Geneva: Author.
4
Module 1Training Introduction, Summary
The global problem
Psychoactive substance use continues to be a global problem. A survey done by the
United Nations Ofce on Drugs and Crime (UNODC) found that, in 2009, 149 to 272
million people between the ages of 15 and 64 used illicit substances at least once.
1
Illicit substances in the survey included opioids, cannabis, cocaine, other
amphetamine-type stimulants, hallucinogens, and ecstasy, among others.
A signicant number of the people who use psychoactive substances develop
substance use disorders (SUDs).
SUD is a general term used to describe a range of problems associated with
substance use (including using illicit drugs and misusing prescribed medications),
from substance abuse to substance dependence and addiction.
SUD is also a subcategory of substance-related disorders as described in the
American Psychiatric Associations Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (or DSM-IV-TR).
2
SUDs include both substance abuse and substance dependence.
The broad category of substance-related disorders also includes the subcategory of
substance-induced disorders, which includes:
Substance intoxication;
Substance withdrawal; and
Substance-induced mental disorders.
SUDs are labeled Harmful Use and Dependence Syndrome in the World Health
Organizations International Classication of Diseases (ICD-10).
3
The United Nations (U.N.) survey found that between 15 and 39 million people
between the ages of 15 and 64 could be dened as problem drug users.
The survey determined problem drug use based on:
4
The number of people reported to be dependent on a substance;
The number of people who injected substances; and
The number of people reporting long duration of use of opioids, amphetamines, or
cocaine.
28
The U.N. survey also found that:
1
Between 11 and 21 million people injected drugs in 2009.
About 18 percent of those who inject drugs are HIV positive.
About half of those who inject drugs are infected with the hepatitis C virus.
Global consequences of SUDs are far-reaching and include, for example:
Higher rates of hepatitis and tuberculosis;
Lost productivity;
Injuries and deaths resulting from automobile and other accidents;
Overdose hospitalizations and death;
Suicides; and
Violence.
The numbers are signicant. However, the Executive Director of UNODC notes
that there continues to be an enormous unmet need for drug use prevention,
treatment, care and support, particularly in developing countries.
2
There are a number of reasons for this, but one reason is a lack of adequate
treatment capacity.
The training series
This curriculum is part of a training series developed through funding from the U.S.
Department of State to The Colombo Plan for the Asian Centre for Certication and
Education of Addiction Professionals.
The overall goal of the training series is to reduce the number of health, social, and
economic problems associated with SUDs by building international treatment capacity
through training, professionalizing, and expanding the global treatment workforce.
The series prepares counselors for professional certication at the entry level by
providing them with necessary information and with specic skills training.
Curricula in the series are as follows:
Curriculum 1: Physiology and Pharmacology for Addiction Professionals is a
3-day course that presents a comprehensive overview of addiction, provides an
understanding of the physiology of addiction as a brain disease, and describes the
pharmacology of psychoactive substances.
Addiction Professionals is a 5-day foundational course. By this we mean that it provides
a necessary foundation, or basis, for learning about SUD counseling. It is not a how-to or
1
2
Ibid.
29
skills-based course, but it provides a context for the skills-based curricula later in the series.
Curriculum 2 provides an overview of recovery, recovery management, stages of change,
principles of effective treatment, components of treatment, factors affecting treatment
outcomes, and evidence-based practices, including couples and family counseling.
Curriculum 3: Common Co-Occurring Mental and Medical DisordersAn Overview
for Addiction Professionals is a 2-day course. It is also foundational and provides an
overview of the relationship of co-occurring disorders to one another and to related
treatment issues, as well as outlines brief descriptions of the most commonly co-
occurring mental and medical disorders.
Curriculum 4: Basic Counseling Skills for Addiction Professionals is a 5-day skills-based
course. It provides an overview of the helping relationship and intentionality, or focus, in
counseling. It also provides opportunities to learn and practice cross-cutting counseling
skills. By cross-cutting, we mean those skills that are essential at every stage of treatment
and in every type of counseling situation, including work with families. The curriculum also
teaches basic motivational interviewing skills and provides practice in teaching clients
recovery skills, an important aspect of treatment. Basic group (for clients and family
members) counseling and psychoeducational group skills also are covered.
Curriculum 5: Assessment and Intake, Treatment Planning, and Documentation for
Addiction Professionals is a 4-day skills-based course that teaches effective, integrated
assessment and treatment/service planning. It also addresses documentation as a
treatment tool.
Curriculum 6: Case Management for Addiction Professionals is a 2-day foundational and
skills-based course that provides an overview of case management in SUD treatment
and provides skills practice in case management functions such as planning, linkage,
monitoring, advocacy, consultation, and collaboration. The curriculum also includes
guidelines for and practice in crisis management, including managing suicide risk.
Curriculum 7: Crisis Intervention for Addiction Professionals, a 2-day foundational
and skills-based course, addresses the concept of crisis as a part of life and provides
guidelines for and practice in crisis management, including managing suicide risk.
It also addresses ways counselors can avoid personal crisis situations by providing
information and exercises about counselor self-care.
Curriculum 8: Ethics for Addiction Professionals is a 5-day course that addresses
professional conduct and ethical behavior, condentiality, ethical principles and
professional codes of ethics, and ethical decision-making. The curriculum also
addresses the importance of supervision as part of ethical practice.
Curriculum 9: Working With Families in Substance Use Disorder Treatment is a 3-day
course that provides an overview of the impact of SUDs on family systems and the
benets of involving family members in treatment. The curriculum addresses ways
of engaging family members in treatment and provides information and practice in
providing a range of family services, such as psychoeducation, conjoint family sessions,
and multifamily group counseling. The course also addresses the differences between
family counseling and family therapy and how to make appropriate referrals for more
intensive services when necessary.
31
MODULE 2
RECOVERY AND RECOVERY MANAGEMENT
Content and timeline ................................................................................. 33
Training goals and learning objectives ...................................................... 33
PowerPoint slides ...................................................................................... 34
Resource pages ......................................................................................... 49
Summary .................................................................................................... 53
33
Participant Manual: Module 2Recovery and Recovery Management
Training goals
To provide an overview of the concept of recovery, the overall goal of treatment for
substance use disorders (SUDs); and
To provide an introduction to recovery management.
Learning objectives
Dene recovery;
Dene abstinence in the context of recovery;
List and briey describe at least six guiding principles of recovery;
Dene recovery management; and
Dene recovery-oriented systems of care.
Activity Time
Introduction to Module 2 5 minutes
Presentation: A consensus denition of recovery 20 minutes
Small-group exercise: Guiding principles of recovery 35 minutes
Lunch 60 minutes
Small-group exercise: Guiding principles of recovery (continued) 60 minutes
Presentation: Introduction to recovery management 20 minutes
Break 15 minutes
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Resource Page 2.1: Guiding Principles of Recovery
1
There are many pathways to recovery. Individuals are unique with specic needs,
strengths, goals, health attitudes, behaviors, and expectations for recovery. Pathways
to recovery are highly personal and generally involve a redenition of identity in the
face of a crisis or a process of progressive change. Furthermore, pathways are often
social, grounded in cultural beliefs or traditions. Pathways to recovery involve informal
community resources, which provide support for abstinence. Pathways may include one
or more episodes of psychosocial and/or pharmacological treatment. For some, recovery
involves neither treatment nor involvement with mutual aid groups. Recovery is a process
of change that permits an individual to make healthy choices and improve the quality of
his or her life.
Recovery is self-directed and empowering. The pathway to recovery may involve one or
more periods when activities are directed or guided to a substantial degree by others.
However, recovery is fundamentally a self-directed process. The person in recovery is
the agent of recovery and has the authority to exercise choices and make decisions
based on his or her recovery goals. The process of recovery leads individuals toward the
highest level of autonomy of which they are capable. Autonomy means the capacity of
an individual to be independent and to make informed, un-coerced decisions. Through
self-empowerment, individuals become optimistic about life goals.
Recovery involves a personal recognition of the need for change and transformation.
Individuals must accept that a problem exists and be willing to take steps to address it; these
steps usually involve seeking help for a substance use disorder. The process of change can
involve physical, emotional, intellectual, and spiritual aspects of the persons life.
Recovery is holistic. Recovery is a process through which one gradually achieves greater
balance of mind, body, and spirit in relation to other aspects of ones life, including
family, work, and community.
Recovery has cultural dimensions. Each persons recovery process is unique and
impacted by cultural beliefs and traditions. A persons cultural experience often shapes
the recovery path that is right for him or her.
Recovery exists on a continuum of improved health and wellness. Recovery is not a
linear process. It is based on continuous growth and improved functioning. It may involve
relapse and other setbacks, which are a natural part of the continuum but not inevitable
outcomes. Wellness is the result of improved care and balance of mind, body, and spirit.
It is a product of the recovery process.
1
U.S. Center for Substance Abuse Treatment. (2007). National Summit on Recovery: Conference report. HHS
Publication No. (SMA) 07-4276. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved
July 12, 2011, from http://www.pfr.samhsa.gov/docs/Summit_Rpt_1.pdf
50
Recovery emerges from hope and gratitude. Individuals in or seeking recovery often
gain hope from those who share their search for or experience of recovery. They see
that people can and do overcome the obstacles that confront them, and they cultivate
gratitude for the opportunities that each day of recovery offers.
Recovery involves a process of healing and self-redenition. Recovery is a holistic
healing process in which one develops a positive and meaningful sense of identity.
Holistic means relating to or concerned with the whole rather than with individual parts.
In this context, for example, it would mean healing physically, mentally, and spiritually.
Recovery involves addressing discrimination and transcending shame and stigma.
Recovery is a process by which people confront and strive to overcome stigma.
Recovery is supported by peers and allies. A common denominator in the recovery
process is the presence and involvement of people who contribute hope and support
and suggest strategies and resources for change. Peers, as well as family members
and other allies, form vital support networks for people in recovery. Providing service
to others and experiencing mutual healing help create a community of support among
those in recovery.
Recovery involves (re)joining and (re)building a life in the community. Recovery involves
a process of building what a person never had or rebuilding what a person has lost
because of his or her condition and its consequences. Recovery involves creating a
life within the limitation imposed by that condition. Recovery is building or rebuilding
healthy family, social, and personal relationships. Those in recovery often achieve
improvements in the quality of their lives, such as obtaining education, employment,
and housing. They also increasingly become involved in constructive roles in the
community through helping others, productive acts, and other contributions.
Recovery is a reality. It can, will, and does happen.
51
Resource Page 2.2: The Eleven Principles of Behavioral
Health Recovery Management
1
Focus on recovery. The Behavioral Health Recovery Management (BHRM) model
emphasizes recovery processes over disease processes by working toward full and
partial recoveries and by emphasizing client strengths and resiliencies rather than client
decits. Recovery reintroduces the notion that any and all life goals are possible for
people with severe behavioral health disorders.
Application of technology. The rapid advances in technology must be applied to
recovery from serious mental illness and addictions. Technology being used in other
elds may be adopted or adapted to addressing behavioral health issues.
Client empowerment. The client, rather than the professional, is at the center of
the BHRM model. The goal is the assumption of responsibility by each client for the
management of his or her long-term recovery process and the achievement of a self-
determined and self-fullling life.
Service integration. Based on the recognition that severe disorders heighten
vulnerability for other disorders and problems, the BHRM model seeks to coordinate
categorically segregated services into an integrated response focused on the person
rather than on territorial ownership of the persons problems.
Fighting stigma. The BHRM model seeks to normalize or otherwise respect a persons
experiences with behavioral health disorders and, subsequently, provides ongoing
support services. The public begins to endorse positive images of behavioral health that
undermine the prejudice and discrimination that frequently accompany service delivery.
Formation of recovery partnerships. In the BHRM model, the traditional professional
role of expert and treatment provider progressively shifts to a recovery
management partnership with the client. Within this partnership, the professional serves
primarily as a recovery consultant.
Use of evidence-based practices. The BHRM model emphasizes the application of
evidence-based interventions at all stages of the disease stabilization and recovery
process, but the ultimate proof is the t between the intervention and the client at a
particular point in time as judged by the experience and response of the client.
Ecology of recovery in the community. The family (as dened by the client) and
community constitute a reservoir of support for long-term recovery from behavioral
health disorders. The BHRM model seeks to enhance the availability and the support
capacities of family, intimate social networks, and indigenous institutions (e.g., mutual
aid groups, faith-based organizations) to persons recovering from behavioral health
disorders. The BHRM model also extends the locus of service delivery from the
professional environment to the natural environment of the client.
1
International Network of Drug Dependence Treatment and Rehabilitation Resource Centres. (2008). Drug
dependence treatment: Sustained recovery management. Vienna: UNODC.
52
Use of clinical algorithms
1
. As knowledge and application of evidence-based
practices advance, the challenge becomes knowing what treatment approaches
to use with specic individuals as they progress through the stages of change and
treatment. Medication algorithms have been developed that specify preferred rst-
line prescriptions for specic diagnoses, dosing, and timeframes for evaluating the
effects. Similar practice support algorithms are needed for clinicians using psychosocial
treatments.
Provision of monitoring and support. The BHRM model emphasizes the need for
ongoing monitoring, feedback, and encouragement; linkage to indigenous supports;
and, when necessary, reengagement and early reintervention. This model of sustained
monitoring and recovery support services contrasts with models that provide repeated
episodes characterized by assess, admit, treat, and discharge, as is traditional in the
treatment of substance use disorders. It also contrasts with mental health programs that
focus on stabilization and maintenance of symptom suppression rather than on recovery
and personal growth.
Continual evaluation. Service and support interventions must be matched to the
unique and stage-specic needs of each client as he or she evolves through the stages
of recovery. In the BHRM model, both assessment and evaluation become continual
activities rather than activities that mark the beginning and conclusion of a service
episode.
1
The term algorithm is borrowed from mathematics. It basically means a step-by-step procedure for solving a
problem in a nite number of steps.
53
Module 2: Recovery and Recovery Management, Summary
Denition of Recovery
This curriculum uses a consensus denition of recovery from SUDs developed
by a panel convened by the U.S. Substance Abuse and Mental Health Services
Administrations (SAMHSAs) Center for Substance Abuse Treatment. This denition
is used for two reasons:
It is one of very few attempts to come to a consensus agreement on what
recovery is; and
It was accompanied by a list of guiding principles of recovery (see Resource
Page 2.1).
These principles provide a more thorough look at the process of recovery and some
of the lessons that have been learned over time.
One problem in the eld of SUD treatment has been the lack of a consensus
denition of recovery. The U.S. SAMHSAs Center for Substance Abuse Treatment
attempted to rectify this by convening a National Summit on Recovery in September
2005. Summit participants were leaders in the treatment and recovery eld. This
group developed this consensus denition of recovery:
Recovery from alcohol and drug problems is a process of change through
which an individual achieves abstinence and improved health, wellness,
and quality of life.
1
First, recovery is dened as a process of continuous growth and improved
functioning. It is not a goal that one achieves. It is instead a process of recovery
management over a persons lifetime.
Next, it is generally agreed that abstinence is necessary (though not sufcient) for
recovery. Abstinence can be dened as not using alcohol or any non-prescribed
psychoactive drugs and not misusing any prescribed psychoactive drugs.
Using the term non-prescribed allows for use of psychoactive medications to treat
substance use disorders, mental disorders, or medical conditions (such as severe
pain) when necessary.
But what about nicotine and caffeine, both of which are psychoactive substances?
There is little controversy about caffeine because the potential for social or
physical problems related to caffeine use is very low. Nicotine, however, is another
matter. Although it is legal everywhere, its potential for harm is very high. There
is controversy about whether abstinence from nicotine should be included in the
general denition of abstinence.
1
Center for Substance Abuse Treatment. (2007). National Summit on Recovery: Conference report. HHS Publication
No. (SMA) 07-4276. Rockville, MD: Health and Human Services Administration. Retrieved May 9, 2011, from http://
www.pfr.samhsa.gov/docs/Summit_Rpt_1.pdf
54
For now, anyway, most people in the eld consider a person who continues to use
nicotine after he or she has stopped using other substances as still abstinent and in
recovery.
There are many ways of looking at wellness. It is clear that wellness is a concept with
multiple dimensions:
Social;
Occupational;
Spiritual;
Physical;
Intellectual;
Emotional;
Environmental; and
Financial.
In 2010, SAMHSA again convened a panel to look at what is meant by recovery. This
panel consisted of experts in the elds of both mental disorders and SUDs. They
developed a unied consensus denition of recovery that covers both mental and
substance use disorders:
1
Recovery is a process of change whereby individuals work to improve their own
health and wellness and to live a meaningful life in a community of their choice while
striving to achieve their full potential.
There is signicant overlap between the two denitions: both speak of a process
of change and address the concept of wellness. Other aspects of the 2010 unied
denition were addressed in the original guiding principles of recovery we mentioned
earlier.
Recovery Management
Recovery management is the context in which we will examine the continuum of care.
This model of care shifts the focus away from discrete episodes of treatment, or acute
care, toward a long-term, client-directed view of recovery.
William White, a thought leader in the eld of SUD treatment, and his colleagues
identify seven elements of a comprehensive program of recovery management:
2
Client empowerment;
1
SAMHSA Blog. (2011, May 20). Retrieved July 5, 2011, from http://blog.samhsa.gov/category/
community-andrecovery-support/
2
White, W.L., Boyle, M.G., Loveland, D.L., & Corrington, P.W. (2005). What is behavioral health recovery management?
A brief primer. Retrieved June 23, 2011, from http://www.bhrm.org/papers/BHRM%20primer.pdf
55
Assessment;
Recovery resource development;
Recovery education and training;
Ongoing monitoring and support;
Recovery advocacy; and
Evidenced-based treatment and support services.
Client empowerment includes ensuring that those in treatment participate fully in
their treatment and recovery planning. In a larger context, it also means that people in
recovery are included in the planning, design, and evaluation of treatment programs.
Assessment includes identifying both the problems and the strengths of individuals
and their families. Recovery management is a strengths-based model, so assessing
strengths is a critical (and sometimes neglected) aspect of assessment.
Recovery resource development means creating a full continuum of treatment
and recovery support services. This includes linking personal, professional, and
indigenous community resources into recovery management teams. It also
means guiding the individual and his or her family into a relationship with a larger
community of shared experience (a recovery community).
In this context, indigenous community resources could mean support groups,
spiritual or religious resources, tribal or community support resources, and so
on. This linking of resources is known as a recovery-oriented system of care. To
clarify what we mean, a recovery-oriented system of care is not a government or
nongovernmental system. Instead, it refers to the complete network of indigenous
and professional services and relationships that can support the long-term recovery
of individuals and families.
Recovery education and training refer to enhancing the recovery-based knowledge
and skills of individuals in recovery, their families, service providers, and the larger
community.
Ongoing monitoring and support mean continuity of contact and support over time,
usually over a long period. They can include professional checkups, where program staff
keeps in at least minimal and periodic contact with former clients. It also can include
peer mentoring and recovery coaching. The concept of peer mentoring and recovery
coaching is related to sponsorship in 12-Step programs but is not limited to that.
Ongoing monitoring and support are part of a recovery-oriented system of care.
Recovery advocacy means advocating for social and institutional policies that
counter the stigma and discrimination we talked about in Curriculum 1. It also means
advocating for systems that promote long-term recovery.
56
Finally, evidenced-based treatment and support services mean replacing less
effective treatment and recovery support services with approaches that have a
sturdier foundation of scientic support. This aspect also includes developing
services that remove barriers to recovery and enhance individuals recovery capital.
Although White and his colleagues described the seven elements of recovery
management, a practice document published by the United Nations Ofce on Drugs
and Crime (UNODC) describes an 11-element model.
1

Both models overlap in signicant ways. The UNODC model description is in
Resource Page 2.2 in your manuals.
1
57
MODULE 3
FACTORS AFFECTING TREATMENT OUTCOMES
Training goal and learning objectives ....................................................... 59
Summary .................................................................................................... 78
59
Participant Manual: Module 3Factors Affecting Treatment Outcomes
Activity Time
Small-group exercise: Identifying factors that may affect treatment
outcomes
30 minutes
Presentation: Recovery Capital 15 minutes
Day 1 review and introduction to case study exercise 15 minutes
Wrap-up and Day 1 evaluation 15 minutes
End of Day 1
Day 2 welcome 5 minutes
Small-group Exercise: Case Study 80 minutes
Break 15 minutes
Module 3 Goal and Objectives
Training goal
To discuss the effects that individual, program, and societal factors have on treatment
outcomes.
Learning objectives
List four main categories of factors that can affect treatment;
Provide at least three examples of specic factors for each category;
Dene and provide examples of recovery capital; and
Identify, from a case study, factors that may affect treatment for an individual.
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Module 3: Factors Affecting Treatment Outcomes,
Summary
On an individual basis, one can never really predict who will do well in treatment
and who wont; too many factors (including timing) can inuence treatment.
Understanding these factors helps counselors to plan treatment and case
management services.
Factors
Research has found that the following factors have an effect on treatment outcomes:
The characteristics of individuals seeking treatment;
The nature and severity of their problems;
The treatment process and the services provided;
Environmental and social conditions (including family), both during and following
treatment; and
The interactions among these factors.
Recovery Capital
The phrase recovery capital was coined by Cloud and Graneld
1
, who dened it as:
the sum of personal and social resources at ones disposal for
addressing drug dependence and, chiey, bolstering ones capacity and
opportunities for recovery.
The concept of recovery capital involves identifying and building upon a clients
personal and social assets. Some of these assets may still be alive and well, and some
may have been developed early in the clients life and then lost through addiction.
Recovery capital that never existed in the clients life also can be developed: Social
supports can be marshaled, and clients can learn new skills that support recovery.
The practice document we mentioned in Module 2, published by the United Nations
Ofce on Drugs and Crime (UNODC),
2
identies eight domains, or life areas, of
recovery capital:
Physical and mental health;
Family, social supports, and leisure activities;
Safe housing and healthy environments;
1
Cloud, W., & Graneld, R. (2001). Natural recovery from substance dependency: Lessons for treatment providers.
Journal of Social Work Practice in the Addictions, 1(1). 83104.
2
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Peer-based support;
Employment and resolution of legal issues;
Vocational skills and educational development;
Community integration and cultural support; and
(Re)discovering the meaning and purpose in life.
These areas correlate to the general categories of factors that have been found to
affect treatment outcomes.
While assets in each of these domains strengthen a persons recovery, a lack of
assets can hamper the recovery process and desired outcomes. This is called
negative recovery capital.
White identies three types of recovery capital that can be inuenced by addictions
professionals:
1
Personal;
Family and social; and
Community and cultural.
Personal recovery capital can be further divided into physical and human capital. A
clients physical recovery capital includes things like:
Physical health;
Financial assets;
Safe and recovery-conducive shelter;
Clothing;
Food; and
Access to transportation.
Human recovery capital includes a clients:
Values;
Knowledge;
Educational and vocational skills and credentials;
Problem-solving capacities;
Self-awareness;
1
White, W. L., & Cloud, W. (2008). Recovery capital: A primer for addiction professionals. Counselor Magazine, 9(5). 2227.
