Principles of Intensive Outpatient Treatment

This section presents 14 principles that integrate the findings of addictions research with the opinion of the consensus panel. By synthesizing research and practice, the consensus panel will assist clinicians in applying these principles to the clinical decisions they face daily. The 14 principles are expressed throughout this TIP in the form of specific recommendations. They are summarized here to provide a concise overview of effective intensive outpatient treatment (IOT) principles.

The Principles of Drug Addiction Treatment: A Research-Based Guide (National Institute on Drug Abuse 1999) offers a valuable starting point for the principles that are described in this chapter. The National Institute on Drug Abuse (NIDA) principles pertain to the full spectrum of addiction treatment modalities, not only to IOT. The consensus panel chose to accentuate the principles that are critical to effective IOT.

The 14 principles described in this section are

1. Make treatment readily available.
2. Ease entry
3. Build on existing motivation.
4. Enhance therapeutic alliance.
5. Make retention a priority.
6. Assess and address individual treatment needs.
7. Provide ongoing care.
8. Monitor abstinence.
9. Use mutual-help and other community-based supports.
10. Use medications if indicated.
11. Educate about substance abuse, recovery, and relapse.
12. Engage families, employers, and significant others.
13. Incorporate evidence-based approaches.
14. Improve program administration.

Principle 1: Make Treatment Readily Available

Accommodate a Wide Spectrum of Clients Who Are Substance Dependent

Clinical research and practice have established that IOT is an effective and viable way for individuals with a range of substance use disorders to begin their recovery. In the 1980s, it commonly was believed that only clients who were relatively high functioning, employed, and free of significant co-occurring psychiatric disorders could benefit from IOT and that IOT was not effective with clients who were compromised by significant psychosocial stressors such as homelessness or co-occurring disorders. Today substantial research and clinical experience indicate that IOT can be effective for clients with a range of biopsychosocial problems, particularly when appropriate psychiatric, medical, case management, housing, and other support services are provided.

IOT programs have adjusted successfully to the challenges of working with many special population groups that include

• Clients who are economically disadvantaged (Gruber et al. 2000; Milby et al. 1996)
• Clients who are psychiatrically compromised (Drake et al. 1998a, 1998b; Rosenheck et al. 1998)
• Pregnant women (Eisen et al. 2000; Howell et al. 1999)
• Individuals involved with the criminal justice system and other clients coerced into treatment

IOT programs have modified their treatment models to be responsive to the needs of adolescents (Jainchill 2000) and women with children (Nardi 1998; Volpicelli et al. 2000). In addition, panel members have described the benefits of IOT programs with culturally specific components for Native American and Spanish-speaking clients and IOT services for clients at various stages of treatment readiness. The unique needs of specific client populations often can be met in IOT by adding services and creating linkages with other service providers.

Principle 2: Ease Entry

Make Access to Treatment Straightforward and Welcoming

IOT programs need to examine policies and procedures to remove unnecessary hurdles in the admission process. From the moment a client or family member first contacts the program, efforts should be made to communicate that IOT exists to serve the client. Delays in the admission process contribute significantly to premature dropout from treatment (Festinger et al. 2002). IOT programs should strive to make the initial appointment available on demand.

Programs should address the following:

• Can the admission process be streamlined without hurting revenues?
• Are the program’s hours convenient for clients?
• How can the program facilitate transportation for clients?
• How can the program accommodate clients with childcare responsibilities?
• Is the program individualizing treatment for each client?

The initial encounter with the IOT program should help the client feel like a welcomed participant who is responsible for his or her recovery. IOT programs need to develop a strong customer-focused orientation, making entry into treatment a positive and therapeutic experience.

Principle 3: Build on Existing Motivation

Employ Strategies That Enhance the Client’s Motivation

One of the oldest, yet still surviving, misconceptions in the substance abuse treatment field is the notion that people have to “hit bottom” before they can be helped. Studies indicate that individuals who enter treatment for “the wrong reasons” (e.g., complying with external pressures) have outcomes that are comparable with outcomes of those who come into treatment for the “right reasons” (e.g., personal commitment to recovery) (Lawental et al. 1996).

Internal or external pressures drive people to enter treatment. Reasons include negative consequences related to substance use such as an arrest for driving under the influence, pressure from family or friends, fear that substance use is out of control, despair, job insecurity, or a trauma. An IOT program should accept that a client’s presence in its office indicates some desire for treatment services.

Regardless of how well or poorly motivated clients appear at treatment entry, their motivation is likely to waver repeatedly over time. Both IOT programs and clients benefit when counselors keep clients mindful of what led them to treatment. Counselors should try to understand what clients care about and connect client concerns with addressing substance use. For example, if a client talks frequently about her daughter, the counselor might ask the client to consider how substance use affects her relationship with the child.

Because of the central importance of motivation in substance abuse treatment, strategies to enhance and maintain client motivation have been a priority in substance abuse research. Two well-researched approaches offer insights into and strategies for maximizing client motivation:

• Contingency management and related behavioral interventions use incentives to increase client retention in treatment and abstinence. Contingency management in addiction treatment has been studied for more than 30 years, but recent studies have focused on how its principles can be applied in community-based settings (Budney and Higgins 1998; Higgins and Silverman 1999; Katz et al. 2001; Kirby et al. 1999a; Petry 2000). These behavioral intervention studies show that motivation is negotiable and can be increased when incentives are applied strategically and systematically. IOT programs are encouraged to find creative ways to use incentives to increase treatment adherence and enhance outcomes.
• Motivational enhancement and interviewing are techniques whereby the counselor responds to client denial and resistance by proposing thoughtful and detailed strategies that are designed to increase client readiness to change (CSAT 1999c; Miller and Rollnick 2002; Prochaska and DiClemente 1984). The approach is based on the theory that clients being treated for substance use disorders go through five stages of change: precontemplation, contemplation, action, relapse, and maintenance. Client resistance to treatment indicates that the counselor may be attempting to move the client to the next stage too quickly.

