Program Goals
The identified goal of treatment varies depending on the expectations, aspirations, motivations, and sometimes, mandated requirements of different stakeholders related to the patient. A spouse may demand sobriety as a condition of returning to the home. A court may mandate a certain number of days in treatment in lieu of custody. Probation and Parole want to reduce recidivism. A child welfare agency may want to keep children safe and so remove children from a home pending completion of a treatment program and the return a certain number of clean drug tests.
Identified goals also vary among patients. One may be motivated to live a healthier life. Another may be motivated to avoid adverse social consequences such as a job loss or incarceration. Another may be motivated to move out of homelessness.
A patient-centered treatment program works to align these diverse goals. Note that it is common for recovery goals to change as a person progresses through their recovery. For example:
Detoxification: I want to stop hurting.
Post-acute Withdrawal Management: I want to think clearly and sleep through the night.
Residential Treatment:
I want to satisfy a court mandate.
I want to qualify for a pass.
I want to reconcile with my family.
I want to live a healthy life.
Intensive Outpatient Program
I want to avoid relapse.
I want to learn about my reasons and patterns of my relapses
I want to find a job.
I want to find a stable place to live.
Outpatient Program
I want to learn to manage stress in healthy ways.
I want to become a trustworthy person.
I want to balance my family, work, and social life.
I want to give back to my community.
ARS works with community partners to help patients remain free of alcohol and other drug problems so they may become positive contributor to society. We create a structured environment that holds patients accountable to personal recovery goals while feeding their motivation and providing support that encourages recovery.
Assessment and Treatment
The ASAM Criteria informs a person’s need for SUD treatment and their level of care. An ASAM assessment uses “Six Dimensions” to measure biopsycosocial and environmental indicators of the acuity of a SUD using a Likert scale between 0-None and 4-Very Severe. We also map behavior against DSM V diagnostic criteria for SUD in four categories:
Impaired Control
Physical Dependence
Social Problems
Risky Use
The DSM breaks these four categories down into eleven symptoms. Acuity is determined by the number of symptoms a person has from Mild (2-3) and Moderate (4-5) to Severe (more than 6).
Patients referred to us through CPC frequently assess at a need for detoxification and withdrawal management services. They are diagnosed with Severe SUD. The diagnosis indicates a need for residential treatment following withdrawal management. Despite this diagnosis, many are placed at an outpatient level of care. This is most often due to patient motivation. A related factor is that an ASAM assessment relies on the self-report of the patient. A less experienced clinician may fail to adjust for minimizing in the patient self-report.
Unmotivated patients, patients in active denial, and/or patients who carry a significant burden of shame tend to minimize their self-report during an assessment interview. A clinician must explore patient responses to questions with the intent to understand the patient’s substance use pattern and history while building a positive and affirming therapeutic alliance. Patients must sometimes be re-assessed once they have experienced the treatment environment to be a safe place for self-disclosure.
A need for reassessment is frequently indicated by the simple observation that patients are actively using substances while in an outpatient level of care. They express behavior consistent with a precontemplation stage of change. In the Precontemplation stage, patients do not recognize/believe they have a problem with substance use. Or, if they recognize a problem, they are not ready to address their behavior.
From time to time a patient may present with a cooccurring mental health disorder that remains unstablized, either through medication or lack of coping skills. Many live in social environments that undermine recovery goals. They may live with family members who actively use and encourage use. They may live in a neighborhood where use is common, and/or they associate with peers who encourage use.
One goal of treatment with this population is for our counselors to maintain a nonjudgmental orientation to the patient and focus on building a patient-centered, strength-based therapeutic alliance. The primary goal of the treatment plan is to encourage the patient to appear for groups and 1x1 counseling sessions. Note: Those who do appear experience progress in recovery.
We have seen successful CPC patients who have completed the program at the IOP and OP level of care. We have also seen patients who had been intermittent in appearance at their IOP treatment group, and who were actively using substances, develop the motivation to seek a higher level of care. They admit to our detoxification and residential treatment program. Patients who remain connected to the program, even while continue to use substance at first, eventually experience success. The goal is to feed patient motivation despite resistance and to allow time for patient motivation to grow.