80
Self-esteem; and
Self-efcacy (meaning a clients self-condence in managing high-risk situations).
Human recovery capital also includes a clients:
Hopefulness and optimism;
Perception of his or her past, present, and future;
Sense of meaning and purpose in life; and
Interpersonal skills.
Family and social recovery capital includes any intimate relationships, family, and
kinship relationships, and any social relationships that are supportive of recovery
efforts. Before we move on, we need dene what we mean by family. Kinship is
straightforward; it means blood ties. Family, however, can be dened in a number
of ways.
Family and social recovery capital is indicated by:
The willingness of intimate partners and family members to participate in
treatment; and
The presence of others in recovery within the family or among social contacts.
Family and social recovery capital is also indicated by:
Access to opportunities for recovery-basedor at least abstinentfellowship
and leisure activities; and
Connections to conventional institutions, such as school, a workplace, a place of
worship, and community or tribal organizations.
The last type of recovery capital is community and cultural. Community recovery
capital involves community attitudes, policies, and resources related to addiction
that promote recovery.
Community recovery capital includes:
Active efforts to reduce stigma;
Visible and diverse local recovery role models (for example, a community leader
who is open about being in recovery);
A full continuum of addiction treatment services; and
Recovery mutual aid and support resources that are accessible and diverse (for
example, 12-step programs).
81
Community recovery capital also includes:
Local recovery community support institutions (recovery centers/clubhouses,
Treatment alumni associations, recovery homes, recovery schools, recovery
industries, recovery ministries); and
Sources of sustained recovery support and early re-intervention (for example,
recovery checkups through treatment programs or recovery community
organizations).
Finally, cultural capital, a form of community capital, is the local availability of
indigenous cultural pathways of recovery, like incorporating tribal values and
practices into recovery programs.
As we learned earlier, many factors affect treatment outcomes. Research is showing
that the concept of recovery capital is a useful way of looking at these factors.
1

Both the quantity and quality of a persons recovery capital may play a major role in
determining the success or failure of treatment and recovery, and counselors play a
critical role in helping clients to maximize the recovery capital they already have and
develop additional recovery capital.
1
White, W. L., & Cloud, W. (2008). Recovery capital: A primer for addiction professionals. Counselor Magazine, 9(5). 2227.
83
MODULE 4
INTRODUCTION TO MOTIVATION AND STAGES OF CHANGE
Training goal and learning objectives ....................................................... 85
Resource pages ......................................................................................... 96
Summary .................................................................................................... 99
85
Training goals
To provide an overview of the concept of motivation;
To provide an overview of the nature and stages of change; and
To give participants a chance to explore the characteristics of people in each stage
of change.
Learning objectives
List at least three characteristics of motivation;
List the six stages of change; and
Describe two or three characteristics of clients in each stage of change.
Activity Time
Exercise: Personal change 15 minutes
Break 15 minutes
Interactive presentation: The nature of motivation 30 minutes
Presentation: Introduction to the stages of change model 10 minutes
Small-group presentations: Characteristics of clients in each stage
of change
55 minutes
Lunch 60 minutes
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Resource Page 4.1: Characteristics of Clients in Each Stage
of Change
Precontemplation
During the precontemplation stage, people who use substances are not considering
change and do not intend to change behaviors in the foreseeable future. People in this
stage tend to defend their substance-using behavior. They may be partly or completely
unaware that a problem exists or that a change is needed. They may need help to
change. They may be defensive when others pressure them to quit. They also may be too
discouraged to change their behavior. Individuals in this stage may not have experienced
adverse consequences or crises because of their substance use and often are not convinced
that their pattern of use is a problem or even risky. Even people who have previously
recognized that they have a problem and have made efforts to change may revert back to
the precontemplation stage. They may say to themselves, Its really not that bad.
People in the precontemplation stage must raise their awareness before they can
consider change.
Contemplation
As individuals become aware that a problem exists, they begin to realize there may be
cause for concern and reasons to change. Typically, they are ambivalent, simultaneously
admitting reasons to change and reasons not to change. Individuals in this stage are
still using substances, but they are thinking about stopping or reducing use in the near
future. At this point, they may seek relevant information, reevaluate their substance-using
behavior, or seek help for possibly changing behavior. They typically weigh positive and
negative aspects of making a change (I know I need to quit using, but ...). Individuals
frequently remain in this stage for long periods, often for years, vacillating between
wanting and not wanting to change.
People in the contemplation stage need help resolving their ambivalence and choosing
positive change over their current situation.
Preparation
Once a person begins to plan for change, he or she enters the preparation stage,
during which commitment is strengthened. Preparation entails specic planning
for change, such as deciding whether treatment is needed and, if so, what kind.
Preparation also involves an examination of perceived ability to change. Individuals in
the preparation stage are still using substances, but typically they intend to stop using
very soon. They may experiment with small changes as their determination to change
increases. They may have already attempted to reduce or stop use on their own or may
be experimenting with ways to quit or cut back. They begin to set goals for themselves
and make commitments to stop using, even telling people close to them about their
plans. Too often, people skip this stage; they try to move directly from contemplation
into action and are unsuccessful because they have not adequately researched or
accepted what is required to make a major lifestyle change.
97
People in the preparation stage need help identifying potential change strategies and
choosing those that are most appropriate for them.
Action
Individuals in the action stage choose a strategy for change and begin to follow it.
At this stage, clients believe they can change their behavior and actively modify their
habits and environment. They make drastic lifestyle changes and may face challenging
situations and experience the physiological effects of withdrawal. In this stage,
individuals develop plans to deal with both personal and external pressures that may
lead to slips. They begin to reevaluate their self-image as they move from excessive or
hazardous use to abstinence or safe use. People in this stage also tend to accept help
and seek support from others. The action stage can last from 3 to 6 months following
termination or reduction of substance use.
People in the action stage need help carrying out and sticking with change strategies
and learning to prevent or minimize recurrence.
Maintenance
During the maintenance stage, people try to sustain the gains achieved during the
action stage. People work to stay abstinent and prevent recurrence. Extra precautions
may be necessary to avoid problem behaviors. Individuals learn to detect and guard
against dangerous situations and other triggers that may cause them to use substances.
People in maintenance look at how they live their lives. They work on acquiring new
skills to deal with challenges and avoid relapse. This often means changing routines,
making new friends, and trying new activities. People can anticipate relapse situations
and prepare coping strategies. In most cases, individuals attempting long-term
behavior change return to use at least once and revert to an earlier stage. Recurrence of
symptoms is part of the learning process. Knowledge about personal cues for substance
use is helpful for future change attempts. Maintenance requires prolonged behavioral
changeby remaining abstinent or reducing consumption to acceptable, targeted
levelsand continued vigilance for a minimum of 6 months to several years.
People in the maintenance stage may need help develolping new skills and social
networks for maintaining a recovery lifestyle.
Recurrence
Most people do not immediately sustain the new changes they are attempting to make,
and a return to substance use after a period of abstinence is the rule rather than the
exception. These experiences provide information that can help or hinder subsequent
progression through the stages of change. Recurrence, often referred to as relapse, is
the event that triggers the individuals return to an earlier stage of change and cycling
through the process again. Individuals may have had unrealistic goals, used ineffective
strategies, or put themselves in environments that are not conducive to successful
change. Most people who use substances require several cycles through the stages of
change to achieve successful recovery. After a return to substance use, clients usually
revert to an earlier stage of changenot always to maintenance or action but more
often to contemplation. They often feel demoralized and possibly even hopeless about
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change. They may even become precontemplators again, temporarily unwilling or
unable to change soon. However, a recurrence of symptoms does not necessarily mean
a client has abandoned a commitment to change.
People experiencing recurrence need help assessing what may have contributed to
recurrence, and help resuming their recovery process.
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Module 4: Introduction to Motivation and Stages of
Change, Summary
Treatment and recovery are ultimately about change. As we all know, change is not
always easy for people.
Before we begin to talk about the process of treatment, it is important to understand
the process of change. This module introduces the concept of motivation for change
and a model of stages of change.
The stages of change model is used around the world to address a range of issues,
including:
Medically necessary lifestyle changes;
Following medication schedules (e.g., in treating heart disease or diabetes);
Coping with mental disorders; and
Stopping substance use.
This module is only an introduction to the stages of change model. A counselor
could devote many training hours to fully learning how to incorporate the stages of
change model and motivational approaches into practice. Later in this training and
in future curricula, you will learn more about approaches to treatment that are based
on the concepts of motivation and stages of change.
Motivation
It is important to understand the concept of motivation because motivation for
change is closely related to the level of probability that a person with a substance
use disorder (or SUD) will:
Enter treatment;
Continue in treatment; and
Adhere to a specic change strategy.
Motivation often has been considered static, something a person either does or
does not have. According to the view of motivation as static:
A counselor has little chance of inuencing a clients motivation; and
If a client is not motivated to change, that lack of motivation is the clients
problem (or even his or her fault).
But motivation has been found to actually be dynamic rather than static and is:
Purposeful;
Intentional;
100
Positive; and
Changeable.
Research and experience suggest that motivation is a dynamic state that can
uctuate over time and in relation to different situations and can go back and forth
between conicting goals. For example, a person may be motivated to quit using
drugs so that he can focus on nishing school but also, he may be motivated to t in
with or please his friends, which may mean continuing drug use.
Motivation also varies in intensity, slowing in response to doubts and increasing as
doubts are resolved and goals are envisioned clearly. It also can vary greatly among
potential behavioral changes. For example, a clients motivation to quit injecting heroin
may be very high, whereas her motivation to quit smoking marijuana may be very low.
A person in active addiction is also likely to have impaired judgment and
decisionmaking capabilities, which will affect normal motivational processes.
Motivation is inuenced by these and other internal factors and by external factors
as well.
Internal inuences can include a clients:
Emotional states;
Life goals;
Perceptions about risks and benets of behaviors; and
Cognitive appraisals of the situation (what the client thinks about the situation).
External factors can include a clients family and friends:
One persons family members may express concerns about their loved ones drug
use and support his efforts to change.
Another persons family may use drugs regularly and may not support or may
even actively undermine their loved ones efforts to change.
A family member who protects (enables) the person from consequences of use
may facilitate decreased motivation for change.
A persons peer group can either increase or decrease his or her motivation for
change.
Situations and experiences can also affect motivation:
Critical life events can affect motivation for change. Such events could include
pregnancy, a wedding, death of a loved one, or a friends overdose.
A person may be forced to consider change when faced with consequences for
not making a change, such as after an arrest.
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Finally, community support (or lack of community support).can affect motivation:
Communities can support a persons change efforts by providing adequate
treatment programs.
The availability of support groups may play a role.
Lack of either employment or housing opportunities may reduce motivation for
change.
Negative public views of substance use may discourage people from asking for help.
Stages of Change
The stages of change model was developed based on a study of how people
change; the study found that people go through predictable stages as they attempt
to change.
1
Understanding the process of change, including how people change
without professional help, can help counselors develop and use interventions to
increase clients motivation to change their behavior:
A person in the pre-contemplation stage is either not thinking aboutor is
unwilling or unable tochange.
A person in the contemplation stage acknowledges concerns about behavior and
is considering the possibility of change but is ambivalent (has mixed feelings) and
uncertainty.
A person in the preparation stage is planning to make a change in the near
future but is still considering what to do and how to do it.
A person in the action stage is taking steps to change but has not yet reached a
stable state.
A person in the maintenance stage has achieved initial goals, such as abstinence,
and is now working to maintain the change.
Recurrence of substance-using behavior (lapse or relapse) is sometimes considered
a sixth stage of change. Recurrence is between maintenance and pre-contemplation,
but it can happen at any time in the change process. Many clients move through
different stages several times before achieving stable abstinence; recurrence is
normal but does not have to happen.
People typically do not go through the stages smoothly; rather, they move back and
forth among the stages.
The change process is inuenced by a persons level of motivation, which we have
learned is not static but changeable.
1
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for good. New York: William Morrow and Company.
102
People often linger in the early stages of change, and they go through the stages at
different rates.
Counselors can enhance their clients motivation for change at each stage of
the change process. Its important to understand where a client is in the stages
of change because clients need and use different kinds of motivational support,
according to their stage of change.
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MODULE 5
TREATMENT: AN OVERVIEW
Content and timeline ............................................................................... 105
Training goal and learning objectives ..................................................... 105
PowerPoint slides .................................................................................... 106
Resource pages ....................................................................................... 116
Summary .................................................................................................. 123
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Participant Manual: Module 5Components of Treatment: The Continuum of Care
Activity Time
Exercise: Ways of Looking at Treatment 70 minutes
Break 15 minutes
Small-group exercise: Principles of Effective Treatment 60 minutes
Learning Assessment 30 minutes
Day 2 wrap-up and evaluation 10 minutes
Module 5 Goal and Objectives
Training goal
To provide an overview and framework for understanding addiction treatment.
Learning objectives
Describe at least four ways of looking at treatment;
List at least six principles of effective treatment; and
Identify three ways these principles are currently incorporated into treatment in
participants home areas.
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Resource Page 5.1: Elements of Drug Treatment
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Resource Page 5.2: Ways of Looking at Treatment
Setting (where)
Treatment setting refers to where services are offered. Treatment services are made
available in a variety of settings:
Outreach settings include drop-in centers, homeless shelters, and/or the street.
Outpatient substance-free programs provide treatment at a program site, but the
person lives elsewhere (usually at home). These programs are abstinence based
and do not typically use treatment medications. Outpatient treatment is offered
in a variety of places: health clinics, community mental health clinics, workers
ofces, hospital clinics, local health department ofces, or residential programs with
outpatient clinics. Many programs provide services in the evenings and on weekends
so that participants can go to school or work.
Medication-assisted outpatient treatment for opioid addiction is provided in
outpatient methadone clinics, general medical clinics, or doctors ofces.
Hospital-based inpatient treatment settings typically are separate units in a general
medical hospital. They may provide detoxication and ongoing treatment (usually
short term), as well as treatment of other medical problems.
Nonmedical residential programs provide a living environment with treatment
services. These programs typically do not have full-time medical staff, and clients
must have completed detoxication before entering.
Halfway houses or transitional living facilities provide a supportive living environment
for clients who have typically completed primary residential treatment and are
ready to go back to work and/or school. These facilities typically provide relapse
prevention treatment, behavioral guidelines, and a place to live for those who have
no family or are not ready to return to their families.
Intensity (how often) and Duration (for how long)
Intensity is related to how many hours per day a person is involved in treatment activities:
Restrictive settings (inpatient or residential programs) are more intensive than others
because clients typically spend much of the day involved in treatment activities.
Outpatient programs may be more or less intensive. Outpatient day treatment
or partial hospitalization programs may offer nearly as many hours of treatment
activities per day as residential or inpatient programs, typically 5 days per week.
Intensive outpatient programs may offer treatment activities for 9 to 20 hours per week.
Other outpatient programs may meet once a week for 1 or 2 hours.
118
Duration is related to how many days a person can be involved in treatment activities:
Duration of treatment varies. For example, treatment programs may provide
structured service for weeks, months, or a year or more.
Research consistently shows that treatment is most effective if it lasts for at least 90
days. However, insurance providers or government-subsidized treatment may permit
only shorter duration treatment.
How Treatment is Provided
Modality refers to how services are offered: in groups with peers, individually, with family
members, or in any combination of the three.
Components of Treatment
Interventions refer to the range of services offered in program settings. Examples of
interventions are:
Detoxication;
Assessment;
Education about substance use disorders for clients and family members;
Counseling;
Treatment for mental health problems;
Establishment of special groups or other services for particular populations, such as
women or prison inmates;
Relapse prevention training;
Medication;
Orientation to support groups;
Case management;
Employment training and general schooling for adolescents and young adults; and
Continuing care.
Module 5 addresses the components of treatment.
Continuum of Care (treatment and other services over time)
A continuum of treatment is the range of treatment and other services offered over time
to a client based on his or her specic needs. This continuum may include:
Moving from a more intensive form of treatment to a less intensive form (e.g., from
residential treatment to a halfway house or from a transitional living program to
outpatient treatment); or
119
Moving from less intensive to more intensive treatment when necessary (e.g.,
moving from a drop-in group to medication-assisted treatment when the person
needs more help with abstinence).
A continuum also includes consistent case management to make sure clients other
needs are met (e.g., referral for medical care, voluntary counseling and testing [VCT] for
HIV, nancial advice, family therapy, housing, job skills training).
The graphic below shows a continuum of care for one client:
Outreach
Drop-in Group
Case Management
Residential
Treatment
Vocational
Training
Evaluation for
Depression
VCT
A peer outreach counselor talks to an individual about a drop-in center, and the
individual decides to join a group at the center.
The individual continues to use cocaine even though he wants to quit. He has little
family support, and all his friends use drugs. He is referred to a residential program
for more intensive services.
At the same time, his counselor works with him to initiate HIV testing, obtain a
psychiatric evaluation for depression, and (once the client has been on methadone
for a while) become involved in vocational training.
Treatment Models or Practices
A treatment model is a set of guiding principles and specic techniques for working
with clients. Some theoretical models of treatment have been found to be more
effective than others in helping people with substance use problems. These models
have been studied extensively, though primarily in the West.
The primary research-based models (also called evidence-based practices) used in
many countries around the world are:
Medication-assisted treatment for opioid addiction;
Cognitive-behavioral therapy;
Motivational approaches;
Outpatient
Continuing
Care
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Matrix model for methamphetamine and other stimulant use;
12-Step facilitation therapy;
Contingency management;
Therapeutic community; and
Family approaches for couples and adolescents.
Module 7 addresses these models.
121
Participant Manual: Module XModule Title
Resource Page 5.3: Basic Principles of Effective Drug Treatment
1
1. No single treatment is appropriate for all individuals. Matching treatment
settings, interventions, and services to each individuals particular problems
and needs is critical to his or her ultimate success in returning to productive
functioning in the family, workplace, and community.
2. Treatment needs to be readily available. Because individuals who are addicted
may have mixed feelings about entering treatment, taking advantage of
opportunities when they are ready for treatment is crucial. Potential treatment
applicants can be lost if treatment is not immediately available or is not readily
accessible.
3. Effective treatment attends to multiple needs of the individual, not just his
or her substance use. To be effective, treatment must address the individuals
substance use and any associated medical, psychological, social, vocational, and
legal problems.
4. An individuals treatment and services plan must be assessed continually and
modied as necessary to ensure that the plan meets the persons changing
needs. A client may require varying combinations of services and treatment
components during the course of treatment and recovery. In addition to
counseling or psychotherapy, a client at times may require medication, other
medical services, family therapy, parenting advice, vocational rehabilitation, and
social and legal services. It is critical that the treatment approach be appropriate
to the individuals age, gender, ethnicity, and culture.
5. Remaining in treatment for an adequate time is critical for treatment
effectiveness. The appropriate duration for an individual depends on his or her
problems, needs, and resources. Research indicates that, for most clients, the
threshold of signicant improvement is reached at about 3 months in treatment.
Because people often leave treatment prematurely, programs should include
strategies to engage and keep people in treatment.
6. Counseling (individual and/or group) and other behavioral therapies are critical
components of effective treatment for addiction. In therapy, clients address
issues of motivation, build skills to resist substance use, replace substance-
using activities with constructive and rewarding non-substance-using activities,
and improve abilities to solve problems. Behavioral therapy also facilitates
interpersonal relationships and the individuals ability to function in the family and
community.
1
Adapted from U.S. National Institute on Drug Abuse. (1999). Principles of drug addiction treatment: A research-based
guide (pp. 35). Bethesda, MD: Author.
122
7. Medications are an important element of treatment for many clients, especially
when combined with counseling and other behavioral therapies. Methadone is
very effective in helping people who are addicted to heroin stabilize their lives
and reduce their drug use. For clients with mental disorders, both behavioral
treatments and medications can be critically important.
8. Individuals who have addictions or abuse substances and have co-occurring
mental disorders should receive integrated treatment for both disorders.
Because substance use disorders and mental disorders often co-occur, clients
presenting for either condition should be assessed and treated for the co-
occurrence of the other type of disorder.
9. Medical detoxication is only the rst stage of addiction treatment and by itself
does little to change long-term substance use. Medical detoxication safely
manages the acute physical symptoms of withdrawal associated with stopping
substance use. Although detoxication alone is rarely sufcient to help people
who have addictions achieve long-term abstinence, for some individuals it is a
necessary element of effective addiction treatment.
10. Treatment does not need to be voluntary to be effective. Strong motivation can
facilitate the treatment process. However, sanctions or enticements in the family,
employment setting, or criminal justice system can increase treatment entry,
retention rates, and treatment success.
11. Possible substance use during treatment must be monitored continuously.
Lapses to substance use can occur during treatment. The objective monitoring
of a clients drug use during treatment, such as through urinalysis or other tests,
can help the client withstand urges to use substances. Such monitoring also can
provide early evidence of substance use so that the individuals treatment plan
can be adjusted. Feedback to clients who have positive test results for illicit drug
use is an important element of monitoring.
12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and
C, tuberculosis, and other infectious diseases, as well as counseling to help
clients modify or change behaviors that place themselves or others at risk of
infection. Counseling can help patients avoid high-risk behavior. Counseling also
can help people who are already infected manage their illnesses.
13. Recovery from substance addiction can be a long-term process and frequently
requires multiple episodes of treatment. As with other chronic illnesses,
substance use relapses can occur during or after successful treatment episodes.
Individuals who are addicted may require prolonged treatment and multiple
episodes of treatment to achieve long-term abstinence and fully restored
functioning. Participation in mutual-help support programs during and following
treatment often is helpful in maintaining abstinence.
123
Module 5: Treatment: An Overview, Summary
There are a number of ways to look at treatment:
Treatment setting refers to where treatment is provided: for example, in a drop-in
center, hospital, clinic, or residence.
Treatment intensity and duration are related to one another. Intensity refers to
how often treatment is provided. Duration refers to how long a person receives
treatment services.
Treatment can be provided in a number of ways. For example: one-on-one with
an addiction professional; in a group with peers, or with other family members.
These days, treatment may even be provided over the phone or internet.
Treatment components refer to the elements, or pieces, of treatment; for
example, assessment, counseling, education, and so on.
The continuum of care is related to the types of treatment and the other services
a person can receive over time. This is another way of looking at ongoing
recovery management.
The model of treatment intervention refers to the theoretical basis and specic
techniques a professional uses to provide treatment interventions; for example,
cognitive-behavioral therapy and other evidence-based practices.
Resource Page 5.2 provides more detailed descriptions of these ways of looking at
treatment.
Resource Page 5.3 provides the U.S. National Institute on Drug Abuses Basic
Principles of Effective Drug Treatment.