Principle 4: Enhance Therapeutic Alliance

Implement Strategies That Build Trust Between Counselor and Client

In treating mental and substance use disorders, research repeatedly has found one factor to be particularly important in influencing positive outcomes: therapeutic alliance (Martin et al. 2000). In fact, therapeutic alliance is one of the few aspects of treatment that consistently has been linked with increased retention in treatment and improvement in a variety of treatment outcomes. The achievement and maintenance of therapeutic alliance are high priorities in treatment.

Therapeutic alliance has four components (Gaston 1991):

• The client’s capacity to work on his or her problem
• The client’s emotional bond with the therapist
• The therapist’s empathic understanding of the client
• The agreement between client and therapist on the goals and tasks of treatment

Therapeutic alliance tends to be enhanced when clinicians are active listeners, empathic, and nonjudgmental and approach treatment as an active collaboration (Mercer and Woody 1999). Clinical supervisors should consider the counselors’ ability to establish and maintain a therapeutic alliance when hiring and evaluating staff. Staff training and supervision should emphasize consistently that therapeutic alliance is an important element of any clinical interaction. Performance monitoring and quality improvement activities can capture and measure data on therapeutic alliance, so staff members can improve their skills at fostering this important treatment element (see CSAT 2006f).

Principle 5: Make Retention a Priority

Place a Premium on Retaining Clients

Early termination of treatment harms the client and staff morale. When clients drop out of treatment prematurely, they are at increased risk of relapse. Completing a prescribed treatment episode is associated with better outcomes, regardless of the length of the treatment (Gottheil et al. 1998).

Given the large number of clients who drop out in the first few weeks of treatment, programs should use strategies and approaches that ensure that clients will complete treatment, such as conducting pre-admission interviews (Martino et al. 2000), delivering phone reminders and mailed reminders, using phone orientations, and decreasing the initial call-to-appointment delay (Stasiewicz and Stalker 1999).

A major strength of IOT is that clients have the opportunity to cope with their illness and make changes in their behavior while living at home. Individual differences in how quickly clients adopt new behaviors call for clinical sophistication and flexibility on the part of counselors and the program as a whole. It can be frustrating when clients do not accept immediately the clinical approach that the IOT program is using. Clients can be frustrated when they are forced into making major lifestyle changes that do not yet make sense to them. Under such circumstances, clients may drop out. Programs need counseling approaches that help clients move toward higher levels of healthy functioning.

Principle 6: Assess and Address Individual Treatment Needs

Match Treatment Services to Clients’ Needs

At intake, treatment providers gather preliminary information from clients; then, shortly after admission, programs typically complete a comprehensive biopsychosocial assessment. Many programs administer standardized assessments, such as the Addiction Severity Index (McLellan et al. 1992a, 1992b) as well as other specific and multidomain assessments. After collecting detailed information about clients’ histories and future goals, programs need to use this information to tailor treatment services to clients.

When clients have unmet psychiatric, medical, legal, housing, social, family, or other personal needs, their ability to focus on recovery can be compromised. When programs match the individual treatment needs of clients to treatment services that address those needs, outcomes improve  (Hser et al. 1999; McCaul et al. 2001; McLellan et al. 1998, 1999). NIDA’s Principles of Drug Addiction Treatment notes that “matching treatment settings, interventions, and services to each individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society” (National Institute on Drug Abuse 1999, p. 3). IOT programs need to find increasingly efficient strategies for assessing treatment needs and implementing individualized care plans.

Principle 7: Provide Ongoing Care

Employ a Chronic Care Model, Adjusting Intensity According to Clients’ Needs

A substance use disorder is a complex biopsychosocial illness that is not amenable to a quick fix. In addition to their substance use disorders, clients often have significant psychiatric disorders, criminal involvement, histories of physical and sexual trauma, serious medical illnesses, or profound economic challenges or are homeless. IOT programs contribute to society when they successfully assist clients in improving their ability to function in the community, in the workplace, and in their families. The successful initiation and maintenance of this transformation require sustained and conscientious efforts by the client, his or her support system, and a clinical team.

Substance abuse is a chronic illness similar in many respects to other chronic diseases such as asthma, diabetes, and hypertension (McLellan et al. 2000). During the early phase of treatment, intensive interventions may be required, including hospitalization. As the client’s condition changes, the intensity of treatment gradually can be increased or decreased depending on the client’s condition. Eventually client care may be reduced to periodic checkups that evaluate the client’s status and adjust treatment accordingly. A substance use disorder often is treated as if it were an acute illness that responds to a brief, acute course of treatment. Frequently, a 6-week IOT experience is not followed by a stepped-down phase of counseling sessions. For many clients, this abrupt shift from intensive treatment to discharge is destabilizing. Because substance abuse is a chronic condition and relapse is always a possibility, IOT programs are encouraged to examine how they can provide smoother stepdown processes and continuing care services that are responsive to the chronic nature of substance use disorders.

Following their successful completion of an intensive phase of treatment, clients should be evaluated for their readiness to be transferred to less intensive levels of care. Gradually, clients should be transitioned from several therapeutic contacts per week to weekly contact to semimonthly contact and so on. The concept of graduation should be reframed to convey clearly—as it is in colleges and universities—not an ending but a commencement or a new beginning.

Principle 8: Monitor Abstinence

Recognize the Progress That Clients Make in Achieving and Maintaining Abstinence

Programs might consider requiring 30 days of abstinence before transitioning clients to a less intense level of care because extended abstinence is associated with positive longterm outcomes (McKay et al. 1999). Although it is true that not all clients readily can achieve abstinence without relapsing a few times, it also is true that outcomes are best for those clients who have stopped using drugs and have submitted a drug-free urine sample before entering treatment (Ehrman et al. 2001). To monitor abstinence, IOT programs should use urine drug screens, Breathalyzer™ tests, or other laboratory tests to confirm self-reported abstinence. Urine drug screens can be an effective adjunct in treatment and can contribute to improved treatment outcomes (National Institute on Drug Abuse 1999). Although cost considerations may limit the frequency of urine drug screens and Breathalyzer tests, the consensus panel strongly encourages the use of these objective measures of abstinence.