Treatment Progress
The ASAM Criteria not only informs an initial assessment, but it also provides a framework for tracking progress through treatment. We use the Six Dimensions to measure biopsycosocial progress in recovery.
Dimension 1
Dimension 1 (D1) indicates active use and assesses for acute intoxication and withdrawal potential. Normally, a patient at an outpatient level of care must score “0” in severity in D1. Note also that only patients who score “0” in D1 are eligible for residential treatment. All others should be placed in detox for withdrawal management.
Patient motivation is a necessary criterion for successful completion of treatment. In pre- and early recovery limited patient motivation is not surprising. Maintaining contact with a patient who is continuing to use is a valuable first step toward recovery even with the patient is in a Precontemplation stage of change.
ARS supports placing patients in an outpatient level of care even when they assess for a higher level of care when the patient lacks motivation for residential treatment. Placement can serve as a harm reduction measure. Some education is better than no education. It also provides a gateway to greater treatment engagement as patient motivation changes.
Dimension 2
Dimension 2 assesses for biomedical conditions. Patients with a long history of substance use sometimes live with undiagnosed medical complications. The Department of Health Care Services requires a physical exam to have been completed within one year of admission to treatment.
Patients who pass through our residential program all receive a physical exam (if they had not had one in the prior year). An outpatient patient (who assesses for needing residential treatment) commonly resists completing a physical exam. A willingness to take responsibility for self-care is an indication of progress in recovery. For example, a patient may give the counselor permission to help address their medical conditions when they withhold permission to address their SUD. Clinical engagement around the D2 issues provide an opportunity to build therapeutic alliance.
Dimension 3
D3 assesses for emotional, behavioral, and cognitive conditions. From time to time, we receive a CPC patient who presents with an untreated mental health disorder. Because stronger and cheaper formulations of methamphetamine are now available on the street, we see more “meth induced psychosis.” An untreated mental health condition can be disruptive in a SUD therapeutic group setting. We refer patients to the appropriate mental health provider to be stabilized as we work with their SUD.
We frequently see emotional conditions related to trauma. Many CPC patients disclose they have grown up with multiple adverse childhood experiences. Childhood trauma is a leading risk factor for developing SUD later in life. Because CPC patients are also justice involved, many also present with adult trauma associated with their participation in a criminogenic culture.
Progress in this domain is indicated by a willingness to begin to address trauma memory and to develop new coping strategies to help them self-soothe without reliance on illicit substances. A readiness to be compliant with medication prescribed by a mental health provider is also an indicator of progress.
Dimension 4
Dimension 4 assess for the patient’s readiness to change. As discussed above, encouraging patient motivation is with rare exception the counselor’s first challenge. One myth suggests that a person “must be ready” before addiction treatment can work. Studies indicate that SUD treatment begins to work at any time when it is grounded in the patient’s lived experience. That is, motivation to stay out of jail, to avoid losing one’s children, or even to come in out of the rain to receive a warm meal is sufficient motivation where recovery can begin.
Using the Transtheoretical Model of Change, we assess patient motivation based on what they say and do. A patient who succeeds at the outpatient level of care is generally ready to act. An SUD patient who is in the Precontemplation stage of change is best served in a residential treatment setting. As stated earlier, the goal of an outpatient treatment setting for patients who are actively using is to feed their motivation to be ready to admit to residential treatment. We rarely see an active user succeed at the outpatient level of care except as a transition to residential treatment.
In residential treatment patients address denial. For example, we see “Flight into Health” (one of Terry Gorski’s 12 Denial Patterns) is a common denial pattern patients use. “Feeling better means that I’m ‘cured’.” Patients leave against medical advice when they have convinced themselves that they no longer “need” treatment. Immediate relapse is an indicator that their unspoken motivation is to return to use.
A successful graduate of the residential treatment program has learned about the 12 Denial Patterns. They have taken time to reflect on the consequences of prior drug use. They have learned to nurse a vision of what their life may be like without substance use.
Progress in treatment at D4 s measured by changes in patient motivation. Patients who have successfully initiated recovery in residential treatment, find in an outpatient setting an opportunity to clarify and reinforce their motivation for recovery. For those who have not yet initiated recovery, the challenge is to raise awareness of their denial patterns and help them to imagine a new and better life. This feeds their motivation.