The World Health Organization
1
and the United Nations Ofce on Drugs and Crime
jointly developed a set of principles for drug treatment. These principles are similar
to the NIDA principles, but they are more detailed. They are available at:
http://www.unodc.org/documents/drug-treatment/UNODC-WHO-Principles-of-
Drug-Dependence-Treatment-March08.pdf
1
United Nations Ofce on Drugs and Crime & World Health Organization. (2008). Principles of drug dependence
treatment. Geneva: Authors. Retrieved September 15, 2011 at http://www.unodc.org/documents/drug-treatment/
UNODC-WHO-Principles-of-Drug-Dependence-Treatment-March08.pdf
125
MODULE 6
COMPONENTS OF TREATMENT: THE CONTINUUM OF CARE
Training goal and learning objectives ..................................................... 128
Resource pages ....................................................................................... 200
Summary .................................................................................................. 213
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Activity Time
Welcome, review of day 2, and introduction to Module 6 20 minutes
Presentation: Pretreatment components 60 minutes
Small-group exercise: Pretreatment components 40 minutes
Break 15 minutes
Presentation: Case management 25 minutes
Small-group exercise: Case management components 30 minutes
Presentation: Primary treatment, Part 1Group counseling 10 minutes
Small-group presentations: Types of groups 60 minutes
Lunch 60 minutes
Presentation: Primary treatment, Part 2Individual counseling 10 minutes
Presentation: Primary treatment, Part 3Other components 45 minutes
Break 15 minutes
Small-group exercise: Primary treatment 40 minutes
Presentation: Continuing care 15 minutes
Day 3 Wrap-up and evaluation 15 minutes
End of day 3
Small-group exercise: Continuing care 60 minutes
Small-group exercise: Case study 90 minutes
Break 15 minutes
128
Training goals
To provide a comprehensive overview of the various components of effective
treatment; and
To provide an opportunity for participants to understand the concept of continuum
of care by applying it to a client.
Learning objectives
Provide a general description of an effective continuum of care for substance use
disorders (SUDs);
Identify differences between screening and assessment;
Describe detoxication options;
Dene case management;
Name and briey describe at least ve interventions typically offered in primary SUD
treatment;
Name and briey describe four types of groups often used in SUD treatment;
Name and briey describe the self-help/mutual-help options available in the
community/area;
Dene continuing care; and
Apply the concept of continuum of care by identifying an appropriate continuum for
a client via a case study.
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203
Resource Page 6.2: Benets of Group Counseling in SUD
Treatment
Groups provide positive peer support and pressure to abstain from substances of
abuse.
Groups reduce the sense of isolation that most people who have substance use
disorders experience.
Groups enable people who abuse substances to witness the recovery of others.
Groups help members learn to cope with their substance abuse and other problems
by allowing them to see how others deal with similar problems.
Groups can provide useful information to clients who are new to recovery.
Groups provide feedback concerning the values and abilities of other group members.
Groups offer family-like experiences.
Groups encourage, coach, support, and reinforce as members undertake difcult or
anxiety-provoking tasks.
Groups offer members the opportunity to learn or relearn the social skills they need
to cope with everyday life instead of resorting to substance abuse.
Groups can effectively confront individual members about substance abuse and
other harmful behaviors.
Groups allow a single treatment professional to help a number of clients at the same
time.
Groups add needed structure and discipline to the lives of people with SUDs, who
often enter treatment with their lives in chaos.
Groups instill hope and a sense that If she can make it, so can I.
Groups help clients identify community resources and barriers to recovery.
Groups encourage individuals to assess and build on their recovery capital.
204
Resource Page 6.3: Psychoeducation Groups
Overview
These groups provide a supportive environment in which clients learn about
substance dependence and its consequences.
Psychoeducational groups feature a low-key rather than emotionally intense
environment.
Didactic components often are supplemented by videos or slides to accommodate
different learning styles.
Psychoeducational groups focus on substance use disorders but also may include
education about mental disorders and common co-occurring medical disorders.
Psychoeducation groups may be clients only, include clients and their families, or
include only family members.
Psychoeducational groups start at the beginning of treatment, and topics change
according to clients length of time in treatment.
Typical Sequence of Topics Addressed in Psychoeducational Groups
Early Recovery
Learning about biopsychosocial disease and recovery processes;
Understanding the effect of specic drugs on the brain and body;
Placing symptoms of substance use disorders in the context of other behavioral
health problems;
Learning about early and protracted withdrawal symptoms for specic drugs;
Knowing the stages of recovery and the clients place in the continuum of care;
Learning strategies for quitting and nding the motivation to stop;
Minimizing risks of HIV/AIDS, hepatitis C, and sexually transmitted diseases;
Identifying high-risk situations that are cues or triggers to substance use: people,
places, and things;
Identifying peer pressures and compulsive sexual behavior as triggers;
Understanding cravings and urges, learning to extinguish thoughts about substance
use, and coping with cravings;
Structuring personal time;
Coping with high-risk situations;
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Understanding abstinence and the use of prescription and over-the-counter
medications;
Understanding the goals and practices of various 12-Step or other mutual-help
groups;
Identifying and using positive support networks; and
Understanding the relapse process and common warning signs.
Maintenance and Continuing Care
Identifying tools to prevent relapse;
Developing personal relapse plans;
Counteracting euphoria and the desire to test control;
Improving coping and stress management skills;
Learning anger management and relaxation techniques;
Enhancing self-efcacy for handling risky situations;
Responding safely to slips and avoiding escalation;
Finding recovery resources;
Structuring leisure time and nding recreational activities;
Knowing the importance of personal health: diet, exercise, hygiene, and checkups;
Taking a personal inventory;
Handling shame, guilt, depression, and anxiety;
Understanding family dynamics: enabling and sabotaging behaviors;
Rebuilding personal relationships;
Understanding sexual dysfunction and healthy sexual behavior;
Developing educational and vocational skills;
Learning daily living skills: money management, housing, and legal assistance;
Embracing spirituality and recovery and nding meaning in life;
Recognizing grief and loss and the relationship to substance use;
Learning about parenting: basic needs of children and their developmental stages
and developmental tasks; and
Maintaining balance in life.
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Resource Page 6.4: Types of Treatment Groups
Treatment Engagement Groups
Treatment engagement groups focus on:
Understanding motivation and committing to treatment;
Counteracting ambivalence and denial;
Determining the seriousness of the substance use problem;
Facilitating self-assessment, setting goals, and self-monitoring progress;
Overcoming common barriers to treatment (transportation, time, child care); and
Learning about treatment goals, expectations, and rules.
Relapse Prevention Groups
Relapse prevention groups focus on helping clients:
Understand cravings and urges;
Learn specic strategies for coping with cravings;
Structure personal time;
Understand abstinence and the use of prescription and over-the-counter medications;
Identify personal issues that could interfere with recovery;
Identify, develop, and use positive social support networks;
Analyze one anothers personal triggers and high-risk situations for substance use
and determine ways to manage or avoid them; and
Learn substance refusal skills by acting out scenarios in which they are invited to use
substances and practice appropriate responses.
Skills Development Groups
These groups offer clients the opportunity to practice specic behaviors in the safety
of the treatment setting.
Common types of skills training include:
Assertiveness training. Clients learn the differences among assertive, aggressive,
and passive behaviors and practice being assertive in different situations.
Stress management. Clients identify situations that cause stress and learn a
variety of techniques to respond to stress.
Problem solving. Clients learn strategies and specic steps to solve problems.
207
Life skills training. These groups can include learning and practicing employment
skills, leisure activities, social skills, communication skills, goal setting, anger
management, and money and time management.
Support Groups (for example, process-oriented recovery groups)
These groups include clients in the same recovery stageusually a middle to late
phase of treatmentwho are working on similar problems.
Members focus on immediate issues and on:
Practical ways to change negative thinking, emotions, and behavior;
Learning and trying new ways of relating to others;
Tolerating or resolving conict without resorting to violence or substance use;
and
Looking at how members actions affect others and the function of the group.
Support groups may be led by either counselors or peers.
Special Interest Groups
These groupsusually organized at a later stage of treatmentfocus on an issue of
particular signicance to and sensitivity for group members.
Special interest groups include:
Mens or womens issues;
Sexual orientation;
HIV/AIDS;
Criminal history/reentry into the community;
Co-occurring mental or physical disorders; and
Physical and sexual abuse.
Family Groups
Family groups can be multifamily and include a mix of spouses, parents, and older
children.
They focus on providing a supportive environment for families to interact and
discuss common concerns and problems.
Family groups also can by psychoeducational, focusing on educating family members
about addiction, its individual and family consequences, recovery, and relapse.
Couples groups focus on the interplay between couples dynamics and issues of
recovery.
208
Family groups in treatment programs focus on the issues of addiction and are
typically not family therapy, which must be conducted by trained family therapists
and which focuses on serious and longstanding family issues and problems.
An exception would be the family groups in certain models of family treatment for
adolescents. These models will be discussed in Module 7.
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Resource Page 6.5: 12 Steps of Narcotics Anonymous
1. We admitted that we were powerless over our addiction, that our lives had become
unmanageable.
2. We came to believe that a Power greater than ourselves could restore us to sanity.
3. We made a decision to turn our will and our lives over to the care of God as we
understood Him.
4. We made a searching and fearless moral inventory of ourselves.
5. We admitted to God, to ourselves, and to another human being the exact nature of
our wrongs.
6. We were entirely ready to have God remove all these defects of character.
7. We humbly asked Him to remove our shortcomings.
8. We made a list of all persons we had harmed, and became willing to make amends
to them all.
9. We made direct amends to such people wherever possible, except when to do so
would injure them or others.
10. We continued to take personal inventory and when we were wrong promptly
admitted it.
11. We sought through prayer and meditation to improve our conscious contact with
God as we understood Him, praying only for knowledge of His will for us and the
power to carry that out.
12. Having had a spiritual awakening as a result of these steps, we tried to carry this
message to addicts, and to practice these principles in all our affairs.
Reprinted by permission of NA World Services, Inc. All rights reserved. The Twelve
Steps of NA reprinted for adaptation by permission of AA World Services, Inc.
210
Resource Page 6.6: Case StudyDilip
Dilip is 22 years old and single. He is unemployed and does not attend school.
He lives with his parents and two older brothers. His father works in a private
enterprise and spends a lot of time traveling. His mother is a housewife. Both
brothers have graduated from high school and are working. Dilip is close to the
older of his brothers but is not close to his mother. He respects his father a great
deal.
At 16, he started smoking tobacco and cannabis with schoolmates and drinking in
pubs socially on weekends.
In the past 6 months, he has started injecting heroin intravenously. His health has
deteriorated.
Dilip started college 6 months ago but missed a lot of classes; when he did attend,
he tended to nod off during class. His work has been sloppy or incomplete. He was
given several warnings, but he did not change his behavior. His parents tried to
intervene, but eventually he was suspended from the college.
The older of his brothers has been an enabler, covering up for Dilips drug use: he
has paid back Dilips small debts, has not informed their parents about some of
the consequences of Dilips drug use, and has lied to their parents about Dilips
whereabouts.
Dilip does not speak to his other brother. This brother is aware of Dilips drug use
and the resultant problems. He realizes that Dilip needs treatment and has tried to
motivate Dilip to seek help.
Dilip has mood swings; he feels very anxious and has difculty sleeping.
His girlfriend of 2 years broke up with him a month ago because of his drug use, and
at that time he let his brother take him to an outpatient treatment program.
He has been attending group sessions but has been unable to resist his drug
cravings and continues to use. Over the past 2 months, he has become motivated to
join the inpatient treatment program.
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Resource Page 6.7: Case StudyHa
Ha is 25 years old and has been a sex worker since she was 16. Her mother was also
a sex worker and died of AIDS a year ago.
Ha started using marijuana and drinking at age 12.
She has used a variety of drugs over the years. She spent 2 years in a rehabilitation
center when she was 20 but stayed in recovery only 9 months.
She tried to change her life at that point, but she could not nd a job that lasted. Ha
eventually went back to sex work and was soon using drugs again. She says sex work
is difcult without being high.
She started injecting heroin 4 years ago. She is currently homeless but stays with
friends when she can.
Her mothers death has scared her, but she hasnt been tested for HIV. She is
ambivalent about being tested. She knows she should be tested, but she is worried
the test results will be positive for HIV.
Ha occasionally goes to a drop-in center. She has told a worker that she feels tired
and old and wants to get out of sex work.
She recently found a job in a shop, but she continues to see old clients from time to
time for extra money.
She has attempted to stop her heroin use on her own but cannot make it through
withdrawal.
She doesnt fully trust the drop-in center staff or volunteers and feels hopeless.
Still, she continues to visit the drop-in center.
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Resource Page 6.8: Case StudySekar
Sekar is 39 years old and married. He has worked as an accountant in a private rm
for the past 2 years.
He lives with his wife and 11-year-old daughter. His wife is a schoolteacher. It is a
marriage of choice, and the relationship with his wife and daughter was intimate
until a year ago.
He and his family rent a one-bedroom house in a middle-class community.
Three years ago, during a period of high work stress, Sekar began taking
amphetamines he got from a friend to help him cope with an increased work load.
Because of the stimulant effects, he began having chronic insomnia (inability to sleep).
His doctor prescribed a barbiturate to help him sleep, and Sekar has continued using
both amphetamines and barbiturates, both now bought on the street.
Over the past 4 months, he has missed many days of work. As a result, he received a
formal warning. There have been instances of verbal abuse at home, as his wife has
become angry at his drug use and that he is risking his job.
His health has deteriorated, and he recently developed hypertension.
His wife has difculty running the household with her income. They argue constantly.
His daughter is scared of him and avoids him.
He has borrowed money from friends and money lenders at a high interest rate,
which is a burden on his wife. She faces a lot of abuse from the money lenders.
His wife is on the verge of leaving him. This has motivated him to seek residential
treatment. He is not sure whether his workplace will allow him to come back when he
completes treatment.
He reports that he tried to quit both the amphetamines and barbiturates last year.
He had a seizure during withdrawal from the barbiturates, felt very depressed, and
considered committing suicide.
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Module 6: Components of Treatment: The Continuum
of Care, Summary
Continuum of care refers to the whole range of services a client can receive directly
from a treatment program or coordinated by the treatment program, the recovery-
oriented systems of care we learned about in Module 2. We will address these
services or components, roughly in the order in which a client typically participates
in them.
Weve learned that a person usually does not follow a straight path in the stages of
change.
Similarly, a person may not follow a linear path from the beginning to the end of
treatment.
Pretreatment Components
We will begin with pretreatment components. These parts of the continuum of care
happen before primary treatment:
Outreach;
Screening and brief intervention;
Assessment and treatment planning; and
Detoxication.
Outreach
Outreach can be dened as the act of reaching out in an effort to build connections
from one group or program to another. It also means extending services or
assistance to people or groups not previously served.
SUD program outreach includes organized efforts to identify and screen individuals
who might have a problem with substance use, rather than wait for them to be
referred to treatment programs or to decide to enroll in a program themselves.
The ultimate goals of outreach are to:
Establish contact;
Build trust;
Develop relationships;
Provide needed healthcare linkages; and
Engage individuals in SUD brief interventions or treatment.
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Outreach is important because many people who use substances will not approach
SUD treatment programs and other health services. Some reasons for this are that
treatment programs are often seen as:
Intimidating;
Difcult to get to;
Too rigid or judgmental in their approach;
Irrelevant to an individuals immediate needs; and
Too costly.
Outreach efforts can be conducted in a variety of ways and in different settings. For
example:
A treatment program can offer community education about SUDs and treatment
options at meetings of business and religious community leaders or community
workshops.
An addiction professional can conduct outreach in homeless shelters, HIV,
or other medical clinics, community centers, drop-in centers, and so on. The
professional could be an employee of either a local treatment program or of the
shelter, clinic, or center.
Professionals or peers (individuals who are in recovery from SUDs) can offer either
education or screening services, or both, in schools, social centers, and clinics.
Additionally, outreach efforts can be provided by a variety of staff members in other
settings:
Paraprofessionals can place literature at and be present in dance-clubs and
gambling casinos where substance use is encouraged.
Peer educators can spend time in places frequented by people who are known
to inject drugs or by sex workers.
Medical staff in the emergency room, orthopedic centers, or primary care ofces
can provide brief interventions or referrals, or both, to SUD professionals.
Although these examples involve specic settings, outreach efforts should target
the cross-section of people who use substances and not focus exclusively on only
the most visible populations.
Screening
Screening is the process of identifying individuals with possible SUDs. Screening
provides an opportunity to initiate discussions with individuals about their
substance use.
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The screening process does not exactly identify what kind of problem the person
might have or how serious it might be; it simply determines whether a problem
exists and whether further assessment is needed.
The difference between screening and assessment is that assessment tries to
identify as closely as possible the nature of an SUD and other issues and the level of
intervention that may be needed.
Screening should be conducted using a validated brief instrument (e.g., test) to
quickly identify a persons pattern of substance use. The validity of a screening
instrument is the degree to which it actually measures what it claims to measure.
In the past, screening instruments were used to identify active cases of drug
dependence, but, in recent years, screening has expanded to identify individuals
across the full spectrum of usefrom risky substance use to addiction.
The World Health Organization (WHO) has developed two screening instruments
that have been tested and validated with international populations:
The Alcohol Use Disorders Identication Test (AUDIT) is a 10-item screening
tool developed to identify individuals whose alcohol consumption has become
hazardous or harmful to their health.
The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST),
developed by an international group of SUD researchers for the WHO, identies
substance use and related problems in primary and general medical care settings.
Many other screening instruments have been designed for use with adults and
adolescents. Resource Page 6.1 provides a list of available screening instruments.
These instruments have not been validated for all age groups or for all cultural groups.
Screening usually identies individuals as having:
No or low risk of an SUD;
Moderate risk of an SUD; or
Severe risk of or active addiction.
Individuals who screen as having no or low risk of an SUD can be congratulated and
encouraged to maintain the status quo. If there is a history of drug dependence in
their family (mother, father, uncle, aunt, grandparent), then information about the
genetic components of addiction should be provided.
Those found to be at moderate risk may need only a brief intervention, whereas
those found to be at high risk should be referred for assessment and treatment.
Brief Intervention
Brief intervention focuses on increasing a persons insight into and awareness of
substance use and behavioral changes.
216
Brief intervention can be provided through either a single or multiple sessions
of motivational interventions. These interventions can be provided by an SUD
counselor or peer counselor. They may also be provided by trained medical or social
services program staff.
Assessment
Individuals who have screening results that indicate a severe risk of developing SUDs
or that indicate an active addiction should be referred to a program for assessment
and treatment planning.
The goals of a comprehensive assessment are to:
Provide a foundation for treatment planning;
Establish a baseline for measuring a clients progress;
Prioritize a clients problems;
Set priorities for treatment and case management intervention; and
Identify client strengths and other recovery capital that can support recovery.
Assessment begins with engaging the client, obtaining the clients history, collecting
data on the client, and observing the client during the rst visit. Its important to
remember that although it begins at the rst visit, assessment is an ongoing process
as the clients needs change over time.
During a comprehensive assessment, the counselor should obtain at least the
following basic information:
The clients reason for seeking treatment and his or her opinion of the problem;
Current and past substance use and drug treatment;
Family history of substance use;
Medical conditions or complications;
Risk of withdrawal and need for supervised detoxication;
Suicide, health, and other crisis risk assessment;
Emotional/behavioral/cognitive status, including the presence of a mental
disorder;
Educational and vocational background;
Legal status;
Readiness to change;
Natural supports within the family, workplace, and community;
217
Relapse or continued-use potential; and
Recovery environment (e.g., living situation, barriers, and supports for recovery).
A number of methods can be used for assessment:
Clinical interview;
Assessment instruments;
Collateral sources, with the clients permission (e.g., family, friends, employer,
referral sources); and
Urine or other testing for substances.
Treatment Planning
A thorough assessment is the basis of treatment planning. The treatment plan is an
individualized outline for treatment and services, based on the clients specic needs
and identied in the assessment process.
Treatment planning is a joint activity that involves the counselor, the client, other
treatment providers, and sometimes the clients family members.
An effective treatment plan identies and clearly distinguishes needs that:
Will be addressed during treatment;
Require referral to other providers; and
Will be deferred to a later time.
The treatment plan needs to be:
Individualized;
Flexible;
Realistic with behavioral objectives that are achievable, observable, and
measurable;
Simple so that clients being served, their families, and staff members can
understand them;
Useful with measurable indicators of progress;
Focused on solutions and strengths and not on negative factors;
Clear in identifying the type and frequency of interventions; and
Responsive to changes and progress.
The rst step of treatment planning is to decide the level of care the client needs
and is willing to accept, including the intensity, duration, and setting. This step
includes determining whether the program can adequately meet the clients needs
or whether the client should be referred to a different program.
218
Treatment planning includes determining whether:
The program can meet the clients needs or should be referred;
Treatment for co-occurring mental or medical disorders is needed; or
The client is in need of supervised detoxication.
Detoxication
Detoxication is the process of
Stopping substance use;
Clearing the substance from the body; and
Managing the withdrawal syndrome.
A withdrawal syndrome is a predictable set of signs and symptoms that occur when
a person abruptly stops taking a psychoactive substance or rapidly decreases the
amount taken.
The particular signs and symptoms, their intensity, and the risk involved in withdrawal
depend on:
The substance used;
The amounts taken over time; and
The length of time the substance was used regularly.
Many people manage detoxication on their own, but others either benet from
or must have additional support and monitoring. Untreated withdrawal may be
dangerous or fatal, particularly withdrawal from benzodiazepines or barbiturates.
Withdrawal from other drugs, like opioids, is not life threatening but can be
extremely painful without medical support.
Medications are available to help with detoxication from opioids, benzodiazepines,
barbiturates, and other sedatives. Currently, no medications can help with stimulant
withdrawal.
Medications are available to help with detoxication from:
Opioids;
Benzodiazepines;
Barbiturates; and
Other sedatives.
Scientic literature is still mixed on whether medications should be used with
stimulant withdrawal. In most of the cases, the physical symptoms are very limited
after stopping cocaine or amphetamines. Antidepressant medications seem to help
219
some clients cope with the depression that often accompanies withdrawal from
stimulants.
There are three immediate goals for detoxication:
To provide a safe withdrawal from the substances of dependence and to enable
the person to become drug free;
To provide a withdrawal that is humane; and
To prepare the person for ongoing treatment.
There are several types of detoxication services:
Outpatient, home-based, or residential services without medication but with
psychosocial support (sometimes called social detox);
Outpatient services with medication and periodic monitoring (medication
supported); and
Inpatient services with medication (medically managed).
For individuals who are dependent on benzodiazepines or sedatives, a medical
evaluation to determine withdrawal risk is essential.
It is important to understand that, although detoxication is often the rst step
toward recovery, it is only a rst step. Detoxication is not treatment. It does
not address the psychological, social, and behavioral problems associated with
addiction. Detoxication alone does not typically produce the lasting behavioral
changes needed for recovery.
Case Management
The next part of the continuum of care is case management.
Although case management is being discussed separately from treatment, it is an
integral part of treatment. Case management begins with screening and assessment
and continues throughout a persons treatment and into ongoing recovery.
There are many denitions of case management, but one simple denition is that
case management is the coordination of professional social or medical services, or
both, to assist people with complex needs, often for long-term care and protection.