Principle 9: Use Mutual-Help and Other CommunityBased Supports

Assist Clients in Successfully Integrating Into Mutual-Help and Other Community-Based Support Groups

Participation in mutual-help programs, such as 12-Step programs and treatment programs that facilitate 12-Step membership, is associated with better outcomes than participation in types of treatment that do not facilitate 12-Step membership (Humphreys et al. 1997; Moos et al. 1999; Project MATCH Research Group 1997; Vaillant 1983; see McCrady and Miller 1993, for a review of the Alcoholics Anonymous [AA] research literature). Clients who become involved in 12-Step programs after they step down from IOT tend to do significantly better than those who do not participate in such programs (Moos et al. 1999). IOT programs should facilitate clients’ becoming integrated successfully into healthy, community-based mutual-help groups, such as AA (www.alcoholics-anonymous.org) and Narcotics Anonymous (NA) (www.na.org), during treatment. IOT programs should assist clients directly in locating a home group and a sponsor and in becoming oriented to the culture of 12-Step programs.

It is not sufficient simply to refer clients to AA or other 12-Step groups. Just as a physician works with patients to find the right medication and dosage, counselors need to help clients identify the right type of meeting and frequency of attendance (Forman 2002). Just as patients often have unwanted side effects from medications, particularly when they first start taking them, clients who begin attending 12-Step and other mutual-help groups often experience some minor side effects. IOT programs can help clients minimize the negative side effects by providing orientation and support as clients adjust to this important treatment element. (There are many 12-Step meetings for the family, such as Al–Anon/Alateen [www.al-anon.alateen. org] and Nar-Anon [naranon.com], as well as groups for compulsive behaviors such as sex, gambling, spending, and eating.)

Many individuals who are substance dependent find abstinence through participation in faith-based organizations, and many religious groups offer support for individuals who are seeking recovery. Other individuals have benefited from support groups such as Rational Recovery (www.rational.org), Smart Recovery (www.smartrecovery.org), or Women for Sobriety (www.womenforsobriety.org) that offer an alternative to 12-Step meetings. Giving clients a choice of support groups is empowering because it enables them to make informed decisions.

Principle 10: Use Medications if Indicated

Use Appropriate Medications To Manage Co-Occurring Substance Use and Psychiatric Disorders

A substantial percentage of clients with substance use disorders also have co-occurring psychiatric conditions (Kessler et al. 1996; Marlowe et al. 1995). Psychiatric medications are critically important in the treatment of these co-occurring conditions (Carroll 1996a; Drake et al. 1998b; Minkoff 1997). Ideally, IOTs should provide psychiatric evaluation and medication management on site. If funding limitations make it impossible to offer this care on site, then efficient and functioning links with mental health providers need to be maintained. Resistance to the use of psychiatric medications by substance abuse treatment clinicians is gradually being replaced by an appreciation for the valuable role these medications can play when used appropriately. Likewise, both NA and AA historically  had been averse to medications of any kind, but both have published statements supporting the appropriate use of medications (Alcoholics Anonymous World Services 1991; Narcotics Anonymous 1998).

A number of pharmacotherapies have been shown to be effective adjuncts to the treatment of substance abuse. Naltrexone has been effective with some people who are alcohol dependent (Guardia et al. 2002). However, a multisite study by Krystal and colleagues (2001) found that naltrexone was not effective in treating men with chronic, severe alcohol dependence. Under certain conditions, naltrexone has been effective in treating individuals addicted to opioids (Cornish et al. 1997). Similarly, disulfiram (Antabuse®) has been an effective adjunct in the treatment of alcoholism (O’Farrell et al. 1998). Some IOT programs have implemented treatment tracks for clients maintained on methadone. Buprenorphine (Ling et al. 1998; O’Connor et al. 1998) and buprenorphine combined with naloxone (Fudala et al. 1998; Mendelson et al. 1999) are now available for the treatment of opioid dependence and can be prescribed at IOT programs that have medical personnel on staff.

Principle 11: Educate About Substance Use Disorders, Recovery, and Relapse

Provide Clients and Family Members With Information About Substance Use Disorders, Recovery Skills, and Relapse Prevention

An important task in IOT is educating clients about substance use disorders and the skills they need to live comfortably in recovery. A wealth of accurate, free information about substance abuse and recovery skills is available to clinicians through Web sites and other sources mentioned throughout this volume, but a good starting place is chapter 4 of TIP 33, Treatment for Stimulant Use Disorders (CSAT 1999e). IOT programs are encouraged to develop recovery curricula for clients (or use one already developed) and to facilitate opportunities for clients to practice recovery skills while in treatment. Substance refusal training, stress management, assertiveness training, relapse prevention, and relaxation training are important behavioral techniques that can be incorporated into IOT programs (Carroll 1998; CSAT 1999e; Daley 2001, 2003; Marlatt and Gordon 1985; Mercer and Woody 1999). Clients should be provided with up-to-date information about the biology of substance use disorders, mutual-help programs, and appropriate use of medications.

Given the significant body of information that clients might need to support their recovery, programs are encouraged to explore the use of videotapes, written materials, and Web-based resources to help clients understand addiction and recovery. Consideration should be given to multiple approaches to educating clients, including lectures, discussions, workbook assignments, behavioral rehearsals or role plays, and daily logs or journals. Evaluation processes, such as feedback sessions, that monitor the clients’ comprehension of key recovery skills are needed.

Principle 12: Engage Families, Employers, and Significant Others

Include Others Throughout the Treatment Process

The therapeutic involvement of families throughout the recovery process is associated with improved treatment outcomes (Epstein and McCrady 1998; McCrady et al. 1999; O’Farrell and Fals-Stewart 2003; Szapocznik and Williams 2000; White et al. 1998; Winters et al. 2002). Families can be a vital resource and a source of support and encouragement. Conversely, families also can influence the client adversely and undermine recovery. All clients are part of a group that functions as a “family” and as such are subject to the values, traditions, and culture of that family. IOT programs can marshal families’ powerful positive influences or counter their negative influences by educating, counseling, and providing therapeutic family services. Referrals to therapists and organizations that provide family therapy should be considered when family therapy is unavailable in the IOT program.

