Unit One: Core Knowledge
In this unit, we explore the key areas of counselor knowledge. The chapters focus on information that is relevant to anyone working in addictions treatment and is foundational to good clinical practice.
Included are sections on the core functions of the addictions counselor, ASAM assessment and placement criteria, understanding diagnostic criteria, and becoming familiar with the Illinois administrative code governing treatment services – referred to at the 2060 law. Note that the information relating to the Illinois 2060 code is for the benefit of those seeking certification in the state of Illinois.
Being familiar with this content is important for all counselors to be successful in the field. The core functions encompass a group of fundamental aspects of the job, while assessment and diagnostic elements speak to the ways we establish a need for treatment and a path for working with an individual. The 2060 law outlines the requirements of all licensed treatment programs in the state of Illinois and provide critical expectations for all counselors to be aware of.
For many years, alcoholism treatment providers predominantly assumed that people with drinking problems[1] were a homogeneous group that could be treated optimally with only one treatment modality. This modality involved inpatient care with a fixed length of stay and a treatment approach based on the 12-step model of Alcoholics Anonymous. In recent years, however, both assumptions—that of patient homogeneity and treatment uniformity—have been abandoned. As the articles in this journal issue illustrate, researchers and clinicians now recognize that problem drinkers are a diverse group and differ substantially in the causes and manifestations of their alcohol-related problems. Furthermore, most researchers now believe that no single form of treatment is effective for all people presenting with alcohol-related problems (Hester and Miller 1989). Consequently, alcohol researchers now are conducting many studies designed to determine what types of interventions are most effective for what types of patients. This approach is founded on the “matching hypothesis,” which states that an optimal matching of patients and treatments will produce the greatest overall treatment effectiveness.
The need to acknowledge formally the heterogeneity of treatment needs among people with alcohol-related problems recently has received additional impetus from a direction unanticipated when the subtyping of alcoholics first became popular—namely, from the proliferation of managed care systems as a means of controlling health care costs (see sidebar, p. 38.). With the widespread use of managed care in treating alcohol and other drug (AOD) abuse in both the private and public sectors, the demand for specific types or levels of treatment (e.g., inpatient detoxification or residential rehabilitation) now depends on more than just the patient’s wishes or the physician’s perceptions of what the patient needs. Patients now must meet utilization review criteria set by the managed care providers in order to be eligible for treatment reimbursement. In addition to controlling costs, the development of such criteria will enable health care delivery systems to account for meaningful and valid differences among problem drinkers and to determine more accurately the mix of treatment services the patients need. Ultimately, the improved match between patient needs and the types of services avail able within the system will enhance the efficiency and effectiveness of the alcoholism treatment system. This matching process likely will focus on selecting specific treatment modalities rather than on the settings in which these modalities are provided.
The ASAM Criteria
The ASAM criteria were developed from numerous and widely disseminated drafts and revisions and were evaluated in field tests at 15 different sites (MeeLee 1993). The primary goal of the criteria was to provide a common language for both providers and payers when determining the severity of a patient’s problems, the different levels or settings of the treatment modalities offered, and the criteria for patient placement within the continuum of AOD treatment. These criteria not only described patient characteristics that might warrant inpatient care but also provided guidelines for different types of outpatient treatment and outlined the process of moving across different levels of care.
The ASAM system is built around criteria dimensions that are used to place patients in one of four levels of care originally presented in an Institute of Medicine report (1990) describing transitions in the alcoholism treatment field. The four levels of care are as follows:
• Level I: Outpatient treatment.
Such settings include organized nonresidential services or office practices in permanent facilities with designated addiction treatment personnel who provide professionally directed evaluation, treatment, and recovery services to addicted patients. The services are provided in regularly scheduled sessions of usually fewer than 9 hours per week.
• Level II: Intensive outpatient and partial hospitalization treatment. In these settings, an organized service with designated addiction personnel provides a planned treatment regimen consisting of regularly scheduled sessions of at least 9 hours per week within a structured program. This level of care affords patients the opportunity to interact with the realworld environment while still benefiting from a programmatically structured therapeutic milieu.