Case management is often used to mean either a role (or job description) or a set
of functions. Because a role or job description varies, depending on a persons
organization, this training focuses on case management as a set of functions.
A counselor will not necessarily perform all case management functions as part of
his or her job description but should understand the full range of case management
responsibilities.
Case management for people who are addicted is critical for a number of reasons.
220
First, treatment must be structured to ensure smooth movement between levels of
care (e.g., moving from a residential center to an outpatient program) while avoiding
gaps in service. Treatment services also must be prepared to respond rapidly to the
threat of relapse.
Second, addiction affects so many areas of a persons life that a range of support
services are typically needed to help the individual maintain long-term recovery while
managing to live in the community.
Finally, case management provides the client with a single contact person who is
responsible for nding and mobilizing needed resources, ensuring that the client
does not fall through the cracks.
Ideally, a client in SUD treatment could receive all necessary services in one place
or through integrated partnerships of service providers. However, in most places
around the world, services tend to be scattered, like pieces of a puzzle, and difcult
to access.
No one program or system can meet all the needs of a person who uses substances.
Case managers help put the pieces together for their clients.
Case management functions include:
Assessment;
Service planning;
Linkage and referral;
Monitoring; and
Advocacy.
Assessment and service planning for case management are closely related to the initial
assessment and treatment plan discussed earlier. A case management plan can be
incorporated into a clients overall treatment plan but can also be done as a separate
process that looks specically at what a client needs, in addition to SUD treatment.
Linkage and referral occurs both within a program and between programs (inter-
program). Within a treatment program, a case manager helps clients navigate between
levels of care (e.g., outpatient to residential or primary treatment to continuing care)
Inter-program linkage is a critical part of case management because no one program
can meet all of a clients needs. The goal of inter-program case management is to
connect programs to one another to provide more services to clients.
A counselor can establish linkages either within his or her own program or with other
programs to help clients obtain:
Treatment for mental disorders;
Family therapy;
221
Childcare;
Transportation;
Housing assistance;
Financial assistance;
Legal assistance;
HIV/AIDS or other medical testing and care; and
Educational or vocational services.
Referring a client for a particular service is not enough. A case manager ensures that
the client engages in services and monitors the clients progress. The case manager
identies barriers (related to both clients and services) and works with the client and
referral source to overcome them. This type of close coordination requires that a case
manager have excellent communication skills.
Advocacy is a process of speaking out on issues of concern to apply inuence on
behalf of a person or persons. Advocating for clients can be difcult at times, but it is
an important function of case managers.
Case managers need to advocate with many systems, including other agencies,
healthcare providers, legal systems, and families.
Case managers can advocate by educating non-SUD treatment service providers
about the specic needs of a given client or about SUDs in general. At times, the
case manager must negotiate directly with a service provider on behalf of a client.
Case management functions must be adapted to t the particular needs of a
treatment program within its community context.
How has advocacy t into the work you do with your clients? In what ways does
the concept of advocacy t or not t into the context of your communities? What
difculties have you encountered while advocating for your clients?
Primary Treatment
Group Counseling
Although both individual and group counseling sessions are important parts of primary
treatment for SUDs, group counseling typically is the most frequently used modality.
Group counseling is a cost-effective way of providing treatment because it allows
a single treatment professional to help a number of clients at the same time. But
beyond cost-effectiveness, group counseling is particularly appropriate for treating
SUDs because it:
Provides opportunities for clients to develop communication skills and participate
in socialization experiencesthese activities are particularly useful for individuals
whose socializing has revolved around using drugs;
222
Creates an environment in which clients help, support, and, when necessary,
confront one another;
Introduces structure and discipline into the often chaotic lives of clients;
Provides norms that reinforce healthful ways of interacting and a safe and
supportive environment that is crucial for recovery;
Helps clients broaden understanding of their recovery capital, and barriers to
recovery;
Supports individual assessment of critical risk and protective factors
Advances individual recovery (group members who are further along in recovery
can help other members); and
Provides a venue for group leaders to transmit new information, teach new skills,
and guide clients as they practice new behaviors.
Placement of a client in a group must be based on the clients particular needs and
stage of recovery. In addition, some clients should never be assigned to the same
groups. For example:
Perpetrators and victims of domestic violence must be in separate groups.
Neighbors, friends, relatives, spouses, or signicant others should not be
assigned to the same group (with the exception of family groups). In rural and
remote areas, this may not be possible. In those cases, careful preparation and
discussions about condentiality must take place.
The optimal size of a group is between 8 and 15 members. Group sessions usually
do not last more than 1.5 hours because people tend to have a difcult time
continuing to focus.
Individual Counseling
Although group counseling has many benets, it is not appropriate for all clients.
For example:
Some socially anxious or very introverted clients cannot tolerate groups well.
These clients should be offered individual counseling until they are comfortable
participating in group sessions or at least placed in low-intensity group sessions
that focus on coping skills training.
Some clients with severe mental disorders, such as schizophrenia or antisocial
personality disorder, cannot participate in groups and can attend individual
therapy only.
Clients who violate the principles of group therapy by failing to honor group
agreements or dropping out regularly and those who cannot control their
impulses might respond better to individual counseling.
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Although individual counseling may be the only appropriate modality for some,
individual sessions also are benecial for all clients and some are usually provided as
part of treatment.
The focus of individual counseling sessions varies, depending on the type of
program, the clients stage of recovery, and the clients individual needs. However,
there is usually some sort of structure to an individual session.
In individual counseling, a counselor can:
Ask how the client is feeling;
Ask the client for his or her reactions to a recent group meeting; and
Explore how the client spent his or her time since the last session.
The counselor also may:
Inquire about substance use;
Ask whether there are any urgent issues;
Review treatment plans and coping strategies; and
Address fears and anxieties related to change.
An individual session is also a time for the counselor to:
Provide personalized feedback on substance testing results and
Probe into sensitive issues that are difcult to discuss in a group.
Counselors also use individual sessions to help clients access services they need that
are outside the treatment programs capabilities and to plan the transition to either
another level of care or discharge.
Counselors often give clients individual assignments. People in treatment can
be asked to either read certain things (or listen to audiotapes); complete written
assignments (or record them on audiotapes); or try new behaviors.
A counseling session usually ends with a summary of the clients plans and a
schedule for the next few days.
Other Components
In addition to group and individual counseling, programs typically offer other
components as part of primary treatment. Major components can include:
Testing for drug use;
Pharmacotherapy; and
Orientation to mutual-help groups.
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Testing for Drug Use
Well begin by talking about testing for substance use. Testing clients for drug use
can be useful in a number of ways. Testing can:
Verify, contradict, or add to a clients self-report of substance use;
Identify a relapse to substance use;
Help assess the efcacy of the treatment plan and the current level of care; and
Encourage abstinence.
Substances show up and can be tested for in blood, urine, saliva, breath, and hair.
Most treatment programs test urine for substances.
There are two main types of testing: laboratory testing and point-of-care testing
(POCT). When a program uses laboratory testing, it collects the sample (urine, for
example) at the program site and sends it to a local laboratory to test.
When a program uses POCT, it collects and tests the sample onsite. A number of
POCT kits are available for testing urine, blood, or saliva; programs usually test urine
or saliva to avoid having onsite medical staff.
POCTs have both advantages and disadvantages, compared to laboratory testing.
Some advantages are that they:
Reveal results quickly;
Can be less expensive than laboratory testing; and
Are relatively simple to perform.
Disadvantages are that:
Some kits test for only a few substances; those that test for many substances may
be more expensive than laboratory testing.
They are usually limited to indicating only positive or negative results. They do
not indicate the level of the substance in the body.
Other potential disadvantages are that:
Programs need to have secure storage facilities and provide regular staff training
on POCT use.
POCT may not be admissible in court.
Laboratory testing and POCT can be misleading in monitoring abstinence. For
example, clients can abstain from their substance of choice while using other
substances that may not be included in a particular drug test. Programs usually test for
the clients substance of choice, as well as other drugs commonly abused in the area.
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Pharmacotherapy
Pharmacotherapy (sometimes called medication-assisted treatment) is the use of
medications to assist in treatment of SUDs. Pharmacotherapy is used in a number of
ways:
To aid in acute withdrawal or tapering from psychoactive substances;
To discourage use of a substance by reducing its reinforcing properties or by
creating negative effects when the substance is used; and
To aid early recovery by reducing cravings or counteracting longer-term
symptoms of withdrawal.
Medications are available for treating dependence on opioids. These medications
generally need to be prescribed by a doctor. One of the best-known forms of
pharmacotherapy is methadone maintenance therapy.
Methadone can be used short term, to aid withdrawal, or long term as a
maintenance therapy. Methadone acts on the opioid receptors in the brain, blocking
withdrawal. However, it is less rewarding than opioids like heroin and morphine.
Methadone maintenance can therefore help people function well in their lives.
There is controversy surrounding methadone maintenance and it is not available or
even legal in many countries.
Pharmacotherapy is typically used along with counseling and other treatment
services, and not in place of them.
Mutual-Help Programs
Treatment programs typically educate clients about self-help and mutual-help
programs.
Mutual-help programs are alternatives or enhancements to professional counseling.
In these programs, ordinary citizens meet to discuss similar struggles. Participants
in mutual-help groups support and encourage one another to become or stay
drug free. Twelve-Step programs are perhaps the best known of the mutual-help
programs.
Alcoholics Anonymous (AA) was the rst mutual-help group, created in the mid-
1930s in the United States by Bill Wilson and Bob Smith. Narcotics Anonymous (NA)
was developed in the 1950s for those who were dependent on substances other
than alcohol.
AA and NA use the experiences of their members, a 12-step process, and spirituality
to combat substance dependence.
The hallmarks of AA and NA include the 12 Steps to recovery.
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Another hallmark of AA and NA is group meetings. Group meetings can be open,
meaning that the general public is welcome to attend, or closed, meaning that
only those with an alcohol use disorder may attend. Meetings are led by members
on a rotating basis. There are different types of group meetings, including:
Discussion meetings, in which a leader introduces a topic with some brief
comments and then invites others to share on the topic;
Speaker meetings, in which the person in recovery shares his or her story; and
12-Step meetings, in which a particular step is discussed.
In addition to the main types of meetings, there also are special meetings for
women, men, gay and lesbian members, and others.
Sponsorship is also an important part of 12-Step programs of recovery.
A sponsor is a 12-Step program member who has had successful experience within
the program and who works personally with a member with less experience.
A sponsor is similar to a mentor, but 12-Step programs see sponsorship as a
relationship of equals.
The programs strongly recommend that a sponsor be of the same gender as the
person being sponsored.
Over the years, many additional recovery programs have been developed based on
the AA 12-Step process, including Marijuana Anonymous, Cocaine Anonymous, and
Nicotine Anonymous.
Twelve-Step group meetings can be found in most countries, although they may
be difcult to nd outside large cities in some countries. There are, however, online
meetings for those who cannot attend live meetings.
There also are 12-Step programs for family members and friends of those with SUDs.
These programs include:
Al-Anon (for adult or older adolescent family members and friends);
Alateen (for older children and younger adolescents);
Alatot (for young children); and
Nar-Anon (for all family members).
Some studies have found 12-Step programs to be an effective program of recovery;
however, other studies have not found signicant effects. Twelve-Step programs are
very difcult to study scientically, because:
They are anonymous, so obtaining a roster of participants is impossible; and
Participation is voluntary, so controlled studies are difcult, if not impossible.
227
Twelve-Step programs are not for everyone. Some people are uncomfortable with
the spiritual aspects of the program. Although AA and NA literature states that
even atheists can use the programs productively, group meetings tend to include
Christian elements like reciting the Lords Prayer. Those who have difculty in group
and social situations may not be able to effectively use a group recovery program.
Additional mutual-help groups have been developed over the years, including
several that build upon the AA and NA model but use other treatment approaches:
Women for Sobriety
Rational Recovery
SMART (Self-Management and Recovery Training) Recovery
Others focus more on specic faith-based or cultural traditions. Because a local
church, temple, synagogue, or spiritual group often hosts them, they also provide
linkage for the participants into a broader support network. Examples are:
Celebrate Recovery;
Millati Islami; and
Native American Wellbriety Movement.
Women for Sobriety is loosely based on rational-emotive-behavioral principles, but
uses certied facilitators to run meetings addressing the unique needs of women in
recovery. They also have Web-based meetings and chat groups.
Rational Recovery is based on the rational-emotive-behavioral approach, but does
not involve group meetings, focusing instead on short-term educational support
to help its members rid themselves of the irrational beliefs that support addiction
without the necessity for a higher power belief.
The SMART program, an off-shoot of RR, is based on a short-term, scientic,
rational-emotive-behavioral approach that addresses:
Motivation;
Urges;
Thoughts;
Feelings;
Behaviors; and
Satisfactions.
The SMART Program does not use sponsors, but does have internet-based groups.
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Celebrate Recovery is one of several Christian-based mutual help groups that have
been established in recent years. Some are based on the AA and NA 12 Steps and
address alcohol and drug abuse. Others, like Celebrate Recovery, are focused on
scriptural teachings that parallel the 12 Steps, but are used to address multiple
problems a participant might bring. They typically include a worship component, but
avoid challenging participants.
The role of the sponsor is replaced by the congregation and the pastor/priest
to provide support for a SUD client in recovery. In the United States, Celebrate
Recovery is accepted as an alternative mutual-help group by most mental health and
drug courts.
Millati Islami is a world-wide fellowship of men and women, joined together on the
Path of Peace. Millati Islami is a religiously specic approach based on spiritual
principles contained in the Quran. Groups integrate the treatment requirements of
both Al-Islam and the 12-step approach to recovery into a simultaneous program
addressing all substances. Participants in groups share experiences, strengths, and
hopes for recovering from active addiction by looking to Allah for guidance on ways
not to be slaves to mind- and mood-altering chemicals and negative people, places,
things, and emotions.
The Native American Wellbriety Movement was created by the White Bison Society,
an organization which has been giving leadership to addressing substance use and
abuse in the American Indian community for several decades.
It was created in response to research documenting the lack of success American
Indians with SUDs have had in non-native treatment and recovery programs. Rooted
in tribal spiritual beliefs and rituals, it incorporates the healthy parts of the principles,
laws, and values of traditional culture. The Wellbriety model has been used both
in AA and NA-type groups and as a public health approach to create sober and
healthy communities, where all individuals work toward being balanced mentally,
emotionally, physically, and spiritually.
There are many other mutual-help groups that address certain populations,
including those with co-occurring mental and medical disorders. However, none of
the programs weve talked about have conducted research that documents their
effectiveness.
SUD treatment counselors should be as familiar as possible with the range of
mutual-help programs so that they can:
Orient clients to what is available;
Encourage clients to try different programs;
Assist clients in selecting a useful support program; and
Advocate for creation of mutual-help groups where they are not available.
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Other Components of Treatment
Weve talked about some basic components of primary treatment: Group and
individual counseling, drug testing, pharmacotherapy, and orientation to mutual-
help programs. In addition to these core services, many programs offer other
components.
Other components offered to those in treatment depend on the type, setting, and
duration of programs, but these additional components can include:
Medical treatmentfor example, a clinic can offer both medical and SUD
treatment services or a hospital-based SUD program can provide a client with all
the medical care he or she needs.
Treatment for mental disordersfor example, some programs can integrate
treatment for both mental and substance use disorders. Others can provide
medication management and intense case management for those with co-
occurring disorders.
General schooling for adolescents or young adultsfor example, a longer term
residential program (like a therapeutic community) can integrate schooling into
the daily schedule.
Other services might include:
Employment skills trainingas with general schooling, a longerterm residential
program can integrate employment skills training into the program.
Child care for group or individual sessionsfor example, some outpatient
programs provide onsite childcare while clients attend treatment sessions. Some
residential programs allow women to bring their children with them to treatment
and provide childcare during treatment sessions.
Transportation to treatment activities and mutual-help group meetingsfor
example, outpatient programs can provide transportation to and from treatment
sessions. Residential programs can provide transportation to mutual-help group
meetings.
Continuing Care
The continuing care process begins with discharge planning. Discharge planning is
nalized as the treatment relationship enters the nal stage with the client, although
it should begin with the initial assessment and treatment planning. Discharge
planning leads to development of a continuing care plan.
A continuing care plan is a documented plan of action developed before discharge
or transfer to another level of care. It is a structured, goal-oriented list of services
developed jointly by the client and the counselor. The plans purpose is to assist in
maintaining the progress a client has made by linking him or her with supportive
resources in the clients environment.
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The plan should incorporate elements of a clients recovery capital, as well as
possible limitations or challenges that will affect the clients ongoing recovery.
Attention should be given to family involvement, nancial constraints, physical
needs, and ongoing therapy needs (for example, treatment for mental disorders or
trauma, family therapy).
The plan contains written, treatment-related, and measurable objectives for the
client to, for example:
Sustain abstinence;
Develop continuing recovery supports; and
Gain community living.
Other objectives would be for the client to:
Gain employment skills;
Gain education;
Obtain gainful employment or attend school; or
Obtain counseling for a co-occurring mental disorder.
The plan should also address ways to achieve less concrete goals, like:
Developing a deeper understanding of self and others;
Increasing responsibility;
Working on resolving family difculties;
Consolidating, reinforcing, and becoming comfortable with the changes in his or
her life; and
Integrating into the community with a meaningful role.
Options include structured continuing care groups (either onsite or by referral).
These groups typically focus on topics such as:
Exploring substance-free social and recreational activities;
Continued work on life skills, such as solving problems;
Relapse prevention training;
Health and wellness;
Education and career planning;
Supportive counseling; and
Leadership skills development.
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Continuing care also includes supports outside structured continuing care groups,
such as:
Mutual-help group attendance;
Individual therapy;
Treatment/medication management for mental disorders;
Methadone maintenance;
Phone therapy or monitoring;
Religious or spiritual institutions;
Cultural traditions and values that support recovery;
Periodic home visits or booster sessions;
Intensive case management monitoring and supports; and
Job training or other schooling.
Some communities also provide transitional living programs in which a client can
gradually become more independent while not having to worry about housing. A
good continuing care plan and program will include a plan for action in response to
a lapse or relapse, including readmission to primary treatment.
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MODULE 7
EVIDENCE-BASED PRACTICES FOR TREATMENT
INTERVENTION
Training goals and learning objectives .................................................... 236
Resource pages ....................................................................................... 341
Summary .................................................................................................. 371
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Participant Manual: Module 7Evidence-Based Practices for Treatment intervention
Activity Time
Presentation: Ways of looking at evidence-based practices 25 minutes
Presentation: Cognitive-behavioral therapy 30 minutes
Small-group exercise: Cognitive-behavioral therapyPart 1, preparation 15 minutes
Lunch 60 minutes
Small-group exercise: Cognitive-behavioral therapyPart 1, preparation
(continued)
10 minutes
Small-group exercise: Cognitive-behavioral therapyPart 2, presentation 25 minutes
Presentation: Motivational approaches 30 minutes
Small-group exercise: Motivational approachesPart 1, preparation 25 minutes
Break 15 minutes
Small-group exercise: Motivational approachesPart 2, presentation 20 minutes
Presentation: Family-based approaches 25 minutes
Exercise: Journal writing 10 minutes
Day 4 wrap-up and evaluation 10 minutes
End of Day 4
Day 5 review and welcome 10 minutes
Small-group exercise: Family-based approaches 45 minutes
Presentation: Therapeutic community 20 minutes
Small-group exercise: Therapeutic communit 45 minutes
Break 15 minutes
Presentation: Contingency management 20 minutes
Small-group exercise: Contingency management 45 minutes
Presentation: Pharmacotherapy for opioid dependence 15 minutes
Small-group exercise: Pharmacotherapy for opiod dependence 45 minutes
Lunch 60 minutes
Small-group discussion: Evidence-based practices 30 minutes
Large-group discussion: Evidence-based practices 15 minutes
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Training goals
To provide an overview of the concept of evidence-based practice;
To provide information about ve evidence-based practices; and
To provide an opportunity for participants to discuss the use of evidence-based
practices in their communities.
Learning objectives
Dene evidence-based practice;
Describe why it is important to know about evidence-based practices;
Identify key components of six specic evidence-based practices; and
Discuss the applicability of these evidence-based practices to their work.
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Participant Manual: Module 7Evidence-Based Practices for Treatment Intervention
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Resource Page 7.1: U.S. National Quality Forum 2007
Consensus Standards for Treatment of Alcohol, Tobacco, and
Drug Use Disorders
1
One of the more ambitious efforts to respond to substandard treatment for substance
use disorders in the United States was the 2007 call for evidence-based practices by the
National Quality Forum (NQF), which provides guidance for 400 organizations in the
United States, including:
Consumer and client groups;
Health care systems and purchasers; and
Research and quality improvement organizations.
With nancial support from the Robert Wood Johnson Foundation, NQF developed
consensus standards for treatment of alcohol, tobacco, and drug use disorders. The
practice standards require evidence-based practices in four areas:
1. Identication of substance use conditions, including:
Systematic screening for alcohol, tobacco, and drug use; and
Diagnosis and assessment for individuals who screen positive.
2. Initiation and engagement in treatment, including:
Brief interventions for excessive alcohol use;
Support for participation in treatment; and
Pharmacotherapy for withdrawal management.
3. Therapeutic interventions to treat substance use disorders, including:
Empirically validated psychosocial treatments; and
Pharmacotherapy for alcohol, tobacco, and drug use.
4. Continuing care management of substance use disorders, including:
Long-term care; and
Ongoing care management and monitoring.
NQF concluded that:
1
National Quality Forum. (2007). National voluntary consensus standards for the treatment of substance use
conditions: Evidence-based treatment practices. Washington, DC: Author.
342
1. Empirically validated psychosocial treatment interventions should be initiated for all
clients with substance use disorders that target:
The cessation or reduction of substance use;
Improved psychological and social functioning;
Prevention of relapse or delayed time to relapse; and
Retention in treatment.
2. Empirically validated approaches for effective substance use disorders treatment
should be implemented and include:
Cognitive-behavioral therapies;
Motivational enhancement therapy:
12-Step facilitation therapy; and
Marital and family therapies.
3. Treatment delivery with an empathic, supportive approach may be as important as
the specic psychosocial technique that is used.
4. Supportive pharmacotherapy, based on systematic assessments of the symptoms
and risk of adverse consequences, should be available and provided to manage
those symptoms and the adverse consequences of withdrawal and include:
Methadone or buprenorphine tapering for opioid withdrawal;
Methadone and buprenorphine for opioid dependence;
Benzodiazepines for managing alcohol withdrawal;
Naltrexone and acamprosate for alcohol dependence;
Nicotine replacement therapy, with bupropion; and
Varenicline for tobacco cessation.
5. Interventions should actively promote involvement with community support and
include:
Family, 12-Step, or other mutual-help groups; and
Spiritual support.
343
1
Powers, E. J., Nishimi, R. Y., Kizer, K. W., Eds. (2005). Evidence-based treatment practices for substance use disorders:
Workshop proceedings (p. ix). Washington, DC: NQF.