When an individual has been referred for treatment by an employee assistance or student assistance program, representatives of the employer and school can play a potent role in supporting adherence to the treatment plan and ongoing recovery.

Principle 13: Incorporate Evidence-Based Approaches

Seek Out Evidence-Based Training Opportunities and Materials

Over the past 30 years a number of treatment approaches have been developed, tested, and demonstrated to be effective in a variety of settings (see chapter 8 for more information). These approaches include

• Cognitive–behavioral therapy (Carroll 1998)
• Motivational enhancement therapy (CSAT 1999c; Miller and Rollnick 2002; Prochaska and DiClemente 1984)
• Individual drug counseling (Mercer and Woody 1999)
• Relapse prevention training (Carroll et al. 1998; Daley 2001, 2003; Daley and Marlatt 1997; Daley et al. 2003)
• Contingency management and incentives (Budney and Higgins 1998; Petry 2000)
• 12-Step facilitation (Nowinski et al. 1992)
• Case management (McLellan et al. 1998, 1999)

IOT programs can adopt methods from these various treatment interventions. NIDA, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the Center for Substance Abuse Treatment (CSAT) have published manuals about these approaches, and most of these manuals are available free of charge. A number of other evidence-based manuals are listed throughout this TIP, including documents from NIAAA Project MATCH and CSAT’s Addiction Technology Transfer Centers and other CSAT publications.

Some counselors who enter the substance abuse treatment profession do not have extensive training. For them, the needed skills are learned on the job. Evidence-based manuals summarize the experience of knowledgeable clinicians and researchers, passing on effective techniques and approaches that have been refined over the years. Not all IOT programs are the same— some achieve better outcomes than others. IOT programs can improve their outcomes by successfully incorporating evidence-based approaches. The consensus panel encourages the use of evidence-based approaches as a means of improving treatment outcomes.

Principle 14: Improve Program Administration

Focus on Financial, Information, and Human Resource Management

Clinicians frequently are promoted into the role of IOT program director without any formal training in how to function as an administrator. The tasks of management differ significantly from those of a clinician, and the transition from one role to the other is not always a smooth or natural one. IOT managers focus on the program’s finances, regulatory compliance, human resource management, information management, administrative report preparation, and a host of other tasks that were not in their list of responsibilities as clinicians. TIP 46, Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT 2006f), addresses the administrative issues that IOT managers need to master to manage programs effectively.

Intensive Outpatient Treatment Approaches

Intensive outpatient treatment (IOT) programs use a variety of theoretical approaches to treatment. No definitive research has established a best approach to treatment, and many factors (such as client characteristics and duration of treatment) influence research outcomes. However, studies have found positive associations between several treatment approaches and client outcomes.

Providers should be aware of the most commonly used approaches and their effectiveness so that they can make informed choices. This chapter contains descriptions of six commonly used and studied treatment approaches that form the core of treatment for many IOT programs:

• 12-Step facilitation
• Cognitive–behavioral
• Motivational
• Therapeutic community
• Matrix model
• Community reinforcement and contingency management

The section highlights each approach’s distinguishing characteristics, theoretical orientation, research support, and other critical elements such as staffing requirements or funding considerations. Exhibits summarize the strengths and challenges of each approach.

These descriptions give readers only a basic overview; they are not recipes for implementing the approaches in an IOT program. Clients often have complex psychosocial needs that demand creativity on the part of providers. These approaches are a means for shaping clinical interventions, but none should be considered complete treatment on its own. Excellent information, books, and treatment manuals are available from the Hazelden Foundation (www.hazelden.org), the National Institute on Drug Abuse (NIDA) (www.nida.nih.gov), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (www. niaaa.nih.gov), and the Substance Abuse and Mental Health Services Administration’s National Clearinghouse for Alcohol and Drug Information (www.ncadi. samhsa.gov) and Center for Substance Abuse Treatment (CSAT) (www.csat.samhsa.gov).

Although this section describes these six approaches as distinct, in reality IOT counselors increasingly use multiple approaches, modifying and blending them to address clients’ specific needs. This type of tailoring is a hallmark of effective treatment, but combining approaches calls for the provider to recognize and adjust for conflicts that may undermine each approach’s effectiveness.

12-Step Facilitation Approach

The Basics

The treatment approach of many IOT pro- grams evolved from the Minnesota Model of treatment, so called because it was first conceptualized at Hazelden Foundation and Willmar State Hospital in Minnesota in the late 1940s (White 1998). The Minnesota Model (also known as 12-Step facilitation) is based on the concepts of 12-Step fellow- ships, such as Alcoholics Anonymous (AA). These programs’ efforts were guided by the philosophical belief that alcoholism was a primary, progressive disease, with biological, psychological, and spiritual features.

The Minnesota Model used treatment teams of physicians, nurses, alcoholism counselors, family counselors, vocational rehabilitation counselors, and AA members in the treatment process. Basic to the process was a thorough introduction of clients to the principles of AA fellowship and the 12 Steps, education about the disease of alcoholism, and participation in AA groups inside and outside the hospital (M.M. Miller 1998).

Over time, the 12-Step approach evolved for use with people who use drugs and those with other compulsive disorders (such as eating disorders) (M.M. Miller 1998). Counselors, originally all in recovery themselves and often with little training, became more professional as training and credentialing standards were implemented (M.M. Miller 1998). Programs also were adapted to a variety of settings, including IOT. However, the basic principles and methods of the 12-Step treatment approach programs remained intact.

IOT programs that use a 12-Step approach focus on helping clients understand AA principles, start working through the 12 Steps, achieve abstinence, and become involved in community-based 12-Step groups, such as AA, Narcotics Anonymous (NA), or Cocaine Anonymous (CA). In these programs, educational efforts present alcoholism as a disease characterized by denial and loss of control. Homework assignments entail read- ing 12-Step literature, keeping a journal, and undertaking recovery tasks that personalize the 12 Steps. Much of the group work focuses on accepting the disease, assuming responsibility for the recovery process and one’s own actions, renewing hope, establishing trust, changing behavior, practicing self-disclosure, developing insights into one’s behavior, and making amends. Problems often are addressed in the context of step work. Clients are encouraged strongly to accept their addiction, develop or adopt spiritual values, and develop a sense of fellowship with others in recovery. IOT programs using a 12-Step approach usually invite AA, NA, CA, or other 12-Step groups to hold onsite meetings.