• Level III: Residential and medically monitored inpatient treatment. These modalities, which are offered in permanent facilities with inpatient beds, include a planned regimen of roundtheclock professionally directed evaluation, care, and treatment for addicted patients provided by designated addiction personnel. The treatment is specific to AOD abuse and does not require the full resources of an acutecare general hospital.
• Level IV: Medically managed inpatient treatment. This level of care, which also is administered by designated addiction professionals, provides a roundtheclock planned regimen of medically directed evaluation, care, and treatment for addicted clients in an acute care inpatient setting. Such a service requires permanent facilities that include, at a minimum, inpatient beds. A multidisciplinary staff and the full resources of a general hospital are available to provide treatment for clients with severe acute problems necessitating primary medical and nursing services. Treatment is specific to AOD-use disorders, although the available support services allow concurrent treatment of coexisting acute biomedical and emotional conditions.
Under ASAM guidelines, clients are assigned to one of the four levels of care after being evaluated along six criteria dimensions reflecting the severity of the client’s problems. Each dimension contains several criteria, and the number of specific criteria that must be met depends on the level of care. These six dimensions are described in the following paragraphs.
Dimension 1: Acute Intoxication and/or Withdrawal Potential. The ASAM criteria assume that a person who is acutely intoxicated cannot be monitored adequately as an outpatient and should receive more intensive care. When assessing withdrawal potential, one of the most important considerations is whether the client is at risk of experiencing lifethreatening withdrawal symptoms or requires medication or other support services to cope with or reduce the discomfort of withdrawal, which otherwise might cause him or her to terminate treatment.
Dimension 2: Biomedical Conditions or Complications. Higher levels of care are indicated when continued AOD use would put the client in danger of health complications. For example, an alcoholdependent woman who is pregnant might benefit from a higher level of care. Similarly, problem drinkers with cardiovascular, liver, or gastrointestinal diseases requiring medical monitoring or treatment should receive a higher level of care.
Dimension 3: Cognitive, Emotional, and Behavioral Conditions and Complications. A wide range of emotional and behavioral conditions and com plications exist in problem drinkers, either as manifestations of alcohol abuse or as independent, coexisting psychiatric disorders. These conditions (e.g., debilitating anxiety, guilt, or depression) deserve special attention during treatment and therefore may necessitate a higher level of clinical care. Moreover, problem drinkers exhibiting signs of an imminent risk of harming themselves (e.g., attempting suicide) or others may require 24-hour monitoring, thus justifying a higher level of clinical care. The same holds true for problem drinkers whose mental status does not allow them to understand the nature of the disorder or the treatment process.
Dimension 4: Readiness to Change. Clients in SUD treatment vary greatly in their willingness to comply with treatment regimens. Clients who seek treatment and cooperate by following clinical instructions typically require a lower level of care. However, alcohol dependence often compromises a person’s capacity to cooperate with treatment protocols. Clients often present for treatment with some level of understanding that alcohol is responsible for their alcohol problems but are still unwilling to participate in the clinical process. Other clients may deny that they have a drinking problem. Thus, some problem drinkers may be unlikely to enter the treatment system without first receiving some form of therapeutic preparation directed at addressing their denial and their resistance to treatment. Under these conditions, a high level of clinical care may be appropriate.
Dimension 5: Relapse/Continued Use Potential. Because drug-related problems involve recurrent patterns of behavior, relapse is a frequent and integral part of the natural history of the disorder. Two major sets of factors that derive from the client’s personal (i.e., psychological and biological) background and social environment contribute to relapse potential. This dimension addresses the personal factors that influence the extent to which people can control their environments (environmental factors are addressed in dimension 6). Accordingly, when these elements impede a client’s control over his or her behavior in the current environment, a higher level of care (e.g., a halfway house rather than outpatient care) may be justified to minimize the relapse risk. For example, if a client experiences marked and persistent cravings for alcohol and thus has higher relapse potential, treatment success may be less likely in an outpatient than in an inpatient setting.