NQF also identied several practices that have been shown to be ineffective treatments
for substance use disorders and that should not be routinely included as part of
treatment. These ineffective practices include:
1
The use of acupuncture, relaxation therapy, didactic group education, or biological
monitoring of substance use as a stand-alone treatment;
Detoxication as a stand-alone treatment for dependence;
Individual psychodynamic therapy;
Unstructured group therapy;
Confrontation as a principal approach to treatment; and
Discharge from treatment in response to relapse.
These materials are adapted from the cited document and information found in NQFs
consensus standards document, which can be found at
http://www.qualityforum.org/Publications/2007/09/National_Voluntary_Consensus_
Standards_for_the_Treatment_of_Substance_Use_Conditions__Evidence-Based_
Treatment_Practices.aspx.
344
Resource Page 7.2: Cognitive-Behavioral Therapy
1,2
Overview
CBT merges two treatment modelscognitive therapy and behavioral therapy.
Cognitive therapy, originally developed by Aaron Beck to treat depression, is based
on the theory that people often have beliefs, assumptions, and automatic thoughts
that inuence their behavior but may be unhelpful and unrealistic.
Cognitive therapy proposes that a persons thoughts and interpretations cause
feelings and behaviors.
A core belief in cognitive therapy is that people can improve the way they think (and
feel and act), even if the situation does not change.
Behavioral therapy, rst conceptualized by Ivan Pavlov and rened by B. F. Skinner
and others, treats emotional and behavioral disorders as learned responses that can
be replaced by healthy ones with appropriate training.
Behavioral therapy helps people identify behavior that is not helping them and try
out new ways of behaving.
Behavioral therapy can include a range of relaxation and coping techniques.
CBT is based on the belief that a client can be helped to recognize and discard
learned self-defeating thoughts, emotions, and behaviors that are causing
dysfunction in his or her life.
Although other therapy models attempt to address why an individual does what he
or she does, the questions that are central to CBT are:
What keeps them doing it?
How do they change?
The what question addresses the reinforcers that maintain patterns of thought,
affect, and behavior. The how question relates to building skills.
The CBT approach to treating SUDs focuses on teaching clients skills that help them
recognize and reduce risks of relapse, maintain abstinence, solve problems, and
enhance self-efcacy (a clients ability to recognize his or her strengths and to believe
that change is possible).
1
Beck, A. T. (1976). Cognitive therapy and emotional disorders. New York: International Universities Press.
2
U.S. National Institute on Drug Abuse. (2010). Principles of drug addiction treatment: A research guide: Evidence-
based approaches to drug addiction treatment: Cognitive-behavioral therapy. Retrieved October 17, 2010, from
http://www.nida.nih.gov/podat/Evidence2.html
345
Primary techniques
Specic techniques that help clients address their SUDs include:
Asking questions and teaching clients to ask themselves questions to explore
the relationship of their thinking to their emotional responses. Example: How do
I really know that those people are laughing at me? Are there any other possible
explanations? Could they be laughing about something else?
Exploring the positive and negative consequences of continued substance use;
Teaching clients self-monitoring skills to recognize substance cravings early on
and to identify high-risk situations for use;
Developing strategies for coping with and avoiding high-risk situations that
trigger the desire to use;
Anticipating likely problems that could trigger a slip or relapse;
Developing effective coping strategies (such as a range of relaxation techniques)
for general life challenges that might trigger their SUDs; and
Teaching problem-solving skills.
Homework is a major part of CBT approaches. Clients are given reading
assignments, asked to keep track of certain behaviors and thoughts, and asked to
practice new skills.
CBT also is applied to other challenges in recovery, such as repairing relationships
and coping with emotions.
One specic type of CBT approach is cognitive-behavioral coping-skills therapy,
originally developed for work with clients with alcohol use disorders.
1
Coping skills therapy is a structured, manual-based approach.
Each session of coping skills therapy includes discussion of the rationale, specic
skill guidelines, behavioral rehearsal role plays, and other practice exercises for a
particular topic, including:
Managing thoughts about substances and using;
Solving problems;
Substance refusal skills;
Planning for emergencies and coping with a lapse; and
Seemingly irrelevant decisions.
1
U.S. National Institute on Alcohol Abuse and Alcoholism. (1995). Cognitive-behavioral coping skills therapy manual:
A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH
Monograph Series, Volume 3: Bethesda, MD: Author.
346
Strengths and Challenges
Strengths Challenges
CBT actively engages clients in therapy
and experiential learning.
Clients with poor reading or cognitive
skills may need alternatives to written
assignments.
CBT is suitable for clients from diverse
backgrounds and with varying histories
of alcohol and drug use.
The approach requires specic counselor
training in CBT principles and techniques.
CBT provides structured methods for
understanding relapse triggers and
preparing for relapse situations.
Client motivation is critical because of the
extent of homework assignments.
CBT can help clients with a number of
life situations.
CBT was developed as an individual, not
group, counseling approach.
Extensive homework allows clients to
practice and evaluate new behavior in
their own environments.
347
Resource Page 7.3: Motivational Approaches
1,2
Overview
Motivational approaches (motivational interviewing [MI] and motivational
enhancement therapy [MET]) are based on the perspectives that change occurs in
stages, motivation for change varies over time, and motivation can be enhanced.
Motivational approaches are based on the principles of motivational psychology and
the trans-theoretical model of change, also known as the stages of change model,
which was developed by James Prochaska and Carlos DiClemente and reviewed in
Module 2 (please go back to Resource Page 2.2: Characteristics of Clients in Each of
the Stages of Change to review the stages of change).
Motivational counseling approaches are methods of counseling that are client-
centered and use nondirective methods. These approaches use strategies that:
Acknowledge that substances of abuse have rewarding properties that can
disguise, at least temporarily, their hazards and negative long-term effects;
Help clients resolve ambivalence about engaging in treatment and stopping
substance use;
Use the internal motivation of clients to evoke and sustain rapid change; and
Are not focused on a counselors discovery, interpretation, and guidance.
Motivational approaches operate in the belief that change is created through the
clients will and motivation.
Motivational approaches frequently include other problem-solving or solution-
focused strategies that build on clients past successes.
The counselor acts as a coach or consultant rather than as an authority gure.
Primary techniques
Through empathic listening and skillful interviewing, the motivational counselor
encourages the client to:
Identify discrepancies between signicant life goals and the consequences of SUDs;
Believe in his or her capabilities for change;
Choose among available strategies and options; and
1
Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1994). Motivational enhancement therapy manual:
Monograph Series, Vol. 2. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.
2
National Institute on Drug Abuse. (2010). Principles of drug addiction treatment: A research guideEvidence-based
approaches to drug addiction treatment: Motivational enhancement therapy. Retrieved on October 17, 2010, from
348
Take responsibility for initiating and sustaining healthful personal behavior.
Counselors pose questions to clients in a way that solicits information while
strengthening clients motivation and commitment to positive change.
FRAMES
The FRAMES acronym reminds a motivational counselor of his or her role and
responsibilities during treatment.
The FRAMES approach was originally developed as a brief intervention. The
acronym stands for:
Feedback regarding personal risk or impairment given to a client following
assessment of substance use patterns and associated problems.
Responsibility for change is placed squarely and explicitly on the client (and with
respect for the clients right to make choices for himself or herself).
Advice about changingreducing or stoppingsubstance use is clearly given to
the client by the counselor in a nonjudgmental manner.
Menus of self-directed change options and treatment alternatives are offered to
the client.
Empathic counselingshowing warmth, respect, and understandingis
emphasized.
Self-efcacy or optimistic empowerment is developed in the client to encourage
change.
Decisional Balance Exercises
Decisional balance is the concept of exploring the pros and consor benets and
disadvantagesof change.
People naturally explore the pros and cons of major life choices.
In the context of recovery from substance use, the client weighs the pros and cons of
changing versus not changing substance-using behavior.
The counselor assists this process by asking the client to articulate the good and
less good aspects of using substances and then list them in two columns on a
sheet of paper.
The purpose of exploring the pros and cons of a substance use problem is to tip the
scales toward a decision for positive change.
The actual number of reasons a client lists on each side of a decisional balance sheet
is not as important as the weightor personal valueof each one. For example, a
20-year-old might not put as much weight on losing a girlfriend as would an older,
engaged man who wants a family. The 20-year-old might be very concerned, though,
about being kicked off his soccer team for missing too many practices.
349
Identifying Discrepancies
One way to enhance motivation for change is to help clients recognize a discrepancy
or gap between their future goals and their current behavior.
The counselor might clarify this discrepancy by asking, How does your drinking t in
with having a happy family and a stable job?
When an individual sees that present actions conict with important personal goals
such as health, success, or family happiness, change is more likely to occur.
Pacing
Every client moves through the stages of change at his or her own pace.
The concept of pacing requires that a counselor meet a client at the clients level and
use as much or as little time as is necessary with the essential tasks of each stage of
change.
For example, some clients may need frequent sessions at the beginning of
treatment and fewer later.
If a counselor pushes a client at a faster pace than the client is ready to take, the
relationship between counselor and client may break down.
Personal Contact With Clients Not in Treatment
Motivational interventions can include simple activities designed to enhance
continuity of contact between counselor and client and strengthen the relationship.
Activities can include personal handwritten letters or telephone calls from counselor
to client.
Research has shown that these simple motivation-enhancing interventions are
effective for encouraging clients to return for another clinical consultation, to return
to treatment following a missed appointment, to stay involved in treatment, and to
increase treatment adherence.
Motivational Interviewing
Motivational Interviewing (MI) is a counseling technique or style that focuses on
creating a favorable climate for change.
The essence of motivational interviewing is in its collaborative nature,
communicating in a partner-like relationship, where the interviewer seeks to create a
positive interpersonal atmosphere.
There are ve primary principles in MI. These are not steps, but concepts to be
applied at all times to enhance the relationship between the counselor and the
client. They are often summarized by the acronym READS:
350
Roll with resistance;
Express empathy;
Avoid argument;
Develop discrepancy; and
Support self-efcacy.
To carry out these ve principles, there are four basic therapeutic skills or methods
an SUD counselor uses in motivational interviewing:
Reective listening or responding to a clients statement by stating back to her or
him the essence or a specic aspect of what was said;
Asking open-ended questions;
Afrming; and
Summarizing.
Motivational Enhancement Therapy
Motivational enhancement therapy is another of the motivational approaches that
researchers have documented as being effective. MET seeks to help clients:
Create their own motivation for change; and
Consolidate a personal decision and plan for change.
This approach is also primarily client-centered, but counseling sessions are planned
and directed by the counselor.
In SUD treatment, MET counselors seek to alter the harmful use of drugs and
alcohol. Because each client sets his or her own goals:
No absolute goal is imposed by a counselor using MET.
MET counselors may advise specic goals, such as complete abstinence.
A broader range of life goals, such as nding a job or reuniting with family
members, may be explored as well.
In MET problems are viewed as behaviors at least partially under the voluntary
control of the client. Thus, they follow the normal principles of behavior change.
Motivational Enhancement Therapy is based on principles of cognitive and social
psychology. The MET counselor:
Seeks to help the client perceive a discrepancy between current behavior and
signicant personal goals; and
351
Emphasizes the clients self-motivational statements regarding both the desire for
and the commitment to change.
The MET counselor works from the assumption that internal motivation is not only a
necessary but often the only factor needed to create change.
MI and MET are client-centered and
relevant to clients personal interests.
MI and MET rely heavily on clients
capabilities and level of self-awareness.
MI and MET focus on realistic, attainable
goals.
Commonly used problem-oriented
assessment instruments are incompatible
with a motivational approach.
MI and MET encourage client self-
efcacy and self-sufciency.
Motivational approaches require signicant
staff training and ongoing supervision.
MI and MET emphasize positive,
empathic support that does not
undermine or elicit anger from clients.
Motivational approaches may be difcult
to combine with approaches that expect
adherence to program-imposed goals.
MI and other motivational approaches
were developed as individual approaches;
their effectiveness for use with groups is
unproved.
352
Resource Page 7.4: Family-Based Approaches
1,2,3,4,5,6
Overview
Although simple family involvement is not a specic model of treatment, research
shows that family involvement in treatment enhances outcomes.
Most programs offer family education, family support groups, and family counseling
as part of their approach. Some programs, particularly those focusing on adolescent,
may primarily use a family-systems therapy approach.
Family-based services ensure that family functioning adjusts to and positively
inuences the recovery of the client.
One main goal of involving families in treatment is to increase family members
understanding of the clients substance use disorder as a chronic disease.
Family-based services can:
Increase family support for the clients recovery. Family sessions can increase a
clients motivation for recovery, especially as the family realizes that the clients
substance use disorder is intertwined with problems in the family.
Identify and support a change of family patterns that works against recovery.
Relationship patterns among family members can work against recovery by
supporting the clients substance use, family conicts, and inappropriate coalitions.
Prepare family members for what to expect in early recovery. Family members
unrealistically may expect all problems to dissipate quickly, increasing the
likelihood of disappointment and decreasing the likelihood of helpful support for
the clients recovery.
Educate the family about relapse warning signs. Family members who
understand warning signs can help prevent the clients relapses.
Help family members understand the causes and effects of substance use
disorders from a family perspective.
1
U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide, 2nd
Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.
2
Edwards, J. T. (1990). Treating chemically dependent families: A practical systems approach for professionals.
Minneapolis, MN: Johnson Institute.
3
U.S. National Registry of Evidence-based Practices and Programs. (2011) Multidimensional family therapy. Rockville,
Maryland: SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/ViewIntervention.aspx?id=16
4
U.S. National Registry of Evidence-based Practices and Programs. (2011) Behavioral couples therapy for alcoholism
and drug abuse. Rockville, Maryland: SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/
ViewIntervention.aspx?id=134
5
U.S. National Registry of Evidence-based Practices and Programs. Multisystemic therapy (MST) for juvenile offenders.
(2007). Rockville, Maryland: SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/ViewIntervention.
aspx?id=26
6
Edwards, J. T. (1990). Treating chemically dependent families: A practical systems approach for professionals.
Minneapolis, MN: Johnson Institute.
353
Take advantage of family strengths. Family members who demonstrate positive
attitudes and supportive behaviors encourage the clients recovery. It is important
to identify and build on strengths to support positive change.
Encourage family members to obtain long-term support. As the client begins to
recover, family members need to take responsibility for their emotional, physical,
and spiritual recovery.
While families can be critical to the success of a client with SUDs, some family
members may actually need treatment themselves before they can be such a helpful
resource for clients. Many clients are from families that are particularly chaotic and
dysfunctional or have multi-generational substance use disorders, mental disorders,
and other problems.
Primary techniques
Several specic family approaches are considered EBPs for treating SUDs:
Behavioral couples therapy (BCT);
Multisystemic therapy (MST) for adolescents; and
Multidimensional family therapy (MDFT) for adolescents.
Behavioral Couples Therapy (BCT)
BCT is based on the assumptions that:
Intimate partners can reward abstinence; and
Reducing relationship distress lessens risk for relapse.
The spouse or partner gains an active role in the treatment, minimizing the sense of
helplessness that often comes with living with a person with an SUD.
Program components include:
A recovery or abstinence contract between the partners and the therapist;
Activities and assignments designed to increase positive feelings, shared
activities, and constructive communication; and
Relapse prevention planning.
Partners generally attend 15 to 20 hour-long sessions over 5 to 6 months. Sessions
follow a particular sequence:
The therapist asks about any substance use since the last session;
The couple discusses compliance with the recovery contract;
The couple presents and discusses homework assigned at the last session;
354
The couple discusses any relationship problems since the last session;
The therapist presents new material; and
The therapist assigns new homework.
BCT is typically used as an adjunct to other SUD treatment approaches.
Multisystemic Therapy (MST)
MST is an intensive, in- home and in-community approach that focuses on changing
the thinking and behavior of both parents and adolescents.
Traveling to the family overcomes the high dropout rates of other treatments,
which often occur because of the difculty caregivers face in getting adolescents to
appointments.
The approach primarily uses cognitive-behavioral and social-development (risk and
protective factors) strategies.
MST focuses on a familys strengths to facilitate positive change.
Interventions are designed to promote responsible behavior and decrease
irresponsible actions by family members.
Interventions focus on the present: what is happening currently in the adolescents
life. Counselors look for action that can be taken immediately, targeting specic,
well-dened problems rather than gaining insight or focusing on the past.
Interventions target sequences of behavior within and between the various
interacting elements of the adolescents lifefamily, teachers, friends, home, school,
and communitythat sustain the identied problems.
A key developmental emphasis is on building the adolescents ability to get along
well with peers and acquire academic and vocational skills that will promote a
successful transition to adulthood.
MST counselors do not label families as resistant, not ready for change, or
unmotivated; their approach avoids blaming the family but rather places the
responsibility for positive treatment outcomes on the MST team.
Interventions are designed to empower caregivers to address the familys needs
after treatment ends. The caregiver is seen as the key to long-term success.
Multidimensional Family Therapy (MDFT)
MDFT views adolescent drug use in terms of a network of inuences (individual,
family, peer, community) and suggests that reducing unwanted behavior and
increasing desirable behavior occur in multiple ways in different settings.
Treatment includes individual and family sessions held in a treatment center, in the
home, or with family members at schools, courts, or other community locations.
355
During individual sessions, the therapist and adolescent work on important
developmental tasks, such as developing decision-making, negotiation, and
problem-solving skills.
Adolescents acquire vocational skills and skills in communicating their thoughts and
feelings to deal better with life stressors.
Parallel sessions are held with family members. Parents examine their particular
parenting styles, learning to distinguish inuence from control and to have a positive
and developmentally appropriate inuence on their children.
Family involvement in substance abuse
treatment is positively associated with
increased treatment engagement,
decreased dropout rates during
treatment, and better long-term
outcomes.
Engaging families in treatment can be
difcult because of the stigma and shame
associated with substance use.
When families are involved in treatment,
the focus can be on the larger family
issues, not just the substance use. Both
the individual with the substance use
disorder and the family members get the
help they need to achieve and maintain
abstinence.
Staff needs specic training in family
therapy to use the family approaches as the
primary means of treatment. Such training
can be time-consuming and expensive.
Family approaches capitalize on family
strengths, mobilizing ongoing support
for the clients and the familys recovery.
Families may be too dysfunctional (or
involved with substance abuse themselves)
to benet from treatment program
services. Programs need to have a well-
developed referral network of sources for
more intensive therapy when necessary.
Some family approaches are highly
intensive and require signicant staff
resources.
356
Resource Page 7.5: Therapeutic Community
1,2,3
Overview
The therapeutic community (TC) is an intensive, primarily long-term (up to 1 year)
residential model.
TCs use an approach known as community as method; this approach views the
community as a wholeits social organization, its staff and clients, and its daily
activitiesas the therapeutic agent.
This community-as-method philosophy and a distinct therapeutic structure dene TCs.
In fact, researchers have documented that restoring warm interpersonal relationships
reverses the damaging changes produced on brain formation, function, and
structure by neglect and abuse during childhood. Within the TC, each participant
has a well-recognized role, is considered with love and respect, and is part of a new
familyall of which lls the affective gaps that may have been created during his or
her destructive personal history.
4

The humanity of caregivers, the warm and friendly relationships with the peers in the
full-time environment of a TC are the real therapeutic engines for the changes that
happen with clients in this setting.
Because of their intense, long-term nature, TCs are particularly appropriate for
clients who have histories of severe substance use disorders and criminal behavior.
TCs feature a structured day that includes ordered, routine activities to counter
the characteristically disordered lives of clients and to distract them from negative
thinking and boredom.
The TC model is used in countries around the world, and every continent (except
Antarctica) has professional associations of TCs.
The Asian Federation of Therapeutic Communities (http://www.asianfedtc.org/
about.html) has 13 member countries.
Primary techniques
TCs center daily activities on group sessions and hierarchical job functions that teach
participants specic behaviors and skills.
1
National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide, 2nd Ed.
NIH Publication No. 09-4180. Bethesda, Maryland: Author.
2
National Institute on Drug Abuse (2002). Research report seriesTherapeutic community: What is a therapeutic
community. Bethesda, Maryland: Author. Retrieved August 29, 2011 from http://www.nida.nih.gov/PDF/RRTherapeutic.pdf
3
De Leon, G. (2000). The therapeutic community: Theory, model, and method. New York: Springer Publishing Company.
4
Personal communication: Gilberto Gerra, M.D., Chief , Drug Prevention and Health Branch, United Nations Ofce for
Drug Control.
357
The TC model can be, and often is, modied to t cultural perspectives, but
generally includes the following components:
A sense of community. Community is created partly by a separation from other
organizational or institutional programs and, more important, from the drug-
using environment. A TC facility contains communal space for promoting a sense
of commonality during collective activities. Treatment or educational services are
delivered within the peer community.
Peers and staff members as role models. TC members and staff members serve
as positive role models by demonstrating expected behaviors and reecting the
values and teachings of the community. The strength of the community for social
learning rests on the number and quality of its positive role models.
Work as therapy and education. Consistent with the TCs self-help approach, all
clients are responsible for the daily management of the facility, and work roles are
designed to bring about essential educational and therapeutic effects.
Awareness and emotional growth training. Groups can heighten clients
awareness of specic attitudes or behavioral patterns that need to change and
help them identify feelings and express them appropriately and constructively.
A therapeutic community might organize a clients treatment in four stages:
Introduction stage: The introductory program would be divided into specic
modules of treatment focused on helping the client accept responsibility for his
or her SUD behaviors and their consequences. Participants would take part in
group and individual counseling sessions and attend educational seminars. At
the completion of this stage, clients would move to the more focused treatment
phase of the programor might request a referral to another organization.
Treatment stage: In the treatment stage clients would live and work in the small
community situation and, with the support and encouragement of staff and
their peers, help one another develop constructive life-coping skills. The social
structure would be a simple hierarchy of positions with degrees of responsibility.
Activities would center on a normal lifestyle of daily work projects and leisure
pursuits, which would be supported by the creative therapy program. Attendance
at outside support meetings would also be initiated during this time.
Commitment stage: Commitment is the link between treatment and the
start of the community reintegration phase. During this phase, clients would
begin to take their place back in society. Emphasis would be placed on career
development, social relationships, and practical living skills. The program would
provide clients with a supportive and gradual community reentrymoving
through voluntary work into full-time employment or education. As clients move
from the protected environment of the therapeutic community into a transition
house and then into their own accommodation in the general community, weekly
support groups and counseling sessions would be held with staff. Clients would
358
also receive additional support from peers who have successfully negotiated this
process. Attendance at Narcotics Anonymous or other similar support groups
would also continue during this stage of the program.
Transition/aftercare stage: Some therapeutic communities insist that no
resident can leave the program without a full-time job, a place to live, and a
support network. Family reconciliation would also be incorporated into reentry.
Maintaining a drug-free lifestyle would means learning more coping skills, so
this part of the transition process could take many months. One of the supports
most commonly identied as essential to resident success once they leave the
therapeutic community is transitional housing (a half way house) and affordable
longer term housing. This is a major obstacle in many places because of a lack of
good basic accommodations.
The TC approach is effective for
people with long histories of substance
dependence and antisocial behavior.