Clients are encouraged strongly to attend meetings in the community and to find a sponsor and home group for ongoing peer support following completion of the formal treatment program. Ideally, 12-Step-oriented IOT programs are in touch with a network of persons in recovery who can accompany ambivalent or reluctant clients to meetings in the community and help them find compatible groups.

Exhibit 8-1 summarizes the strengths and challenges of 12-Step facilitation.

Other Important Aspects

Staff

Staff members who are not in recovery them- selves should read AA, NA, and CA literature and consider regularly attending open meetings to ensure that they understand the beliefs, values, and mores of 12-Step fellowships. Likewise, staff members should familiarize themselves with local meetings and with the level of acceptance of clients with special needs (e.g., those with mental disorders). Familiarity with 12-Step culture and with local meetings help staff members orient departing clients to 12-Step recovery and to the available options.

Clients

Research has attempted to identify the individual characteristics that seem most predictive of affiliation with 12-Step pro- grams, particularly AA, but results often have been contradictory for some variables (McCrady 1998). The 12-Step approach may not be appropriate for every client, but 12-Step groups clearly serve a widely diverse group of people.

Research Outcomes and Findings

The NIAAA-funded Project MATCH com- pared treatment outcomes for persons dependent on alcohol who were exposed to one of three different treatment approaches: 12-Step facilitation (a 12-Step approach that followed a manual), cognitive–behavioral coping skills therapy, and motivational enhancement therapy (MET). All three approaches resulted in positive outcomes regarding drinking behavior from baseline to 1 year following treatment. The study found little difference in outcomes by type of treatment, although 12-Step facilitation showed a slight advantage over the 3 years following treatment (Project MATCH 1998).

Brown and colleagues (2002) investigated matching client attributes to two types of aftercare: structured relapse prevention and 12-Step facilitation. Overall, the 12-Step facilitation approach provided more favor- able outcomes for most people who abuse substances. In particular, the study found that clients reporting high psychological dis- tress, women, and clients reporting multiple substance use at baseline maintained abstinence for longer periods following treatment with 12-Step facilitation than with structured relapse prevention.

Cognitive–Behavioral Approach

The Basics

Cognitive–behavioral therapy (CBT) is based on the theory that most emotional and behavioral reactions are learned and that new ways of reacting and behaving can be learned.

The CBT approach focuses on teaching clients skills that help them recognize and reduce relapse risks, maintain abstinence, and enhance self-efficacy. Clients learn to identify personal “cues” or “triggers”—the people, situations, or feelings that may lead to drinking or drug use. Such triggers may be internal (such as physiological craving or stress reactions) or external (such as seeing friends with whom the client has used drugs). Clients then are taught new coping and problem-solving skills and strategies for effectively counteracting urges to drink or use drugs.

By analyzing their triggers, deciding on recovery-oriented responses and strategies, and role playing high-risk situations and responses, clients gain confidence that they can resist triggered urges to use substances. CBT approaches also are applied to other challenges in recovery, such as interpersonal relations, depression, anxiety, and anger management.

IOT programs are ideal for implementing cognitive–behavioral interventions. Clients usually continue to live and work in their normal environments, which are filled with relapse triggers. These situations provide material for problem-solving exercises, homework, and role plays during group or individual counseling and offer clients opportunities to use new coping strategies, cognitive skills, and behaviors.

The number, duration, and focus of treat- ment sessions vary widely in CBT-oriented programs. The CBT and 12-Step approaches are compatible, and many CBT-oriented programs encourage participation in 12-Step meetings.

Exhibit 8-2 summarizes the strengths and challenges of CBT.

Other Important Aspects

Staff

Counselors must be familiar with the theory and practice of CBT and have basic counseling skills. It is sometimes helpful to have co-therapists lead cognitive–behavioral groups, particularly those involving role plays and other interactive exercises.

Clients

CBT has been effective with a broad range of clients. However, clients with low literacy or intellectual skills or those for whom English is a second language may struggle with homework or group exercises that require reading or writing. Also, people with significant psychiatric disorders that have not been stabilized may be unable to participate sufficiently.

Research Outcomes and Findings

CBT models have been evaluated extensively, and randomized clinical trials found CBT-based relapse prevention treatment to be superior to minimal or no treatment (Carroll 1996b). When CBT was compared with other active therapeutic interventions, results were mixed. Project MATCH found CBT to be comparable with MET and 12- Step facilitation for decreasing alcohol use and alcohol-related problems. All three therapies resulted in positive improvements in participants’ outcomes that persisted for up to 3 years (Project MATCH 1998). Farabee and colleagues (2002) found that clients who received CBT reported more frequent engagement in substance-use avoidance activities 1 year after treatment than did clients who received treatment with contingency management.

Motivational Approaches

The Basics

In practice, motivational approaches include both motivational interviewing (MI) and MET. These motivational approaches can be incorporated into every stage of treatment (see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999c], pages 31–32, for specific suggestions).

MI techniques developed by Miller and Rollnick (2002) were derived from a variety of theoretical approaches to how people recover in progressive stages from addiction and other problem behaviors (Prochaska and DiClemente 1984, 1986). MI is a client- centered, empathic, but directive counseling strategy designed to explore and reduce a person’s ambivalence toward treatment. This approach frequently includes other problem-solving or solution-focused strategies that build on clients’ past successes. Motivational approaches acknowledge that drugs of abuse have rewarding properties that can disguise, at least temporarily, their hazards and negative long-term effects. Through empathic listening and skillful interviewing, the counselor encourages the client to

• Identify discrepancies between significant life goals and the consequences of sub- stance abuse.
• Believe in his or her capabilities for change.
• Choose among available strategies and options.
• Take responsibility for initiating and sustaining healthy personal behavior.