Dimension 5
Dimension 5 assesses for relapse potential. A patient who is appropriately placed in an outpatient level of care who has completed residential treatment, has developed an initial relapse prevention plan. In an outpatient setting the relapse prevention plan is refined and reality tested. Living outside of a structured environment, the patient experiences stressors and triggers that contribute to relapse. The counselor works with the patient to explore how to use the relapse prevention plan. They revise the plan based on the patient’s experiences outside of residential treatment. If a lapse occurs, the counselor conducts a relapse review with the (enthusiastic) participation of the patient who experiences the exercise not as a moment of shame, but rathe empowerment.
CPC patients who are placed at an outpatient level of care and who are continuing to use, lack a relapse prevention plan. They are generally not motivated to create one. Again, for this population the primary goal is to feed motivation for recovery and to address harm reduction.
Dimension 6
Dimension 6 assesses for the patient’s recovery environment. Family life, friends, neighborhood, education, housing, employment, involvement in the justice system, and other social conditions inform the patient’s life-setting. A counselor must challenge suboptimal living conditions the patient has normalized over time. The counselor helps the patient develop an understanding of the value of healthy family and relationships, stable work, and safe housing.
For some, living in a residential setting is the first time they have been treated with respect and unconditional regard. Unconditional regard is an attitude of caring, acceptance, affirmation, and validation that others express to someone without reference to their behavior. This is fundamental to shame reduction and raising self-awareness of personal value and potentional for growth. This is of particular importance for patients who grew up with multiple adverse childhood experiences.
Residential treatment also introduces therapeutic community. In a therapeutic community patients begin to practice prosocial, community living skills. Readiness for discharge from the residential setting is in part indicated by patient behavior that demonstrates their ability to continue to participate as contributing member of a therapeutic community in a less structured sober living environment.
Prosocial values that make community living therapeutic include honesty, responsibility-taking, conflict resolution, a healthy work ethic, an openness to other perspectives, and a willingness to learn. These skills take the place of criminogenic traits that accompany SUD. Prosocial skills learned and practiced in the residential setting continue to develop in an outpatient level of care and when the patient moves into a supervised sober living environment (SLE). The counselor monitors and addresses prosocial behavior as the counselor receives regular reports from the SLE residential staff.
As patients progress through the stages of recovery, the assume greater responsibility in their SLE. They participate in and contribute to therapeutic community with their housemates. The goal is for the patient to leave the program not only alcohol and drug-free, not only employed or in school, but also ready to contribute to society as a person of character.
A patient who admits directly to an outpatient level of care has not experienced the formative influence of a therapeutic community. Some continue to live in a criminogenic, re-traumatizing environment. They have normalized behavior associated with substance use and reinforced by harmful living environments and communities that actively promote substance use. They lack the opportunity to be treated with respect and unconditional regard. Shame persists covered by a thin veneer of bravado.
The outpatient setting must serve as a limited, quasi-therapeutic community. We advise more exposure to this more healthful environment, at least five days a week. In this setting the patient may experience sufficient trust, affirmation, validation, and other prosocial messages that feed their motivation for recovery.
A patient who qualifies for stepping down to treatment in Outpatient setting is in the Action stage of change and transitioning to Maintenance. The patient is no longer using substances. They have a relapse prevention plan in place, and it is working to support their recovery. They have cleared any outstanding medical / mental health issues. They are living in an environment that supports their recovery and they are participating in a recovery community that genuinely supports their emotional needs. Legal issues are resolved, or they are being resolved with positive outcomes.
Having a job is not sufficient criteria for participation in an outpatient program. Placement may be justified as a harm reduction measure and to allow for the growth of patient motivation through the active intervention of the counselor.
Duration of Treatment
We have seen that patients who have medical necessity for, and admit to, residential treatment remains engaged and benefit from treatment for up to sixty days. Some who present with more significant trauma in their history, or who delay engaging fully in treatment in early weeks, may require as many as ninety days of residential treatment.