The approach may be too socially intense
for some clients.
The TC approach is particularly effective
in teaching clients how to plan, set, and
achieve goals and to be accountable.
Effective TC treatment requires extensive
staff training.
The TC approach is effective in reducing
recidivism among clients who have
served time in prison.
Finding an effective mix of professional
clinicians and recovering staff (who may
not be trained in assessment, treatment
planning, and counseling) can take time.
359
Resource Page 7.6: Contingency Management
1,2,3
Overview
Contingency management (CM) is based on operant conditioning theory and was
developed out of applied behavioral analysis and behavior therapy.
Its roots are grounded in the 1950s work that students of B. F. Skinner did when
they applied operant conditioning principles to the treatment of serious conditions
(for example, those with schizophrenia, juvenile justice populations) using token
economies (see below).
Operant conditioning theory maintains that future behavior is based on the positive
or negative consequences of past behavior.
For example, drug use is maintained by the positively reinforcing effects of the drug
itself or by the negative reinforcement of relieving the pain of withdrawal.
The use of contingency management is based on the premise that the pull of
dependence and its immediate rewards are very strong for clients with substance
use disorders.
The process of becoming abstinent has its own eventual rewards, such as:
Healthier lifestyle;
Employment;
Educational opportunities; and
Maintaining positive relationships.
However, it typically takes a long time before internal rewards are experienced by a
client attempting to make such signicant behavioral changes.
So, abstinence in and of itself, may not be sufciently reinforcing to maintain a
persons motivation to stop using drugs, particularly in early abstinence. Other
rewards must be found that reinforce ongoing abstinence and lifestyle change.
CM motivates clients behavioral change and reinforces abstinence by systematically
rewarding desirable behaviors and ignoring or punishing others.
1
U.S. National Institute on Drug Abuse. (2010). Principles of drug addiction treatment: A research guideEvidence-
based approaches to drug addiction treatment: Contingency management interventions/motivational incentives.
Retrieved September 16, 2011, from http://www.nida.nih.gov/podat/Evidence2.html
2
U.S. National Addiction Technology Transfer Center. (2010). Successful treatment outcomes using motivational
incentives. Retrieved September 16, 2011, from http://www.nattc.org/pami/PPT/PAMI_PolicyMakers.ppt
3
Meyers, R. J., & Squires, D. D. (n.d.). The community reinforcement approach: A guideline developed for the
Behavioral Health Recovery Management Project. Albuquerque, NM: University of New Mexico Center on
Alcoholism, Substance Abuse, and Addictions. Retrieved September 16, 2011 from
360
Reinforcers are typically positive, pleasurable, and rewarding events or objects, but
some negative reinforcers also are effective.
Removing a ne or restriction after a client has complied with a specied regimen is
an example of negative reinforcement.
Primary techniques
There are numerous forms of contingency management, each with its own unique
techniques. However, each form is grounded in a set of guiding principles for
contingency management:
Identify a behavior to target that is clearly observable and measurable. For
example, if targeting abstinence as a behavior, onsite drug testing can measure
drug use; a clients self-report is not enough. Similarly, if work activity is the target
behavior, it is not enough to ask clients about their attendance or productivity.
Objective, veriable measures that demonstrate accomplishments must be used.
Attendance and compliance with program rules are easy behaviors to measure.
Select a desired behavior change that contributes to treatment goals. Simply
attending counseling sessions may not affect a persons drug use.
Reward small changes. For example, expecting clients who have never submitted
a drug-free urine sample to achieve immediate abstinence may be optimistic.
Abstinence from a specic substance might precede abstinence from all
substances.
Because incentives that are perceived as desirable by clients are likely to have a
much greater impact on behavior than those that are perceived as being of less
value or use, it is important to choose rewards that would be important to the
clients by asking them which rewards would be most desirable. Something that is
rewarding for one client may not be for another.
Reward the targeted behavior as immediately as possible.
Provide frequent reinforcers. More frequent reinforcers, even if small, have a
greater effect than larger, more remote rewards or punishments.
Deliver all rewards as promised, so the treatment remains credible.
Use an escalating series of rewards (bigger and better rewards to reinforce
bigger and longer lasting behavior change) to provide a greater incentive for
sustaining the desired behavior.
Several basic types of incentive programs have been researched:
Contingent access to clinic privileges: In a clinical setting, clients are allowed to
use privileges that already exist within that setting; level systems are designed
such that once a level is achieved, the client immediately earns all the privileges
for that level and the levels lower than it.
361
Onsite prize distribution: Tangible or material goods are distributed when
a desired behavior is exhibited, based on how long the behavior has been
exhibited.
Vouchers or some other token economy systems: Points or vouchers, which can
be redeemed for goods or privileges, are given for consistently engaging in
specic activities or for meeting specic treatment plan goals.
Refunds or rebate: Clients pay a fee on entering treatment, but they receive a
refund if they complete treatment and remain abstinent.
A challenge of contingency management programs is to identify a reward for a desired
behavior that is both practical and sufciently powerfulover timeto replace or
substitute for the potent, pleasurable, or pain-reducing effects of the drug. The reward
also must be available without too much cost or expenditure of staff energy.
Community Reinforcement
One type of contingency management, community reinforcement (CR), uses social,
recreational, familial, and vocational reinforcers rather than material rewards or
within-program privileges to make an abstinent lifestyle more rewarding than
substance use.
CR is based on the premise that environmental contingencies can be highly effective
in changing substance use behavior. A strong case management component is
essential to using the CR approach.
One form of CR, community reinforcement approach plus vouchers, has been
documented as an EBP. The original model was an intensive 24-week outpatient
therapy for treatment of cocaine and alcohol addiction. There were two primary
treatment goals:
To maintain abstinence long enough for clients to learn new life skills to sustain
that sobriety; and
To reduce alcohol consumption for clients whose drinking is associated with
cocaine use.
In this program, clients attended one or two individual counseling sessions each
week focusing on:
Improving family relationships;
Learning a variety of skills necessary for reducing drug and alcohol use;
Receiving vocational counseling; and
Developing new recreational activities and social networks.
Vouchers were also provided for cocaine-negative test samples, and increased in
value for each consecutive clean sample. The vouchers could be exchanged for retail
goods consistent with a cocaine-free lifestyle.
362
This specic CM approach was found to facilitate:
Clients engagement in treatment; and
Systematically gain increasing periods of cocaine abstinence.
CM has been shown to increase treatment
adherence and reduce drug use
signicantly when incentives are used.
Clients may return to baseline drug use
rates when incentives are terminated.
CR and CM can be combined readily
with other psychosocial interventions and
pharmacotherapies.
CM approaches can be labor intensive,
require specialized staff or training for
implementation, and require frequent
client attendance.
CM can be implemented with a variety
of low-cost incentives such as donated
goods or services.
For maximal effectiveness, rewards must
be sufciently largeand increase in
valueto have continuing appeal to
clients.
CR and CM have extensive and robust
scientic support in both laboratory and
clinical studies.
Many research studies demonstrating CR
and CM effectiveness have used small
samples and incurred large costs for
incentives.
Because CR uses environmental
reinforcers, the effects continue after
the structured program is completed,
becoming integrated into the clients
everyday life.
Resources required for implementing CR
and CM (for example, onsite urine-testing
capabilities or alternatives to costly
incentives) may be unavailable.
363
Resource Page 7.7: Pharmacotherapy
1,2
Overview
Pharmacotherapy can be briey dened as the use of medically prescribed
psychoactive substances to treat psychiatric and behavioral conditions. It is also
known as medication-assisted treatment (MAT).
Pharmacotherapy is used in a number of ways:
To replace a psychoactive substance, either short or long term;
To discourage use of a substance by reducing its reinforcing properties or by
creating negative effects when the substance is used; and
To aid early recovery by reducing cravings or counteracting some of the longer
term symptoms of withdrawal.
Medications are available for treating dependence on alcohol, opioids, and nicotine.
These medications generally need to be prescribed by a medical practitioner,
though medications for nicotine dependence are available without a prescription.
One of the widest used and best known forms of pharmacotherapy is methadone
maintenance therapy for opioid dependence.
services, not in place of them.
Primary applications of pharmacotherapy
Treatment that includes medication is often the best choice for opioid addiction.
MAT uses one of three medicationsnaltrexone, buprenorphine, or methadoneto
treat addiction to heroin or other opioid drugs.
Naltrexone blocks all the effects of opioids, preventing a person from getting high.
To prevent immediate and severe opioid withdrawal symptoms, a person must be
medically detoxied and opioid free for several days before beginning naltrexone.
Client compliance with naltrexone therapy is often a problem, and naltrexone has
seldom been used. The newer injectable form of naltrexone (Vivitrol
) was recently
approved in the United States for use with opioid dependence, which may increase
its use.
1
World Health Organization. (2009). Guidelines for the psychosocially assisted pharmacological treatment of opioid
dependence. Geneva: Author.
2
Center for Substance Abuse Treatment. (2005). Medication-Assisted Treatment for Opioid Addiction in Opioid
Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048.
Rockville, MD: U.S. Department of Health and Human Services.
364
Buprenorphine (Subutex
) reduces or eliminates withdrawal symptoms associated

with opioid dependence but, at proper doses, does not produce the euphoria and
sedation caused by heroin or other opioids.
At high doses, buprenorphine can produce euphoria, so is often combined
with naloxone, a medication that blocks these effects, into a formulation called
Suboxone
to avoid this potential problem.

Methadone is the best know and most widely used medication for opioid treatment.
Methadone may be used short term, as an aid to withdrawal, or over a long period
(maintenance or substitution therapy).
Methadone is on the WHOs list of essential medications.
Maintenance treatment is usually conducted in specialized settings (for example,
methadone maintenance clinics).
In some countries, clients who are stabilized on methadone and have participated in
counseling services are allowed to receive take-home doses for a few days or a week
at a time.
At the right dose, methadone:
Prevents opioid withdrawal;
Blocks the euphoric effects of illicit opioid use; and
Decreases opioid craving.
Clients stabilized on adequate, sustained dosages of methadone can function
normally. By taking methadone and stopping or decreasing their injection drug use,
clients can:
Work;
Take care of their families;
Avoid the crime and violence of the street culture; and
Reduce their exposure to HIV.
365
Strengths and Challenges (pharmacotherapy for opioid dependence)
Clients stabilized on adequate,
sustained dosages of methadone
can function normally and become
contributing members of society.
Methadone must be prescribed and
monitored carefully by medical personnel.
Clients may come to the program for
methadone but stay for the counseling,
enhancing overall recovery.
In some places in the world, methadone
maintenance is not available or even legal.
Implementing such a program could take
many years of advocacy and education on a
policy level.
Pharmacotherapy can help clients
avoid exposure to HIV and other
infectious diseases.
Some clients will need to take methadone
for life, thus requiring consistent, long-term
monitoring and care.
Serious attention must be paid to security to
avoid theft and diversion of methadone to
the street.
366
Resource Page 7.8: Twelve-Step Facilitation Therapy
1
Overview
Twelve-Step Facilitation Therapy is based on the concepts of 12-Step mutual-help
groups, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and
Cocaine Anonymous (CA).
The steps of these programs focus on:
Admitting there is a problem;
Seeking help;
Engaging in a thorough self-examination;
Making a condential self-disclosure;
Making amends for harm done; and
Helping others who want to recover.
Twelve-Step Facilitation Therapy focuses on helping clients understand AA/NA
principles, start working through the 12 steps of recovery, learn about and accept
their addiction, achieve abstinence, and become involved in community-based 12-
Step groups.
Group work focuses on accepting the disease, assuming responsibility for the
recovery process and ones actions, renewing hope, establishing trust, changing
behavior, practicing self-disclosure, developing insights into ones behavior, and
making amends.
Clients are encouraged strongly to:
Accept their addiction;
Develop or adopt spiritual values;
Develop a sense of fellowship with others in recovery; and
Attend meetings in the community.
Primary techniques
Twelve-Step Facilitation Therapy is manual-guided and time-limited; it is implemented
with individual clients over 12 to 15 sessions spread over approximately 12 weeks. The
initial assessment session runs 11/2 hours, and regular sessions last 1 hour.
1
U.S. National Registry of Evidence-based Programs and Practices. (2010). Twelve-step facilitation therapy. Retrieved
on September 1, 2011 from http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=55
367
The assessment session within the model has both informational and motivational
goals. These goals include:
Establishing client-facilitator rapport;
Conducting a collaborative assessment of drug abuse (history);
Discussing the clients efforts to stop or control use;
Discussing negative consequences associated with use;
Sharing a diagnosis with the client and attempting to have it be a collaborative
decision;
Outlining the program; and
Attempting to get a commitment from the client to give the program and AA/NA
a try and to keep an open mind.
Each regular session begins with a 10-minute discussion of the clients recovery
week, including:
Any use that occurred;
Any urges to use that the client experienced;
Reactions to recovery tasks and other specic suggestions made at the end of
the last session;
Reactions to meetings attended; and
Overall progress in getting active in AA or NA.
Since the program is based on the principles of 12-Step fellowships, the counselor
must work within this framework. For example, participation in self-help groups is
central and is regarded as the primary agent of change. Specic objectives include:
Attending 90 AA or NA meetings in 90 days;
Getting and using members phone numbers;
Getting a sponsor; and
Assuming responsibilities within a meeting.
The Twelve-Step Facilitation Therapy manual can be ordered from the U.S. National
Institute on Alcohol and Alcoholism ($6.00 per copy) at http://pubs.niaaa.nih.gov/
publications/match.htm#ordering
368
Twelve-Step Facilitation Therapy
emphasizes an array of recovery tasks in
cognitive, spiritual, and health realms.
It can be difcult to monitor accurately
clients compliance with assigned step
tasks, including meeting attendance.
Research has found that the 12-step
approach can be effective with clients
from diverse backgrounds.
12-Step groups emphasis on a higher
power may be unacceptable to some
clients.
Although 12-Step programs are available
throughout the world, meetings are
not always available in a particular area
(especially rural areas).
369
Resource Page 7.9: Matrix Model
1,2
Overview
The Matrix model was developed during the 1980s as an effective way to treat
people dependent on stimulant drugs, particularly cocaine and methamphetamine.
The model has been modied to include treatment for people who use other
drugs, including heroin, although research has not yet been done to evaluate the
effectiveness of this approach with groups other than stimulant users.
Matrix is a manual-based program. The manual materials, including handouts
for clients that form the basis of therapeutic sessions, were selected through
a behavioral analysis of the type of problems encountered by cocaine and
methamphetamine users as they proceeded through periods of cocaine abstinence.
The Matrix model integrates several research-based techniques (including cognitive-
behavioral, motivational enhancement, education, and family approaches) to target
clients behavioral, emotional, cognitive, and relationship issues.
The Matrix approach includes:
Establishing a strong therapeutic relationship between the client and counselor;
Teaching clients how to structure time and live an orderly and healthful lifestyle;
Providing accurate, understandable information about addiction;
Providing opportunities to learn and practice relapse prevention and coping
techniques;
Involving family and signicant others in the therapeutic and educational
processes to gain their support forand prevent their sabotage oftreatment;
Encouraging clients to participate in community-based support groups; and
Conducting random urinalyses or breath tests to assess treatment effectiveness.
Primary techniques
Detailed treatment manuals contain worksheets for individual sessions; other
components include family education groups, early recovery skills groups,
relapse prevention groups, combined sessions, urine drug tests, 12-Step program
attendance, relapse analysis, and social support groups.
1
Rawson, R. A., Marinelli-Casey, P., Anglin, M. D., Dickow, A., Frazier, Y., Gallagher, C., et al. (2004). A multi-site
comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction, 99(6), 708717.
2
Obert, J. L., London, E. D., & Rawson, R. A. (2002). Incorporating brain research ndings into standard treatment: An
example using the Matrix model. Journal of Substance Abuse Treatment, 23(2), 107113.
370
The elements of the Matrix treatment approach are a collection of group sessions
(early recovery skills, relapse prevention, family education, and social support) and
3 to 10 individual sessions delivered over a 16-week intensive treatment period.
Specically during those 16 weeks, the Matrix model requires:
Three individual/conjoint family sessions;
Eight early recovery skills group sessions;
Thirty-two relapse prevention group sessions;
Twelve family education group sessions; and
Thirty-six social support group sessions.
Clients can begin attending social support groups, which focus on continuing
care, once they have completed the 12-session family education group but are still
attending the relapse prevention group sessions. The Matrix program has found
that overlapping the social support group attendance with the intensive phase of
treatment helps ensure a smooth transition to the 36-week continuing care phase.
Free Matrix Model treatment manuals can be downloaded from: http://www.kap.
samhsa.gov/products/manuals/matrix/index.htm
The model integrates a cognitive-
behavioral approach with family
involvement, psychosocial education, 12-
Step support, and urine testing.
Some materials may need to be
modied for clients whose cognitive
functioning is impaired.
The Matrix manuals provide step-by-step
descriptions to explain how sessions should
be conducted and provide handouts and
all other necessary materials.
Specic staff training and supervision are
highly recommended and may be costly.
The model has been used extensively with
people dependent on stimulants and has
been shown to be effective.
The highly structured content may not
appeal to all clients.
The tight structure and schedule may
not leave enough time for effective case
management.
371
Module 7: Evidence-Based Practices for Treatment
intervention, Summary
Treatment for substance use disorders (SUDs) has steadily evolved over time. Our
understanding of SUDs has increased tremendously thanks to improved brain scan
imaging and other research techniques. Research on treatment also has become
more rigorous and science based, and we now have a better understanding of what
works in treatment.
This doesnt mean one approach will show the same results for every person. It
does, however, mean that we now have a much better understanding of a range of
possible approaches that are most likely to be helpful. We call these approaches
evidence-based practices (EBPs).
Denition of Evidence-Based Practices
One basic denition of evidence-based practices (EBPs) is practices for which
the evidence is strongest and most acceptedand that are most likely to have
signicant impact on improving care.
1
The phrase improving care is critical. For example, a study conducted by the
U.S. Institute of Medicine (IOM)1 found that in the United States substandard
treatment was especially common among individuals with SUDs. The study dened
substandard treatment as treatment that was not:
Safe;
Effective;
Patient-centered;
Timely;
Efcient; or
Equitable (fair).
For example, IOM found that only 10 percent of patients identied with an
alcohol use disorder received recommended care, resulting in increased illness
and mortality. This nding was related to a lack of sufcient services, as well as to
substandard care.
Another aspect of the denition is the term practices. Although EBPs are usually
derived from counseling theories, like behavioral theory, for example, they are more
a set of techniques and approaches. These techniques and approaches may include
elements from several counseling theories.
1
U.S. National Quality Forum. (2007). National voluntary consensus standards for the treatment of substance use
conditions: Evidence-based treatment practices (abridged version). p. v. Washington, DC: Author.
372
In response to the ndings of the IOM study, the Institute made 10
recommendations for better care. These recommendations included the use of
evidence-based decision-making in treatment for mental health and substance use
conditions. The Institute expanded the evidence-based concept to include a
combination of:
Science;
Clinical and nancial feasibility; and
Clinical expertise.
The science part of evidence-based includes the concept of empirically validated
evidence, meaning evidence that is based on information gained through:
Direct observation;
Experience; or
Experiment.
Clinical and nancial feasibility means that the practice is reasonable, achievable,
and economically possible to implement in a real-life treatment situation, not just in
a research setting.
Clinical expertise means that the counselors implementing the practice:
Have basic counseling skills;
Can connect with clients; and
Have been trained in the use of the specic practice.
What We Know About EBPs
EBPs have been shown to improve treatment outcomes. International organizations
have called for the increased use of EBPs to improve treatment globally. For
example, in 2008, the World Health Organization (WHO), in coordination with the
United Nations Ofce on Drugs and Crime (UNODC), issued a discussion paper
titled Principles of Drug Dependence Treatment.
1
The discussion paper emphasized, Evidence-based good practice and accumulated
scientic knowledge on the nature of drug dependence should guide interventions
and investments in drug dependency treatment. The high quality of standards
required for approval of pharmacological or psychosocial interventions in all the
other medical disciplines should be applied to the eld of drug dependence.(p. 9)
1
WHO and UNODC. (2008). Principles of drug dependence treatment: Discussion paper. Retrieved September
1, 2010, from http://www.unodc.org/documents/eastasiaandpacic//china/UNODC-WHO-Principles-of-Drug-
Dependence-Treatment.pdf
373
In 2007, the U.S. National Quality Forum (NQF) developed Consensus Standards for
Treatment of Alcohol, Tobacco, and Drug Use Disorders to advocate for improving
treatment for SUDs in the United States.
1
NQF concluded that certain empirically
validated treatment practices should be used with all clients with SUDs. These
include:
Pharmacotherapy (the use of medications to treat SUDs);
Cognitive-behavioral therapies;
Motivational enhancement therapy;
12-Step facilitation therapy; and
Marital and family therapies.
NQF also identied a number of practices that have been shown to be ineffective
treatments for SUDs and that should not be routinely used. These ineffective
treatments include the use of acupuncture, relaxation therapy, education, drug
testing, and detoxication as stand-alone treatments.
The phrase stand-alone treatment is important to note; the report does not state
that these practices do not have a place in treatment, just that they are insufcient
treatment in and of themselves.
Other treatment approaches noted as ineffective include:
Individual psychodynamic therapy;
Unstructured group therapy;
Confrontation as the main approach to treatment; and
Discharge from treatment in response to relapse.
2
The consensus report also indicated that treatment delivery with an empathic,
supportive approach may be just as important as the specic practices used. This
means that a counselors ability to engage and develop a helping relationship with a
client is critical.
A summary of NQFs work on EBPs is in Resource Page 7.1.
Organizations other than NQF also have studied and identied EBPs. Additional
sources of information about EBPs are in Appendix EResources in your manuals.
1
conditions: Evidence-based treatment practices (p. 20). Washington, DC: Author.
2
Source: U.S. National Quality Forum. (2004). Evidence-based treatment practices for substance use disorders:
Workshop proceedings. Washington, DC: Author.
374
Now were ready to begin talking about six specic EBPs:
Cognitive-behavioral therapy;
Motivational approaches;
Certain family approaches;
Therapeutic community;
Contingency management; and
Pharmacotherapy for opioid dependence.
Were focusing on the rst ve because they are the most broadly used globally.
We are also adding pharmacotherapy, or medication-assisted therapy (MAT).
Although MAT for opioid disorders is not available everywhere, evidence supports
its effectiveness. In addition, methadone is on the World Health Organizations
(WHOs) list of essential medications and WHO supports adoption of methadone
maintenance programs.
Resource Pages 7.8 and 7.9 provide descriptions of two additional EBPs to read
about on your own:
The 12-Step facilitation model, based on the principles of mutual-help groups; and
The Matrix model, an organized set of EBPs originally developed to treat
methamphetamine dependence.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy for SUDs merges two treatment modelscognitive
therapy, originally developed by Aaron Beck to treat depression and behavior therapy,
rst conceptualized by Ivan Pavlov and modied by B. F. Skinner and Albert Bandura.