MI requires the counselor to relate to clients in a nonjudgmental, collaborative manner. Counselors pose questions to clients in a way that solicits information while strengthening clients’ motivation and commitment to posi- tive change. The counselor acts as a coach or consultant rather than as an authority figure. Counselors using MI follow four basic principles (CSAT 1999c):

• Express empathy. The counselor communicates that the client always is responsible for change and respects the client’s deci- sion on this issue.
• Identify discrepancies. The counselor encourages the client to focus on how cur- rent behavior differs from his or her ideals and goals.
• Roll with resistance and avoid arguing. The counselor uses strategies to reduce resistance.
• Support self-efficacy. The counselor recognizes client strengths and encourages him or her to believe that change is possible.

MET uses structured instruments for assessing dimensions of substance use (e.g., consumption, biomedical and social consequences, family history, readiness for change, risk factors). (Several of these instruments are reproduced in appendix B of TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999c].) Counselors provide feedback about assessment results in relation to societal norms and discuss clients’ responses to this feedback.

Exhibit 8-3 summarizes the strengths and challenges of MI and MET.

Other Important Aspects

Staff

Staff members’ educational levels are not critical to a motivational approach. Successful counselors may have graduate degrees and professional certification or be recovering peers. However, to become effective practitioners, counselors need special training as well as ongoing supervision to become proficient. Counselors also need to be flexible and have a high level of therapeutic empathy. Counselors are seen as collaborators or consultants rather than as experts.

Clients

MET was developed for, and has been effective with, clients exhibiting varying severities of alcohol-related problems. Court-mandated clients appear to benefit as much from MET as do self-referred clients.

Research Outcomes and Findings

A four-session version of MET was one of three 12-week approaches tested in Project MATCH. MET was found to be as effective as the other, more intensive interventions (CBT and 12-Step facilitation). Clients who rated high in anger fared better with MET, having more abstinent days (Project MATCH 1998).

Miller and Sanchez (1994) report that studies conducted in at least 14 countries indicate that relatively brief motivational interventions can have lasting, positive effects on drinking behavior that are comparable with the effects obtained with longer term treatment interventions.

Therapeutic Community Approach

The Basics

Therapeutic communities (TCs) have provided residential substance abuse treatment since the 1960s. Some programs have developed a modified, community-based IOT component either to provide treatment on an outpatient basis or to help graduates successfully transition from residential treatment into the community. Some traditional, community-based IOT programs serve clients who participated in TCs while the clients were incarcerated. IOT providers should understand the TC process to ensure continuity for clients.

TCs use an approach known as “community as method” (De Leon 2000). This approach sees the community as a whole—its social organization, its staff and clients, and its daily activities—as the therapeutic agent.

The TC model considers a substance use disorder as a disorder of the whole person. TC program staff members assess each participant’s problems along dimensions of psychological dysfunction and social deficits (e.g., problems with authority, poor impulse control, dishonesty) as well as substance use patterns. The TC approach assumes that recovery is a developmental process entailing mutual help and social learning. The beliefs and values that are essential to a client’s recovery include (De Leon 2000)

• Demonstrating truth and honesty in all situations
• Remaining in the “here and now”
• Assuming personal responsibility for one’s behavior and future
• Demonstrating concern for others
• Developing a work ethic and understand- ing that rewards must be earned
• Understanding the distinction between external behavior and inner self
• Accepting that change is the only certainty
• Valuing the learning process
• Developing economic self-reliance
• Becoming involved in one’s community
• Developing good citizenship

Because many clients served by TCs have histories of severe substance use disorders and criminal behavior, TCs typically strive to habilitate, rather than rehabilitate, cli- ents. TCs focus on all aspects of the client’s life, and all activities in the TC promote recovery and habilitation. TCs follow highly structured schedules, centering daily activi- ties on group sessions and hierarchical job functions that teach participants specific behaviors and skills. In general, participants move from job to job in the community for different learning experiences. Peers confront negative behaviors and erroneous thinking in one another within a supportive milieu.

TCs include the following components (De Leon 1995):

• A sense of community. Community is created partly by a separation from other agency 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 (except individual counseling) must be delivered within the peer community.
• Peers and staff members as role mod- els. TC members and staff members serve as positive role models by demonstrating expected behaviors and reflecting the val- ues and teachings of the community. The strength of the community for social learn- ing rests on the number and quality of its positive role models.
• Work as therapy and education. Consistent with the TC’s 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.
• Peer encounter groups, awareness training, and emotional growth training. The encounter session is the main therapeutic group and heightens clients’ awareness of specific attitudes or behavioral pat- terns that need to change. Other groups focus on helping clients identify feelings and express them appropriately and constructively.

TCs feature a structured day that includes ordered, routine activities to counter the characteristically disordered lives of clients and distract them from negative thinking and boredom. The treatment protocol is organized into phases and stages. When a client masters the objectives in one phase, he or she moves to the next phase. The length of treatment depends on the client’s needs and progress in recovery. Continuing services are part of the TC approach. Clients benefit from a peer network that assists them with ongoing community-based services to sustain recovery.

De Leon (2000) describes the basic stages of a TC program as

• Admission evaluation (a preprogram stage)
• Induction (an orientation stage)
• Primary treatment
• Reentry (into the outside community)

Exhibit 8-4 summarizes the strengths and challenges of the TC approach.

Other Important Aspects

Staff

TC staff members are generally a mix of trained clinicians (certified counselors, nurses, physicians, and case managers) and TC graduates who have had at least some additional training (many become certified). All staff members are part of the community and serve as role models. Staff members typically receive considerable training in TC philosophy and methods. Management staff in particular must be well trained to work effectively in a TC.

Clients

Clients appropriate for TC treatment typically have educational and employment deficits and histories of poverty, relationship problems, criminal behavior experiences or criminal associations, housing instability, psychiatric disorders, or antisocial or other dysfunctional behavior. Many have had pre- vious treatment episodes.

TC approaches should be modified for women, adolescents, and those with co- occurring mental disorders because the confrontational nature and strict hierarchical structure of a standard TC may not be as effective with these groups.