Most patients who successfully complete residential treatment step down into an outpatient level of care and continue to be successful. Those who decline to continue treatment relapse shortly after discharge. Some do so within a week of discharge.
Intensive Outpatient Program
Outpatient treatment is segmented into three levels of care: Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Outpatient Program (OP). We do not provide PHP programing currently. Dosage of treatment in an OP setting is a function of frequency and volume. Frequency is how many treatment episodes a person participates in each week. Volume is the amount of time a person participates in each week.
At the IOP level of care, a patient receives between 9-19 hours a week of treatment. Most self-referred patients who step down to IOP receive 10 hours a week of group (two hours, five days a week) and one or two hours of individual counseling. From time to time some have requested to participate in 18 hours of group each week.
The IOP patient may lapse from time to time. But because they remain in treatment, and because they have developed behaviors associated with honesty, transparency, and an appreciation for the support of a recovery community, it does not result in a relapse.
Motivated patients who engage in treatment experience success and graduate after stepping down to an OP level of care within three to five months. Ten hours of group each week, plus 1 individual counseling session, renders 132 hours of treatment over three months, 176 hours of treatment over four months.
Treatment outcomes are conditioned by the motivation of the patient and the quality of their treatment engagement. As discussed above, a patient who is actively using substances will not experience the same quality of success over a three-to-five-month period as the more motivated patient. The reason is that they are unable to address personal recovery challenges while under the influences of substances.
Episodic and infrequent participation in treatment at the IOP level of care has some benefit insofar as it keeps a patient in relationship with at least one supportive person (the counselor) who is willing to listen to the patient and reflect their ambivalence. Each moment of engagement presents an opportunity to encourage patient motivation and to mitigate risk through harm reduction education that address the motivation-knowledge-attitude-behavior continuum.
While harm reduction is a meaningful outcome, we do not measure success for the episodic and infrequent participant using the same standard as we use for the motivated IOP patient whose dosage (frequency and volume) has the promise of resulting in long-term recovery and prosocial living. Success may be measured in terms of the eventual decision to admit to a residential treatment program.
Outpatient Program
OP is up to nine hours a week of treatment. A candidate for the OP level of care has ceased active use. They have developed and enjoy the support of an active recovery community. They have stable employment
An OP patient who has made the recovery journey from detoxification through residential treatment having stepped down to the IOP level of care will have experienced 5-7 months of living without substances. They have been away from substances long enough now to experience life-stressors without turning to a substance to avoid the genuine difficulty and sometimes real pain of daily living.
As an OP patient, the participant is now able to address feelings and develop coping skills that enable them to be in sustained and sustaining relationship with others and to live a prosocial, productive life. They remain in treatment (for up to nine hours a week) because of the additional support they need to continue through recovery journey. As they gain personal confidence and enjoy genuine support they have learned to receive from a recovery community, the OP patient may step down to one group a week and an individual counseling session. The work at this level is supportive and will lead soon to a successful discharge from the program.
Recovery Services
A final level of care funded by Partnership HealthPlan of California, Recovery Services, provides for post-treatment support services. This is intended to be an “alumni” service for patients who have completed treatment and who are successfully advancing their recovery goals outside the support of a clinical relationship. Services include occasional group sessions (once or twice a month) and individual counseling sessions as requested by the patient for consultation or additional support. Recovery Services is a relapse prevention measure.
Markers for Level of Care
3.2 Detoxification:
Active substance uses with withdrawal potential.
3.1 Residential Treatment
The patient demonstrates they are unable to stop use outside a 24 hour, highly structured and supervised environment.
The patient demonstrates sufficient motivation to be admitted to treatment.
2.1 Intensive Outpatient Program
The patient has stopped using substances but risks relapse without daily support.
The patient demonstrates that motivation to change is shifting from external to internal locus of control.
They patient is taken action to change, and lingering ambivalence may remain.
The patient actively seeks supports from others.
The patient is willing to be transparent and honest in treatment.
The patient participates in treatment on a regular and ongoing basis.
1.0 Outpatient Program
The patient has developed a recovery support community
The patient has a realistic relapse prevention plan that they actively use.
The patient can identify life-stressors, emotional challenges, and barriers to goals and to process then in a constructive way.