Cognitive therapy proposes that a persons thoughts and interpretations cause
feelings and behaviors. Feelings and behaviors are not caused by external things,
such as people, situations, and events.
A core belief in cognitive therapy is that people can change the way they think (and
feel and act), even if the situation does not change.
Even though it feels as though the things that happen to us directly cause our
feelings and behavior, cognitive therapy tells us that there is another step in the
process, one over which we have some control: Our thoughts and interpretations
about what happens to us.
Behavioral therapy treats emotional and behavioral disorders as learned responses
that can be replaced by healthy ones with appropriate training. Behavioral therapy
helps people identify behavior that is not helping them and try out new ways of
behaving.
375
Behavioral approaches focus on:
Identifying factors that initiate and maintain behavior;
Adaptive and maladaptive behaviors that lead to client discomfort and problems;
and
Observable and measurable behaviors.
Strict behavioral approaches do not focus on concepts such as self-esteem,
thoughts, values, the unconscious, or defense mechanisms.
Other therapy models attempt to answer the question: Why does this individual do
what he or she does? The questions that are central to CBT are:
What keeps a person doing what he or she is doing?
How does he or she change?
The what question addresses the things that reinforce patterns of thought, affect,
and behavior. The how question relates to building skills.
The CBT approach to treating SUDs focuses on teaching clients skills that help them
recognize and learn strategies to:
Reduce risks of relapse;
Maintain abstinence;
Solve problems; and
Enhance self-efcacy (a clients ability to recognize his or her strengths and to
believe that change is possible).
CBT techniques include asking questions and teaching clients to ask themselves
questions that explore the relationship of their thinking to their emotional responses
to events. For example:
How do I really know that those people are laughing at me?
Are there any other possible explanations?
Could they be laughing about something else?
Other techniques include:
Exploring the positive and negative consequences of continued substance use;
Teaching clients self-monitoring to anticipate and recognize drug and alcohol
cravings early and to identify high-risk situations for use;
Helping clients develop strategies for avoiding or coping with high-risk situations
that trigger the desire to use;
376
Helping clients develop effective coping strategies (such as a range of relaxation
techniques) for general life challenges that might trigger their SUDs; and
Teaching problem-solving skills.
You are probably familiar with most of these techniques. They are widely used
relapse-prevention tools.
Homework is a major part of CBT approaches. Clients are:
Given reading assignments;
Asked to keep track of certain behavior and thoughts; and
Asked to practice new skills they have learned in treatment (behavioral rehearsal).
One CBT approach is cognitive-behavioral coping skills therapy, originally
developed for work with clients with alcohol use disorders.
1
Coping skills therapy is a
structured, manual-based approach. Each session of coping skills therapy includes:
Discussion of the rationale;
Specic skill guidelines;
Behavioral rehearsal (meaning practicing skills using role-plays); and
Other practice exercises for a particular topic area.
Examples of topic areas are:
Managing thoughts about using substances;
Solving problems;
Developing substance refusal skills;
Planning for emergencies and coping with a lapse; and
Dealing with seemingly irrelevant decisions.
Seemingly irrelevant decisions are those decisions, rationalizations, and
minimizations of risk that move people in recovery close toor even intohigh-risk
situations, although they may seem unrelated to substance use. Seemingly irrelevant
decisions form sort of chain, any one link of which may be insignicant but together
move the person into risky territory. For example:
Ahmed, who had been abstinent for several months, drove home from work on a
night his wife was going to be away.
On the way, he turned left rather than right at an intersection so that he could
enjoy the scenic route.
1
U.S. National Institute on Alcohol Abuse and Alcoholism. (1995). Cognitive-behavioral coping skills therapy manual:
Monograph Series, Volume 3. Bethesda, MD: Author.
377
On this route, he drove past a cafe he had frequented in the past with his friends
who used cocaine with him.
Because the weather that day was hot, he decided to stop in for a glass of cola.
While he was there, he ran into a friend who happened to have a gram of
cocaine and a relapse ensued.
Although deciding to enjoy the scenic route seemed like an insignicant decision, it
led to passing an old using spot, which led to using cocaine.
Coping skills training would have helped Ahmed look at each link in the chain
of events that led to his relapse and would have helped him learn to recognize
decisions that can be the start of a process of relapse.
Future curricula will more thoroughly address:
Relapse prevention counseling;
Refusal skills; and
Other cognitive-behavioral counseling techniques.
Research has found cognitive-behavioral therapy (CBT) to be effective for addressing
SUDs involving:
1
Alcohol;
Marijuana;
Cocaine;
Methamphetamine; and
Nicotine.
Clients have also been proven to consistently maintain new skills and other gains for
at least one year after treatment.
2
Motivational Approaches
Motivational approaches include motivational interviewing (or MI) and motivational
enhancement therapy (MET). We will look at each of these approaches in a few
minutes, after weve reviewed general characteristics of motivational approaches.
Motivational approaches are based on the principles of motivational psychology
and the trans-theoretical model of change, also known as the stages of change
model, which was developed by James Prochaska and Carlos DiClemente. These
perspectives tell us that:
1
Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author. 4647. Retrieved August 29, 2011 from http://www.
nida.nih.gov/podat/Evidence2.html
2
Ibid.
378
Change occurs in stages;
Motivation for change varies over time; and
Motivation can be enhanced.
Motivational counseling approaches are methods of counseling that are client-
centered and use nondirective methods. These approaches use strategies that:
Acknowledge that substances of abuse have rewarding properties that can
disguise, at least temporarily, their hazards and negative long-term effects;
Help clients resolve ambivalence about engaging in treatment and stopping
substance use;
Use the internal motivation of clients to evoke and sustain rapid change; and
Include problem-solving or solution-focused strategies that build on clients past
successes.
Motivational approaches follow the principle that change is created through
the clients will and motivation. They do not focus on a counselors discovery,
interpretation, and guidance. In motivational approaches, the counselor acts as a
coach or consultant rather than as an authority gure, helping the client discover,
understand, and build on past successes.
Basic techniques of motivational approaches include:
FRAMES approach;
Decisional balance exercises;
Identifying discrepancies;
Pacing; and
Personal contact with clients not in treatment.
FRAMES is an acronym that stands for:
Feedback;
Responsibility;
Advice;
Menus;
Empathy; and
Self-efcacy.
FRAMES was originally developed as a brief intervention.
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FRAMES: Feedback
After assessment of substance use patterns and associated problems, the counselor
provides feedback to the client regarding her personal risk or impairment.This
feedback may be based on the clinical interview, test results, or a comparison of the
clients use to a population norm.
Responsibility for change is placed squarely and explicitly on the client, with respect
for the clients right to make choices for himself or herself. This respect can be
demonstrated by showing interest in what the clients perceptions and thoughts are
and using questions rather than statements. For example:
How do you see the situation?
What do you think you might need to do?
FRAMES: Advice
Advice about changingreducing or stoppingsubstance use is clearly given to the
client by the counselor in a nonjudgmental manner and, again, with respect for the
clients right to make decisions. The counselor might say:
Given the results of your screening test, Im concerned about the effects of your use
on your health. My advice to you would be to consider treatment. Is that something
youd be willing to talk about?
FRAMES: Menus
The FRAMES approach includes offering menus of self-directed change options and
treatment alternatives. This might include agreeing to try outpatient counseling with
a client who is unwilling to go into a residential program, even though the counselor
may believe that a residential setting is the more prudent choice.
FRAMES: Empathy
Empathic counselingshowing warmth, respect, and understandingis emphasized
in motivational approaches.
FRAMES: Self-Efcacy
The client develops self-efcacy and is encouraged to change. The counselor can:
Help the client explore his or her strengths and past successes;
Identify skills and abilities to make necessary changes; and
Promote the idea that people can change and that recovery is possible.
Decisional-Balance Techniques
Another technique of motivational approaches is using decisional balance exercises.
Decisional balance is the concept of exploring the pros and consor benets and
disadvantagesof change. People naturally explore the pros and cons of major life
choices.
380
In the context of recovery from substance use, the client weighs the pros and cons of
changing versus not changing substance-using behavior. The counselor assists this
process by asking the client to:
Talk about both the good and less good aspects of using substances; and
Write them down in two columns on a sheet of paper.
The purpose of exploring the pros and cons of a substance use problem is to tip
the scales toward a decision for positive change. The number of reasons a client
lists on each side of a decisional balance sheet is not as important as the weight
or personal valueof each one. For example, a 20-year-old might not put as much
weight on losing a girlfriend as would an older, engaged man who wants a family.
The 20-year-old might be very concerned, though, about being kicked off his soccer
team for missing too many practices.
One way to enhance motivation for change is to help clients recognize a discrepancy
or gap between their future goals and current behavior. A counselor might clarify
this discrepancy by asking:
How does your cocaine use t in with having a happy family and a stable job?
When clients see that present actions conict with important personal goals such as
health, success, or family happiness, change is more likely to occur.
Each client moves through the stages of change at his or her own pace. The concept
of pacing requires that a counselor meet a client at the stage the client is in. The
counselor uses as much or as little time as is necessary to complete the essential
tasks of each stage of change. For example, some clients may need frequent
sessions at the beginning of treatment and fewer later. If a counselor pushes a client
at a faster pace than the client is ready to take, the relationship between counselor
and client may break down.
Motivational interventions can include simple activities designed to enhance
continuity of contact between counselor and client and strengthen the relationship.
Activities can include personal handwritten letters or telephone calls from counselor
to client. Research has shown that these simple motivation-enhancing interventions
are effective for encouraging clients to:
Return for another clinical consultation;
Return to treatment following a missed appointment;
Stay involved in treatment; and
Increase treatment adherence.
Motivational Interviewing
Now lets look at how two motivational approaches incorporate those principles into
their unique EBPs. We will start with Motivational Interviewing (MI).
381
MI is a counseling technique or style that focuses on creating a favorable climate for
change in a person-centered setting. The essence of MI is in its collaborative nature,
communicating in a partner-like relationship, where the interviewer seeks to create a
positive interpersonal atmosphere.
There are ve primary principles in MI. These are not steps; rather, they are concepts
to be applied at all times to enhance the relationship between the counselor and the
client. They are often summarized by the acronym READS:
Roll with resistance;
Express empathy;
Avoid arguments;
Develop discrepancy; and
Support self-efcacy.
To carry out these ve principles, there are four basic therapeutic skills or methods
an SUD counselor would use in MI:
Reective listening or responding to a clients statement by stating back to her or
him the essence or a specic aspect of what was said;
Asking open-ended questions;
Afrming;
Summarizing.
In MI, responsibility for change is left to the client. The overall goal is to increase the
persons intrinsic motivation to make the change that the client determines to be
important, so that change arises from within rather than being imposed.
MI was rst used in treating SUDs to improve adherence. It can be used as both an
assessment strategy and a therapeutic intervention:
To determine a persons readiness to engage in a target behavior, such as
stopping drug abuse;
To explore and resolve ambivalence (mixed feelings) and resistance; and
To apply specic skills and strategies to create a favorable climate for change
based on the persons level of readiness.
Motivational Enhancement Therapy
Motivational Enhancement Therapy (MET) is another of the motivational approaches
that researchers have documented as being effective. This approach is also primarily
client-centered, but the counseling sessions are planned and directed by the
counselor. MET seeks to:
Help clients create their own motivation for change; and
382
Consolidate a persons decision and plan for change.
In MET, each client sets his or her own goals:
No absolute goal is imposed by a counselor using MET.
MET counselors may advise specic goals, such as complete abstinence.
A broader range of life goals, such as nding a job or reuniting with family
members, may be explored as well.
In MET therapy, SUD problems are viewed as behaviors at least partially under the
voluntary control of the client. Thus, they follow the normal principles of behavior
change.
MET is based on principles of cognitive and social psychology. The MET counselor:
Seeks to help the client perceive a discrepancy between current behavior and
signicant personal goals.
Emphasizes clients self-motivational statements of both the desire for and the
commitment to change.
The MET counselor works from the assumption that internal motivation is not only a
necessary but often the only factor needed to create change.
Researchers have found motivational enhancement therapy to be effective for
addressing SUDs involving:
1
Alcohol;
Marijuana; and
Nicotine.
Family-Based Approaches
Simple family involvement is not a specic model of treatment. However, extensive
research shows that family involvement in treatment programs can signicantly
enhance outcomes for a person experiencing SUDs. Most programs offer family
services in their approach to treatment.
Family services frequently include:
Family psychoeducation;
Family support groups; and
Family counseling.
1
383
Families of people who abuse substances live in a world shaped by substance use. In
this world:
There may inconsistent behaviors;
There may be few or very rigid rules;
Family members frequently experience anger, shame, guilt, sadness, and
hopelessness;
Individuals may be isolated, create destructive alliances, be overly involved, and
get locked into rigid roles; and
Individuals may develop stress-related medical problems.
Family involvement is critical to the strength and duration of the clients recovery
because:
Family members were involved with the client before treatment;
Family members will be involved with the client after treatment; and
Family-based services can ensure that family functioning changes to become a
positive inuence for the recovery of the client.
One primary goal of family involvement is to increase members understanding of
substance use disorder as a chronic disease. This helps family members:
Understand how the SUD is intertwined with family problems;
Understand causes and effects of SUDs from a family perspective;
Identify and change family relationship patterns that work against recovery;
Prepare for early recovery challenges; and
Learn about relapse warning signs.
Two other goals include helping family members:
Discover and build on family strengths; and
Obtain long-term support for themselves.
While families can be critical to the success of a client with SUDs, some family
members may actually need treatment themselves before they can be such a helpful
resource for clients. Many clients are from families that are particularly chaotic and
dysfunctional or have multi-generational substance use disorders, mental disorders,
and other problems.
384
Family Approach EBPs
Several specic family approaches are considered EBPs for treating SUDs:
Behavioral couples therapy (BCT) for substance abuse;
Multi-systemic therapy (MST) for adolescents;
Multidimensional family therapy (MDFT) for adolescents; and
Brief strategic family therapy (BSFT) for adolescents.
BCT is typically used as an adjunct to other SUD treatment approaches. BCT is
based on the assumptions that:
Intimate partners can reward abstinence; and
Reducing relationship distress reduces chances for relapse.
BCT program components include:
A recovery or sobriety contract between the partners and the therapist;
Activities and assignments designed to increase positive feelings, shared
activities, and constructive communication; and
Relapse prevention planning.
With BCT, the spouse or partner plays an active role in treatment, minimizing the
sense of helplessness that comes with living with a person with an SUD. Partners
attend between 15 and 20 hour-long sessions over 5 to 6 months.
Sessions follow a particular sequence:
The therapist asks about substance use since the last session;
The couple discusses compliance with the recovery contract;
The couple presents and discusses homework assigned at the last session;
The couple discusses relationship problems since the last session;
The therapist presents new material; and
The therapist assigns new homework.
Researchers have found BCT to be effective for addressing the following populations:
1
Men with alcohol use disorders and their spouses; and
Men and women with drug use disorders and their signicant others.
1
385
Compared to individual treatment, at one-year follow-up, BCT has been shown to
produce higher:
Treatment attendance;
Naltrexone adherence for opiod users; and
Rates of abstinence.
BCT also showed fewer drug-related, legal, and family problems at that one-year
followup point.
The second family approach we will review is multisystemic therapy. MST is an
intensive, in-home and in-community approach that focuses on changing the
thinking and behavior of both adolescents with SUDs and their parents. The
approach uses cognitive-behavioral and social-development (risk and protective
factors) strategies to focus on family strengths to facilitate positive change.
MST interventions occur in the home to overcome the high dropout rates of other
treatments and focus on:
Promoting responsible behavior;
Decreasing irresponsible actions by family members;
Addressing what is currently occurring in adolescents life;
Taking immediate actions targeting specic and well-dened problems;
Assessing patterns of behavior within and between the various elements of the
adolescents lifefamily, teachers, friends, home, school, and communitythat
sustain the identied problems;
Building the adolescents ability to get along well with peers; and
Acquiring academic and vocational skills that will promote a successful transition
to adulthood.
MST does not focus on gaining insights or focusing on the past; nor do MST
counselors label families as resistant, not ready for change, or unmotivated. Rather,
the MST approach avoids blaming the family while it empowers parents (or other
caregivers) to address the familys needs after treatment ends. In fact, the caregiver
is seen as the key to long-term success, whereas the responsibility for positive
treatment outcomes rests completely on the MST team.
Researchers have found
1
MST to be effective in signicantly reducing adolescent
drug use during treatment and for at least six months after treatment.
1
Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author. 46-47.
386
Additionally, fewer incarcerations and out-of-home juvenile placements offset the
cost of providing this intensive service and maintaining therapists low caseloads.
Multidimensional family therapy (MDFT) for adolescents is the third family approach.
Like multi-systemic family therapy, MDFT views adolescent substance use in terms
of a network of inuences (individual, family, peer, community) and suggests that
reducing unwanted behavior and increasing desirable behavior occur in multiple
ways in different settings.
MDFT includes individual and family sessions held in a treatment center, in the
home, or with family members at school, court, or other community locations. In
individual sessions, the counselor and adolescent work on:
Developmental tasks, such as acquiring decision-making, negotiation, and
problem-solving skills;
Vocational skills; and
Skills in communicating thoughts and feelings to deal better with life stressors.
Parallel sessions are held with family members, where parents can:
Examine their particular parenting styles, learning to distinguish inuence from
control; and
Learn to have a positive and developmentally appropriate inuence on their
children.
Researchers have found MDFT to be effective for reducing:
1
The severity of cannabis and alcohol use; and
The overall severity of substance use-related problems.
The nal family approach we will examine is brief strategic family therapy (BSFT).
BSFT is a brief approach delivered in 12 to 16 family sessions. BSFT targets family
interactions that are thought to maintain or worsen adolescent substance use and
other problem behavior, such as:
Conduct problems at home and at school;
Oppositional behavior;
Illegal activities;
Associating with antisocial peers;
Aggressive and violent behavior; and
Risky sexual behavior.
1
U.S. National Registry of Evidence-based Practices and Programs. (2011) Multidimensional Family Therapy. Rockville,
Maryland:SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/ViewIntervention.aspx?id=16
387
BSFT is based on a family systems approach to treatment. The family members
behaviors are assumed to be interdependent such that the symptoms of any one
member indicate, at least in part, what else is going on in the family system.
The role of the BSFT counselor is to:
Identify the patterns of family interaction that are associated with the
adolescents behavior problems; and
Assist in changing those family patterns.
BSFT is meant to be a exible approach that can be adapted to a broad range of
family situations in various settings:
Mental health clinics;
SUD treatment programs;
Other social service settings; and
Families homes.
BSFT can also be adapted to various treatment modalities:
As a primary outpatient intervention;
In combination with residential or day treatment; and
As an aftercare/continuing-care service to residential treatment.
BSFT is a manual-based, highly structured program, and specic training by the Brief
Strategic Family Therapy
Institute is required.
Urban Hispanic families have been the primary recipients of BSFT, although African-
American and European-American families have also participated. Researchers have
found brief strategic family therapy to be effective for:
1
Reducing marijuana and overall substance use;
Reducing conduct problems and socialized aggression; and
Increasing family functioning.
Therapeutic Community
The therapeutic community (TC) is an intensive, primarily long-term (up to 1 year)
residential model. TCs use an approach known as community as method;
2
this
approach views the community as a wholeits social organization, its staff and
clients, and its daily activitiesas the therapeutic agent. This community-as-method
philosophy and a distinct therapeutic structure dene TCs.
1
U.S. National Registry of Evidence-based Practices and Programs. (2011). Multidimensional Family Therapy. Rockville,
Maryland: SAMHSA. Retrieved August 30, 2011, from ttp://nrepp.samhsa.gov/ViewIntervention.aspx?id=151
2
De Leon, G. (2000). The therapeutic community: Theory, model, and method. New York: Springer Publishing Company.
388
TCs feature a structured day that includes ordered, routine activities to:
Counter the disordered lives of clients; and
Distract clients from negative thinking and boredom.
The TCs daily activities include group sessions and hierarchical job functions that
teach participants specic behaviors, skills, and roles. Because of their intense, long-
term nature, TCs are particularly appropriate for clients who have histories of severe
SUDs and criminal behavior.
In fact, researchers have documented that restoring warm interpersonal relationships
reverses the damaging changes produced on brain formation, function, and
structure by neglect and abuse during childhood. Within the TC, each participant
has a well-recognized role, is considered with love and respect, and is part of a new
familyall of which ll the affective gaps that may have been created during his
or her destructive personal history.
1
The humanity of caregivers and the warm and
friendly relationships with the peers in the full-time environment of a TC are the real
therapeutic engines for the changes that happen with clients in this setting.
The TC model is used in countries around the world. Every continent (except
Antarctica) has professional associations of TCs. The Asian Federation of
Therapeutic Communities (http://www.asianfedtc.org/about.html) has 13 member
countries.
The TC model can be, and often is, modied to t cultural perspectives but
generally includes the following components:
A sense of community: Community is created partly by a separation from other
organizational or institutional programs and from the drug-using environment.
A TC facility contains communal space for promoting a sense of commonality
during collective activities. Treatment and educational services are delivered
within the peer community.
Peers and staff members as role models: TC members and staff members serve
as positive role models by demonstrating expected behaviors and reecting the
values and teachings of the community. The strength of the community for social
learning rests on the number and quality of its positive role models.
Work as therapy and education: Consistent with the TCs self-help approach, all
clients are responsible for the daily management of the facility. Work roles are
designed to bring about both educational and therapeutic effects.
Group counseling focusing on awareness and emotional growth training: This
is the main therapeutic group. These groups are used to heighten clients
awareness of specic attitudes or behavioral patterns that need to change and to
help clients identify feelings and express them appropriately and constructively.
1
Personal communication: Gilberto Gerra, M.D., Chief , Drug Prevention and Health Branch, United Nations Ofce for
Drug Control.
389
A TC organizes a clients treatment in four stages:
Introduction;
Treatment;
Commitment; and
Transition/aftercare (or continuing care).
The introductory TC program is divided into modules of treatment to help clients
accept responsibility for their SUD behaviors and consequences. Participants take
part in:
Groups;
Individual counseling sessions; and
Educational seminars.
At the completion of this stage, clients move to the more focused treatment phase
of the programor request a referral to another organization.
In the TC treatment stage, clients live and work in the community and, with the support
and encouragement of staff and peers, help one another develop coping skills:
The social structure is a hierarchy of positions with degrees of responsibility.
Activities focus on normal, daily work projects and leisure pursuits, supported by
a creative therapy program.
Attendance at outside mutual-help meetings is also initiated during this time.
The commitment stage is the link between treatment and the start of the community
reintegration phase. During this phase, clients begin to take their place back in the
larger society. Emphasis is placed on:
Career development;
Social relationships; and
Practical living skills.
The program provides clients with a supportive and gradual community reentry by
helping them:
Move through voluntary work into full-time employment or education; and
Physically move from the protected environment of the TC into a transition
house and then into their own accommodation in the general community. This
accommodation could be a place to live by oneself or reintegration into a family
home.