Training Manuals

CSAT has developed the Therapeutic Community Curriculum (CSAT 2006g, CSAT 2006h) to help supervisors provide TC staff members with an understanding of the essential components and methods of the TC and an appreciation that they are part of a long tradition of community as a method of treatment. The curriculum provides detailed session-by-session instructions for trainers and exercises for participants.

Special considerations

For clients in an outpatient TC, it is important to arrange for drug-free housing.

Research Outcomes and Findings

NIDA has funded treatment outcome studies that have found that TC treatment is associated with positive outcomes. For example, the Drug Abuse Treatment Outcome Study, a long-term study of treatment outcomes, found that clients who completed TC treatment had lower levels of cocaine, heroin, and alcohol use; criminal behavior; unemployment; and depression than they had before treatment (National Institute on Drug Abuse 2002).

Clinical trials of TC day treatment have found that client outcomes for residential TC and for day TC treatment are not significantly different (Guydish et al. 1999).

A study of the effectiveness of extending the TC model from prisons to community-based settings showed that inmates who participated in an institutional TC followed by a TC- oriented outpatient work-release program had lower rates of drug use and recidivism than offenders who participated only in the institutional program (Inciardi 1996).

The Matrix Model

The Basics

Matrix programs orient clients to 12-Step programs and often schedule onsite 12-Step meetings. Clients are encouraged strongly to attend additional meetings in the community and to find a 12-Step sponsor.

Exhibit 8-5 summarizes the strengths and challenges of the Matrix model.

Other Important Aspects

Staff

Trained therapists are crucial to Matrix model treatment. They are expected to create nurturing, nonjudgmental relationships; maintain a supportive attitude in the face of a client’s relapse; foster each client’s self-esteem and dignity; and function as teachers or coaches without being either parental or confrontational. Clients with established long-term abstinence sometimes co-lead groups, serving as role models who put a human face on the recovery process.

Clients

The Matrix model has been used in many different settings (including prisons, substance abuse treatment centers, and hospitals) and with a varied client population across the United States and in Mexico, Thailand, and the Middle East (Rawson 2003).

Treatment manuals

The Matrix model treatment materials contain instructions for therapists on conducting individual, group, and family education sessions (visit www.matrixinstitute. org). Handouts for clients and family mem- bers cover therapeutic session topics. Some materials have been translated into Spanish, Arabic, Thai, and other languages. CSAT has adapted the Matrix treatment manuals and made them available as a package called Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders (CSAT 2006c, 2006d).

Research Outcomes and Findings

Studies support the utility of Matrix model treatment. In a 1985 pilot study, individuals who selected Matrix treatment over a 28-day inpatient hospital program or participation in 12-Step groups reported significantly lower rates of cocaine use 8 months after treatment than those in either of the other groups (Rawson et al. 1986).

A controlled trial of the model found that people from lower income groups who smoke crack are more difficult to retain in Matrix treatment than those who used cocaine intra- nasally and had more social stability and resources (Obert et al. 2000).

Researchers conducting a CSAT-supported outcome study of Matrix model treatment (Rawson et al. 2002) interviewed a nonrandomized sample of clients who had used methamphetamine and received Matrix model treatment. They found that 2 to 5 years after completing treatment these cli- ents had reduced their methamphetamine and other drug use substantially compared with their pretreatment levels. In addition, a substantial number of the former clients were employed and were not in the criminal justice system.

Shoptaw and colleagues (1998) developed a 48-session variation of Matrix treatment for gay and bisexual men who abuse methamphetamine. The model was found to be an important tool for preventing HIV infection because clients reduced their risky sexual behaviors concurrently with reductions in their stimulant use—without any specific focus on HIV/AIDS during treatment (Shoptaw et al. 1997, 1998).

Community Reinforcement and Contingency Management Approaches

The Basics

Community reinforcement (CR) and contingency management (CM) are treatment approaches based on operant conditioning theory. This 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. Abstinence, in and of itself, may not be sufficiently reinforcing to maintain a person’s motivation to stop using drugs, particularly in early abstinence. Other rewards must be found that reinforce ongoing abstinence and lifestyle change.

CM is an approach in its own right, but its operant interventions are also the main treatment tool used in CR. In CR, the positive and negative reinforcers that characterize CM are understood to be socially mediated. CR uses aspects of the client’s life—relationships with family and friends, job, hobbies, social events—to provide the positive reinforcement that motivates the cli- ent to stop using substances. CR is successful when the client chooses the rewarding relationship and activities over substance use. (See Chapter 6 for a discussion of how CR can be used to motivate family members to support the client.) CR and CM approaches motivate clients’ behavioral change and rein- force abstinence by systematically rewarding desirable behaviors and ignoring or punish- ing others. Reinforcers are typically positive, pleasurable, and rewarding events or objects, but some negative reinforcers also are effective. Removing a fine or restriction after a client has complied with a specified regimen is an example of negative reinforcement.

A challenge in this treatment model is to identify a reward for a desired behavior that is both practical and sufficiently powerful— over time—to replace or substitute for the potent, pleasurable, or pain-reducing effects of the drug. The reward must be available without too much cost or expenditure of staff energy. The rewards and punishments must be tailored carefully to clients’ responses, as well as program capabilities. For example, vouchers worth $5 may be motivators for some clients but not others or at a particular point in treatment but not later. Most of the financial or voucher-based CM interventions use an escalating series of rewards for achievement of the target behavior, such as drug-free urine specimens. The escalating rewards provide a greater incentive for sustaining the desired behavior. On the other hand, Kirby and colleagues (1998) found greater reductions in cocaine use when a larger reward was given at the beginning of treatment, coupled with increased requirements for earning vouchers as treatment progressed.

An example of this approach is described in a NIDA treatment manual, A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction (Budney and Higgins 1998). In this approach, abstinence is reinforced by awarding vouchers. Drug avoidance skills and relapse prevention techniques are taught along with social and recreational counseling, relationship counseling, and social and other skills training. Clients earn points for each urine screen that is negative for cocaine. For each consecutive negative urine screen, the number of points is increased. If a client submits a urine specimen that is positive for cocaine, the point value returns to baseline. The client can earn back the points lost by submitting five consecutive negative urine specimens. The client can “redeem” points for a variety of retail items that are purchased by program staff (clients are never given cash). Staff members have veto power over clients’ requests. In general, staff members approve only items that are consistent with a client’s treatment goals and encourage drug-free activities. Examples of items purchased for the pro- gram’s clients include socks, toaster ovens, baby clothes, camera equipment, ski lift tickets, bicycle equipment, and continuing education materials.