Dimension 6: Recovery Environment. The client’s environment can facilitate recovery or increase the risk of relapse. When the social setting is supportive (e.g., family members and friends agree with and encourage recovery) or the client seeks out social surroundings that discourage alcohol abusing behavior patterns, a lower level of clinical care may be justified. However, when a recovering person’s social setting is compromised—for example, by inadequate transportation to the treatment provider, a higher level of family stress, or friends and coworkers who regularly use alcohol—a higher level of care may be required.
Key Takeaways
- Clients are assigned to the four levels of care after being evaluated along six criteria dimensions.
- Greater severity of issues corresponds to a higher level of care on the continuum.
Table 1 summarizes the correlations between the treatment settings and criteria dimensions specified by the ASAM guidelines. The actual criteria for placing an individual into a given level of care vary according to the care level, and placement ultimately depends on the combination of client characteristics in the six assessment dimensions.
For example, treatment in an outpatient setting (i.e., level I) requires that the patient meets level I criteria in all six assessment dimensions, whereas treatment in an inpatient setting (i.e., level III or IV) requires that the client meets the corresponding severity criteria in at least two of the six dimensions. Furthermore, not all dimensions are relevant to all placement decisions. For example, readiness to change, relapse potential, and recovery environment are not used to distinguish between clients requiring level III and level IV care.
| Criteria Dimension | Level I: Outpatient Treatment | Level II: Intensive Outpatient or Partial Hospitalization Treatment | Level III: Medically Monitored Inpatient (Residential) Treatment | Level IV: Medically Managed Inpatient Treatment |
| Acute Intoxication/ Withdrawal Potential | Minimal to no risk of severe withdrawal; will enter detoxification if needed. | Minimal risk of severe with- drawal; will enter detoxifica- tion if needed and responds to social support when com- bined with treatment. | Risk of severe but manage- able withdrawal, or has failed detoxification at lower levels of care. | Risk of severe withdrawal; detoxification requires fre- quent monitoring. |
| Biomedical Conditions | None or noninterfering with treatment. | May interfere with treatment but client does not require inpatient care. | Continued use means imminent danger, or complications or other illness requires medical monitoring. | Complications (e.g., recur- rent seizures or disulfiram reactions) that require medical management. |
| Cognitive/Emotional/ Behavioral Conditions | Some anxiety, guilt, or depression related to abuse, but no risk of harm to self or others. Mental status permits treatment comprehen- sion and participation. | Inability to maintain behav- ioral stability, abuse/neglect of family, or mild risk of harm to self or others. | Symptoms require structured environment, moderate risk of harm to self or others, or history of violence during intoxication. | Uncontrolled behavior, confusion/disorientation, ex- treme depression, thought disorder, or alcohol hallucinosis/psychosis. |
| Readiness to Change | Willing to cooperate and attend treatment; admits problem. | Attributes problems exter- nally; not severely resistant. | Does not accept severity of problems despite serious consequences. | Any difficulties noted in levels I, II, or III. |
| Relapse Potential | Able to achieve goals with support and ther- apeutic contact. | Deteriorating during level I treatment, or will drink with- out close monitoring and support. | Deteriorating and in crisis during outpatient care, or at- tempts to control drinking without success. | Any difficulties noted in levels I, II, or III. |
| Recovery Environment | Supportive social en- vironment or motivated to obtain social support. | Current job environment dis- ruptive, family/support sys- tem nonsupportive, or lack of social contacts. | Environment disruptive to treatment, logistic impedi- ments to outpatient care, or occupation places public at risk if client continues to drink. | Any difficulties noted in levels I, II, or III. |
| 1ASAM = American Society of Addiction Medicine. |
- In this article, the terms “people with drinking problems” and “problem drinkers” refer to all individuals whose alcohol consumption has caused them medical, psychological, or social problems. These overarching terms therefore encompass the more medical diagnoses of alcohol abuse and alcohol dependence as defined by the American Psychiatric Association. ↵