390
Reentry is accompanied by:
Weekly support groups and counseling sessions with staff; and
Additional support from peers who have successfully negotiated this process and
completed the TC program.
Attendance at Narcotics Anonymous or other similar support groups also continue
during this stage of the program.
Some therapeutic communities insist that no resident can leave the program
without:
A full-time job or placement in school;
A place to live; and
A support network.
During the transition/aftercare stage, family reconciliation is also incorporated into
reentry. Maintaining a drug-free lifestyle means learning more coping skills, so this
part of the transition process could take many months.
One of the supports most commonly identied as essential to resident success once
they leave the therapeutic community is transitional housing (a half-way house) and
affordable longer term housing. This is a major obstacle in many places because of a
lack of good basic accommodations.
Conclusions of the long-term U.S. Drug Abuse Treatment Outcome Study (DATOS)
found that those who completed treatment in a therapeutic community had lower
levels of:
1
Cocaine, heroin, and alcohol use;
Criminal behavior;
Unemployment; and
Indicators of depression.
TCs have also been effective when modied to treat individuals with special needs,
including:
2
Adolescents;
Women;
1
National Institute on Drug Abuse. (2002). Research report seriesTherapeutic community: What is a therapeutic
community. Bethesda, Maryland: Author. Retrieved August 29, 2011, from http://www.nida.nih.gov/PDF/
RRTherapeutic.pdf
2
National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide, 2nd Ed.
NIH Publication No. 09-4180. Bethesda, Maryland: Author.
391
Homeless individuals;
People with severe mental disorders; and
Individuals in the criminal justice system.
Contingency Management
Research has demonstrated the effectiveness of treatment approaches that use
contingency management principles. Contingency management is based on
the behavioral principle that rewarding a behavior reinforces it, or makes it more
likely to be repeated. A behavior also can be reinforced by removing a negative
consequence; this is called negative reinforcement.
Contingency management in SUD treatment means that clients are given the chance
to earn low-cost incentives, or rewards, for desirable behavior like showing up for
group sessions, being on time, trying new behavior, or producing a drug-free urine
test. These incentives can include prizes given immediately or vouchers that can be
exchanged for food items, movie passes, or personal items.
From a behavioral perspective substance use is considered to be maintained by the
positively reinforcing effects of the substance itself or by the negative reinforcement
of relieving the pain of withdrawal. Therefore, the pull of dependence and its
immediate rewards are very strong for clients with SUDs.
The process of becoming abstinent does have its own eventual rewards; for
example:
A healthier lifestyle;
Employment and self-sufciency;
Educational opportunities; and
Maintaining positive relationships.
However, the word eventual is key; it typically takes a long time before these
internal rewards are experienced by a client attempting to make such signicant
behavioral changes. So, since abstinence itself might not be sufcient reinforcement
to maintain the motivation to stop using alcohol or drugs, CM uses more immediate
rewards to reinforce both the early stages of abstinence and the lifestyle change.
Therefore, CM motivates clients behavioral change and reinforces abstinence by
systematically rewarding desirable behaviors:
Rewards provided are typically positive, pleasurable, and rewarding events or
objects; but
Some negative reinforcers are also effective, such as removing a ne or restriction
after a client has complied with a specic condition.
392
There are numerous forms of contingency management, each with unique
techniques. However, each form is grounded in a set of guiding principles:
Identifying a behavior that is clearly observable and measurable. For example,
if targeting abstinence as a behavior, onsite drug testing can measure drug and
alcohol use;
Selecting a desired behavior change that can contribute toward meeting
treatment goals;
Rewarding small changes;
Choosing rewards that would be important to the clients by asking them which
rewards would be the most desirable;
Rewarding the targeted behavior as immediately as possible;
Providing frequent reinforcers;
Delivering all rewards as promised, so the treatment remains credible; and
Using an escalating series of rewards to provide a greater incentive for sustaining
the desired behavior.
Several different types of incentive programs have been researched:
Contingent access to privileges; for example, through a system of levels with
increasing privileges;
Onsite prize distribution;
Refunds or rebates;
Vouchers or some other token economy systems.
A challenge of contingency management programs is to identify a reward for a
desired behavior that is:
Practical;
Available without too much cost or expenditure of staff energy; and
Sufciently powerful over time to replace or substitute for the very potent,
pleasurable, or pain-reducing effects of the abused substance.
One type of CM is called community reinforcement (CR) and uses social,
recreational, familial, and vocational reinforcers, rather than material rewards or
within-program privileges. CR is based on the premise that environmental resources
can be highly effective in changing substance use behavior. A strong case-
management component is essential to using the CR approach.
393
One form of CR, community reinforcement approach plus vouchers, has been
documented as an EBP. The model originally studied
1
was an intensive 24-week
outpatient therapy for treatment of cocaine and alcohol addiction. There were two
primary treatment goals:
For clients to maintain abstinence long enough to learn new life skills to sustain
and reinforce abstinence; and
To reduce alcohol consumption for clients whose drinking was associated with
cocaine use.
In this program, clients attended one or two individual counseling sessions each
week focusing on:
Improving family relationships;
Learning a variety of skills necessary for reducing drug and alcohol use;
Receiving vocational counseling; and
Developing new recreational activities and social networks.
Vouchers were also used and provided for cocaine-negative test samples. The
vouchers increased in value with each clean sample. They could be exchanged for
retail goods consistent with a cocaine-free lifestyle.
This specic CM approach was found to:
Facilitate clients engagement in treatment; and
Facilitate increasing periods of cocaine abstinence.
The CR approach with vouchers has since been tested and found effective in
increasing treatment retention and promoting abstinence from substances. Studies
have been conducted with a variety of adult and adolescent populations from a variety
of ethnic backgrounds and in a variety of settings, such as outpatient and residential
programs, methadone maintenance clinics, and specialized programs for adolescents.
Contingency management in general has been documented to be an effective
intervention for a range of SUDS involving:
1
Alcohol;
Stimulants;
Opioids;
Marijuana; and
Nicotine.
1
Budney, A. J., & Higgins, S. T. (1998). A community reinforcement approach: Treating cocaine addictionTherapy
Manuals for Drug Abuse: Manual 2. NIH Publication Number 98-4309. Bethesda, MD: National Institutes on Health.
394
Psychopharmacology for Opioid Dependence
Pharmacotherapy can be briey dened as the use of medically prescribed
psychoactive substances to treat psychiatric and behavioral conditions. It is also
known as medication-assisted treatment (MAT).
Pharmacotherapy is used in a number of ways:
To replace an opioid, either short or long term;
To discourage use of an opioid by reducing its reinforcing properties; and
To aid early recovery by reducing cravings or counteracting some of the longer
term symptoms of withdrawal.
Medications are available for treating dependence on alcohol, opioids, and nicotine.
Medications for opioids need to be prescribed by a medical practitioner. One of the
best-known forms of pharmacotherapy is methadone maintenance therapy.
services, not in place of them. International guidelines developed by the World
Health Organization call for combining pharmacotherapy with counseling
(particularly CBT and CM) and case management.
MAT for opioid use disorders is often the best choice for opioid addiction. MAT
uses one of three medicationsnaltrexone, buprenorphine, or methadoneto treat
addiction to heroin or other opioid drugs.
Naltrexone blocks all the effects of opioids, preventing a person from getting high.
To prevent immediate and severe opioid withdrawal symptoms, a person must be
medically detoxied and opioid free for several days before beginning naltrexone.
Client adherence to naltrexone therapy is often a problem, and naltrexone is not
often used. A new injectable form of naltrexone (Vivitrol
) that requires only monthly

injection was recently approved in the United States to enhance adherence, which
may increase its use there.
Buprenorphine (Subutex
) reduces or eliminates withdrawal symptoms associated

with opioid dependence but, at proper doses, does not produce the euphoria and
sedation caused by heroin or other opioids. At high doses, buprenorphine can
produce euphoria, so it is often combined with naloxone, a medication that blocks
these effects, into a formulation called Suboxone
to avoid this potential problem.

Methadone is the best known and most widely used medication for opioid
treatment. Methadone may be used short term as an aid to withdrawal or over a
long period as maintenance or substitution therapy. Methadone is on WHOs list of
essential medications.
395
Maintenance treatment is usually conducted in specialized settings (e.g., methadone
maintenance clinics). In some countries, clients who are stabilized on methadone
and have participated in counseling services are allowed to take home enough
doses for a few days or a week at a time.
At the right dose, methadone:
Prevents opioid withdrawal;
Blocks the euphoric effects of illicit opioid use; and
Decreases opioid craving.
Clients stabilized on adequate, sustained dosages of methadone can function
normally. By taking methadone and stopping or decreasing their injection drug use,
clients can:
Work;
Take care of their families;
Avoid the crime and violence of the street culture; and
Reduce their exposure to HIV.
397
MODULE 8
INTEGRATING LEARNING INTO PRACTICE
Training goals and learning objective ..................................................... 399
Resource page ......................................................................................... 400
399
Participant Manual: Module 8Integrating Learning Into Practice
Goals and Objective
Training goals
To encourage participants to think about resources, barriers, and strategies for
change; and
To provide an opportunity to develop a personal practice integration plan.
Learning objective
Participants who complete Module 8 will have developed a personal practice
integration plan.
Activity Time
Module 8 and review exercise introduction 10 minutes
Break 15 minutes
Small-group exercise: Developing a practice integration plan 60 minutes
Learning assessment competition 20 minutes
Day 5 and overall training evaluations 15 minutes
Program completion ceremony and socializing 30+ minutes
400
1. The most important thing I learned from this training, and dont want to forget, is:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. Changes I will make in my practice based on what I have learned are:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Some things that could interfere with my plans are (e.g., anticipated barriers):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Ways I could overcome these barriers include:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. The following people (include supervisors, potential mentors, and so on) and
resources (further training, reading) could help me in the following ways:
Person or Resource Possible Ways To Help
Resource Page 8.1: Practice Integration Plan
401
Participant Manual: Appendix AGlossary
APPENDIX AGLOSSARY
Breathalyzer
TM
A device used for estimating blood alcohol content (BAC)
from a breath sample. Breathalyzer is a brand name but
is often used to indicate any device that measures BAC
using breath.
case management A set of administrative, clinical, and evaluative functions that
helps clients nd and use the resources they need to recover
from a substance use or other problem; the coordination of
professional social services to assist people with complex
needs, often for long-term care and protection. The
resources an individual seeks may be external in nature
(e.g., housing, education) or internal (e.g., identifying and
developing skills).
continuum of care The range and types of treatment and other services a
person may receive over time.
defense mechanisms Various, mostly unconscious, psychological strategies that
are used to cope with life experiences and to maintain self-
image. Denial is an example of a defense mechanism.
determinism The philosophical belief that every human act has a very
specic known or previous cause that can be predicted, so
there is no free will.
detoxication The process of stopping substance use, clearing the
substance from the body, and managing the withdrawal
syndrome.
evidence-based
practices
Those practices for which the evidence is strongest and most
accepted and that are most likely to have signicant impact
on improving care.
1
motivation A reason or desire to act; that which gives purpose and
direction to behavior.
outreach Organized efforts to identify and screen individuals who may
have a problem with substance use, instead of waiting for
them to be referred to treatment programs or to decide to
enroll in a program themselves.
1
conditions: Evidence-based treatment practices (abridged version) (p. v). Washington, DC: Author.
402
psychoeducation Education provided to clients who have a mental or
substance use disorder. Psychoeducation also is provided to
clients family members. A primary goal of psychoeducation
is to help the client and his or her family better understand
and learn to cope effectively with the disorder.
psychological theory A set of principles applied to the examination and
explanation of psychological phenomena or behavioral
events. A psychological theory proposes a way of seeing a
person and his or her problems, matched with ideas about
what sorts of interventions are needed for change to occur.
Psychological theory forms the basis of counseling theories
and approaches.
stages of change A model based on a study of how people change. The
study found that people go through predictable stages:
precontemplation, contemplation, preparation, action,
maintenance, and recurrence.
theory A fact-based framework for describing a phenomenon (an
event or series of occurrences); a particular concept or view
of a phenomenon; an evidence-based system of rules or
principles.
treatment
interventions
The components of treatment (e.g., assessment, counseling,
education, case management).
treatment intensity
and duration
How often and for how long a person receives treatment
services.
treatment modality How treatment is provided (e.g., one-on-one with an
addiction professional, in a group with peers, with other
family members).
treatment plan An individualized outline for treatment and services based
on the clients specic needs identied in the assessment
process; a joint activity involving the counselor, the client,
other treatment providers, and (at times) the clients family
members.
treatment setting Where treatment is provided (e.g., drop-in center, hospital,
outpatient program).
withdrawal syndrome A predictable set of signs and symptoms that occur when
a person abruptly stops taking a psychoactive substance or
rapidly decreases the amount taken.
403
Participant Manual: Appendix BResources
APPENDIX BRESOURCES
Global Drug Use Statistics
United Nations Ofce on Drugs and Crime. (2011). World drug report 2011. New York:
United Nations. Retrieved June 29, 2011, from
http://www.unodc.org/documents/data-and-analysis/WDR2011/
World_Drug_Report_2011_ebook.pdf
World Health Organization. (2010). Management of substance abuse: The global
burden. Geneva: Author. Retrieved December 10, 2010, from
http://www.who.int/substance_abuse/facts/global_burden/en/index.html
World Health Organization. (2011). Management of substance abuse: Facts and gures.
Geneva: Author. Retrieved December 10, 2010, from
http://www.who.int/substance_abuse/facts/en/
Treatment for Substance Use DisordersGeneral
Principles and Components
Center for Substance Abuse Treatment. (1999). Brief interventions and brief therapies for
substance abuse, Treatment Improvement Protocol Series 34, HHS Publication No. (SMA)
99-3353. Rockville, MD: U.S. Substance Abuse and Mental Health Services Administration.
http://www.ncbi.nlm.nih.gov/books/NBK14512
Center for Substance Abuse Treatment. (1998). Comprehensive case management
for substance abuse treatment, Treatment Improvement Protocol Series 27, HHS
Publication No. (SMA) 98-3222. Rockville, MD: U.S. Substance Abuse and Mental Health
Services Administration.
Center for Substance Abuse Treatment. (2006). Detoxication and substance abuse
treatment, Treatment Improvement Protocol Series 45, HHS Publication No. (SMA) 06-
4131. Rockville, MD: U.S. Substance Abuse and Mental Health Services Administration.
Center for Substance Abuse Treatment. (2006). Substance abuse: Clinical issues in
intensive outpatient treatment, Treatment Improvement Protocol Series 47, HHS
Center for Substance Abuse Treatment. (2005). Substance abuse treatment: Group
therapy, Treatment Improvement Protocol Series 41, HHS Publication No. (SMA) 05-3991.
Rockville, MD: U.S. Substance Abuse and Mental Health Services Administration.
404
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior
change. American Journal of Health Promotion, 12(1), 3848.
http://www.uri.edu/research/cprc/Publications/PDFs/ByTitle/The%20
Transtheoretical%20model%20of%20Health%20behavior%20change.pdf
U.S. National Institute on Drug Abuse. (1999). Principles of drug addiction treatment:
A research-based guide (2nd ed.), NIH Publication No. 99-4180. Bethesda, MD: U.S.
National Institutes of Health.
http://www.cdhs.state.co.us/adad/PDFs/PODAT.pdf
U.S. Substance Abuse and Mental Health Services Administration. (2010). Family
psychoeducation evidence-based practice kit, HHS Publication No. (SMA) 09-4423.
Rockville, MD: U.S. Department of Health and Human Services.
http://store.samhsa.gov/product/SMA09-4423
World Health Organization and United Nations Ofce on Drugs and Crime. (2008).
Principles of drug dependence treatment. New York: Authors.
http://www.who.int/substance_abuse/publications/principles_drug_dependence_
treatment.pdf
Self- and Mutual-Help Programs
Al-Anon/Alateen/Alatot
http://www.al-anon.alateen.org
Alcoholics Anonymous
http://www.aa.org
Cocaine Anonymous
http://www.ca.org
Marijuana Anonymous
http://www.marijuana-anonymous.org
Nar-Anon
http://www.nar-anon.org/Nar-Anon/Nar-Anon_Home.html
Narcotics Anonymous
http://www.na.org
Rational Recovery
https://rational.org/index.php?id=1
SMART (Self-Management and Recovery Training) Recovery

http://www.smartrecovery.org
Women for Sobriety
http://www.womenforsobriety.org
405
Evidence-Based Practices
General topics
Alcohol and Drug Abuse Institute. (2006). Evidence-based practices for substance use
disorders. Seattle, WA: University of the Washington.
http://adai.washington.edu/ebp
U.S. National Quality Forum. (2007). National voluntary consensus standards for
the treatment of substance use conditions: Evidence-based treatment practices.
Washington, DC: Author.
http://www.rwjf.org/les/research/nqrconsensusreport2007.pdf
U.S. National Registry of Evidence-based Programs and Practices
http://www.nrepp.samhsa.gov/Search.aspx
Specic topics
Cognitive-behavioral therapy
Association for Behavioral and Cognitive Therapies. (n.d.). Learn about CBT. New York:
Author.
http://www.abct.org/Professionals/?m=mPro&fa=learnCBT_menu
Carroll, K. M. (1998). A cognitive-behavioral approach: Treating cocaine addiction,
Therapy Manuals for Drug Abuse 2, NIH Publication No. 98-4308. Rockville, MD: U.S.
National Institute on Drug Abuse.
http://archives.drugabuse.gov/txmanuals/CBT/CBT1.html
Kadden, R. M. (2002). Cognitive-behavior therapy for substance dependence: Coping
skills training. Peoria, IL: Behavioral Health Recovery Management Project.
http://www.bhrm.org/guidelines/CBT-Kadden.pdf
Motivational approaches
Center for Substance Abuse Treatment. (1999). Enhancing motivation for change
in substance abuse treatment, Treatment Improvement Protocol Series 35, HHS
http://www.ncbi.nlm.nih.gov/books/NBK14856/
Center for Substance Abuse Treatment. (2006). Enhancing motivation for change inservice
training, HHS Publication No. (SMA) 06-4190. Rockville, MD: U.S. Substance Abuse and
Mental Health Services Administration.
http://www.kap.samhsa.gov/products/manuals/tipcurriculum/pdf/p_complete_manual.pdf
Center on Alcoholism, Substance Abuse, and Addictions. (2009). Motivational
interviewing. Albuquerque, NM: University of New Mexico.
http://casaa.unm.edu/mi.html
406
Miller, W. R. (n.d.). Motivational enhancement therapy with drug abusers. AddictionInfo.org.
http://www.addictioninfo.org/articles/736/1/Motivational-Enhancement-Therapy-with-
Drug-Abusers/Page1.html
Motivational Interviewing: Resources for Clinicians, Researchers, and Trainers
http://www.motivationalinterview.org
Family approaches
Center for Substance Abuse Treatment. (2004). Substance abuse treatment and family
therapy, Treatment Improvement Protocol Series 39, HHS Publication No. (SMA) 04-
3957. Rockville, MD: U.S. Substance Abuse and Mental Health Services Administration.
Institute for Research, Education, and Training in Addictions. (n.d.). Introduction to
behavioral couples therapy (BCT). Pittsburgh, PA: Author.
http://www.ireta.org/online/ireta_chapters/BCT_chapter1.html
Liddle, H. A. (2002). Multidimensional family therapy treatment (MDFT) for adolescent
cannabis users, Cannabis Youth Treatment Series 5, HHS Publication No. (SMA) 02-3660.
Rockville, MD: U.S. Substance Abuse and Mental Health Services Administration.
http://www.kap.samhsa.gov/products/manuals/cyt
Multisystemic Therapy Services. (2010). What is multisystemic therapy? Mount Pleasant,
SC: Author.
http://www.mstservices.com/index.php/what-is-mst/what-is-mst
U.S. National Institute on Drug Abuse. (n.d.). Behavioral therapies development
programEffective drug abuse treatment approaches: Multidimensional family therapy
(MDFT). Bethesda, MD: U.S. National Institutes of Health.
http://archives.drugabuse.gov/btdp/Effective/Liddle.html
U.S. National Institute on Drug Abuse. (n.d.). Behavioral therapies development
programEffective drug abuse treatment approaches: Multisystemic therapy (MST).
Bethesda, MD: U.S. National Institutes of Health.
http://archives.drugabuse.gov/btdp/Effective/Henggeler.html
Therapeutic community
Center for Substance Abuse Treatment. (2006). Therapeutic community curriculum:
Trainers manual, HHS Publication No. (SMA) 06-4121. Rockville, MD: U.S. Substance
Abuse and Mental Health Services Administration.
http://www.kap.samhsa.gov/products/manuals/tcc/index.htm
U.S. National Institute on Drug Abuse. (2002). What is a therapeutic community? Research
Report Series, NIH Publication No. 02-4877. Bethesda, MD: U.S. National Institutes of Health.
http://www.nida.nih.gov/PDF/RRTherapeutic.pdf
World Federation of Therapeutic Communities
http://www.wftc.org/mission.html
407
Pharmacotherapy
Center for Substance Abuse Treatment. (2005). Medication-assisted treatment for opioid
addiction in opioid treatment programs, Treatment Improvement Protocol Series 43,
HHS Publication No. (SMA) 05-4048. Rockville, MD: U.S. Substance Abuse and Mental
Health Services Administration.
World Health Organization. (2009). Guidelines for the psychosocially assisted
pharmacological treatment of opioid dependence. Geneva: Author.
http://www.who.int/substance_abuse/publications/Opioid_dependence_guidelines.pdf
409
Participant Manual: Appendix CSpecial Acknowledgments

APPENDIX CSPECIAL
ACKNOWLEDGMENTS
A special thank you to the following individuals who participated in pilot testing this
curriculum and created client case studies for the curriculum series. Their input was
invaluable.
Clemente (Junjun) A. Abella, Jr.
Counseling Psychologist
Serenity at the Quarry
Philippines
Muhammad Ayub
Director
Dost Welfare Foundation
Pakistan
Dato Zainuddin A. Bahari
Consulting Trainer
Malaysia
Tapasi Bandyopahyay
Consulting Trainer
India
Tay Bian How
Consultant
The Colombo Plan ACCE
Sri Lanka
Prof. Sun Min Kim
Research Professor
Seoul National University
South Korea
Winona A. Pandan
Guidance Counselor
LaSalle College Victorias
Philippines
Dr. V. Thirumagal
Consultant
TTK Hospital
India
Susmita Banerjee
Trainer
Sri Lanka
Ma. Elena (Malyn) Cristobal
Family Therapist, Private Practice
Living Free Foundation
Philippines
Aditi Ghanerar
Counselor and Training Coordinator
TTK Hospital
India
Mohammed Sharif Abdul Hamid
Clinical Supervisor
Kasih Mulia Foundation
Indonesia
Fadilan Abdul Kayong
Senior Advisor
The Colombo Plan Afghanistan Ofce
Afghanistan
Ibrahim Salim
Trainer
Sri Lanka
Dr. Shanthi Ranganathan
Hon. Secretary
TTK Hospital
India

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