Effective CR and CM programs select a target- ed behavior that is attainable in a reasonable amount of time and has a direct effect on the desired outcome. For example, expecting clients who have never submitted a drug-free urine sample to achieve immediate abstinence may be optimistic. Abstinence from a specific substance might precede abstinence from all substances. Targeting small changes is an effective strategy. More frequent rein- forcers, even if small, have a greater effect than larger, more remote rewards or punishments. It is also important that the desired behavior contribute to the treatment goals. A person’s merely attending counseling sessions may not affect his or her drug use. Of course, all rewards must be delivered as promised for the treatment to remain credible (Crowley 1999; Morral et al. 1999).

Specialized assessment and treatment planning instruments are not required for successful implementation of a CM intervention. However, CM interventions depend on detailed and precise measurements of the targeted behavior. Because of the short half-life of alcohol, using CM procedures to monitor alcohol abuse can be difficult. Self- reported drug use status is not adequate for awarding vouchers. Rather, drug use status must be determined by frequent testing of observed urine specimens (Crowley 1999). Similarly, if work activity is the target behavior, it is not enough to ask clients about their attendance or productivity. Objective, verifiable measures that demonstrate accomplishments must be used.

Activity schedules used in CR and CM pro- grams can vary dramatically. As an example, the activity schedule of an intensive reinforcement-based day hospital program provided abstinence-contingent partial support of housing and food and access to recreational activities, social skills training, and job-finding groups (Gruber et al. 2000). The program required clients recently detoxified from heroin and cocaine to attend treatment for 6 hours a day on weekdays and 3 to 4 hours a day on weekends for the first 2 weeks, then 1-hour individual counseling sessions three times per week for the next 6 weeks, and then two sessions per week for another 4 weeks. Abstinence-based contingencies were in effect for the first month of the program. By contrast, the schedule for a 6-month CR-plus-vouchers treatment entailed 60-minute individual counseling sessions two times a week and urine monitoring three times a week during the first 12 weeks. This was followed by weekly counsel- ing and twice weekly urine testing in weeks 13 to 24 (Budney and Higgins 1998).

Exhibit 8-6 summarizes the strengths and challenges of CR and CM.

Other Important Aspects

Staff

Designing CR and CM treatment programs requires specialized training and knowledge of operant learning principles. In practical terms, however, operant learning principles can be applied by staff members who have proper training and supervision. Some counselors may feel that the theories of operant conditioning or behavioral learning are inconsistent with the disease concept of sub- stance use disorders (Bigelow and Silverman 1999) and are incompatible with their train- ing and practice because behaviorists view addiction as a learned behavior rather than an illness with biological, psychological, and spiritual roots.

Clients

Intensive CM interventions have been used with treatment-resistant clients and with clients who have severe problems related to employment or housing or who have psychological and medical conditions and have been unsuccessful in achieving abstinence through traditional counseling methods.

Behavioral interventions have been effective with people who use cocaine (Higgins 1999), persons who are homeless (Milby et al. 1996), pregnant women (Higgins 1999), and individuals on methadone who need to discontinue other drug abuse (Higgins 1999).

Funding

The cost-effectiveness of CR and CM is affected by the expense of incentives, additional urine screens, and the additional time demands placed on staff members. In some research projects incentives cost $1,200 or more per client. This expense has limited application of CM techniques to research studies or small-scale project demonstrations. However, alternative low- cost incentives can be used to bolster the effect of traditional treatment interventions; donated goods and services can reduce the costs of CR and CM (Amass and Kamien 2004). Anniversary celebrations, special books, reductions in clinic fees, and letters of support to employers and protective ser- vice workers are among the incentives that can be used. Some programs have raised funds to support incentives or solicited local merchants for donations of goods or services (Kirby et al. 1999a).

Research Outcomes and Findings

Studies show that the CM approach to treat- ing substance use disorders has proved effective in motivating clients to achieve and sustain abstinence as well as increase their compliance with other treatment objectives (Bigelow and Silverman 1999; Higgins 1999; Morral et al. 1999). Generally, these studies have been conducted in outpatient settings in which delivery of incentives is coupled with traditional individual or group counsel- ing and education services. More recently, the CM approach has been applied in intensive outpatient and day treatment settings.

The NIDA treatment manual on community reinforcement (Budney and Higgins 1998) has provided an impetus for using empirically established CM techniques for treating cocaine abuse. The manual presents findings from five controlled clinical trials that sup- ported the superiority of CR plus vouchers over standard care. In one study, 75 percent of the clients participating in CR plus vouchers completed the program, compared with only 11 percent of standard care clients. Two subsequent studies showed that adding redeemable vouchers was more effective than CR as a standalone treatment (Higgins et al. 1995). A literature review of similar CR approaches found positive effects on cocaine dependence in 11 of 13 studies (Higgins 1996). Higgins and colleagues (2000) found that incentives delivered contingent on cocaine-free urinalysis results significantly increased abstinence during treatment and at 1-year followup.

Another landmark CM study examined the effectiveness of housing incentives for reducing crack cocaine use among people who are homeless (Milby et al. 1996). Incentives for drug-free housing and vouchers for social and recreational activities were more effective than 12-Step-oriented treatment alone for reducing alcohol and cocaine use as well as homelessness. At the 12-month followup, however, cocaine use in both groups had returned to baseline levels, suggesting the need for more intensive aftercare in this difficult-to-treat population.

Citation

Center for Substance Abuse Treatment. Substance Abuse: Clinical Issues in Intensive Outpatient Treatment. Treatment Improvement Protocol (TIP) Series 47. DHHS Publication No. (SMA) 06-4182. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006.

This work resides in the public domain, unless otherwise indicated.