237 -Clinical Issues in Intensive Outpatient
Counselor Toolbox

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Intensive Outpatient Services:
Clinical and Administrative Issues
TIPs 46 & 47
Dr. Dawn-Elise Snipes, PhD, LMHC
Overview IOT
~ Multidimensional/Biopsychosocial
~ Recognizes dual disorders as chronic
~ Values case management
~ Blends evidence-based with community based services
Core Features
~ 6–30 contact hours per week
~ Individualized step-up and step-down levels of care
~ Minimum duration of 90 days followed by step-down
Core Features cont…
~ Enhanced services
~ Ambulatory detoxification
~ Childcare
~ Outreach
~ Case Management
~ For more detailed information, see TIP 47, pp. 1–6

Core Services
~ Screening
~ Assessment
~ Treatment planning
~ Treatment engagement
~ Group, individual and family counseling
~ Psychoeducational programming
~ Integration into support groups
Core Services cont…
~ Relapse prevention training
~ Substance use screening and monitoring
~ Vocational and educational services
~ Referral to wrap-around services
~ Mentoring?
Principles of IOT
~ Treatment available to a wide spectrum of clients
~ Treatment access
~ Straightforward and welcoming
~ No Wrong Door
~ Enhance existing motivation
~ Trust between counselor and client
~ Client retention priority
~ Individualized assessment and treatment
Principles cont…
~ Implements flexible, chronic/episodic care model
~ Monitor abstinence
~ Help clients integrate into support groups
~ Medications to manage co-occurring disorders
~ Educate clients and family members
~ Families, employers, and significant others
~ Evidence-based training and materials
~ Improve program administration

Clinical Considerations
~ Challenges in Adolescents and Others
~ Inconsistent ability for abstract /future thinking
~ Impulsive/short attention span
~ Vulnerable to peer influence
~ Frequent emotional fluctuations
~ Lack of involvement in pro-social activities
~ Pessimistic/fatalistic attitudes
Treatment Engagement
~ Goals
~ Initiate a treatment contract
~ Resolve acute crises
~ Engage in a therapeutic alliance
~ Involve clients in preparing a treatment plan
~ Duration — A few days to a few weeks

Engagement Activities
 Confirm diagnosis, eligibility, appropriate placement
 Conduct biopsychosocial assessment
 Develop treatment plan
 Develop a relapse prevention plan
 Provide assessment feedback
 Explain program rules and expectations
 Address acute crises
 Resolve administrative issues
 Foster therapeutic alliances
◦ Client, counselor, group members
Engagement Activities cont…
~ Begin psychoeducational activities
~ Identify sources of social support
~ Initiate family contacts and education

Phase 1 Completion Criteria
~ Assessment and treatment plan completed
~ Client completely stabilized
~ Client demonstrates adequate attendance and participation
Early Recovery
~ Goals
~ Abstinence
~ Sustain behavioral changes
~ Identify relapse triggers and develop relapse prevention strategies
~ Identify and begin to resolve personal problems
~ Begin active involvement in a 12-Step or other mutual-help program
~ Duration — 6 weeks to about 3 months
Counselor Activities
~ Help clients follow their plans to recovery
~ Assist identify and develop strategies for relapse triggers
~ Initiate random drug tests and provide rapid feedback of results if appropriate
~ Help clients and families integrate into mutual-help programs
~ Assist develop and strengthen positive social support networks
~ Continue appropriate pharmacotherapy, medical, psychiatric treatments
Completion Criteria
~ Sustained recovery for 30 days or longer
~ Completed treatment plan goals
~ Created and implemented a relapse prevention and continuing care plan
~ Participated regularly in a support group
~ Maintained/developed a support network
~ Resolved medical, psychiatric, housing, personal situations that may trigger relapse
Outpatient Treatment (Level I)
~ Step-down/Stage 3 Maintenance
~ Goals
~ Solidify abstinence
~ Use relapse prevention skills
~ Improve emotional functioning
~ Broaden sober social networks
~ Address other problem areas
~ Duration — About 2 months to 1 year
Counselor activities
~ Help clients practice relapse prevention skills
~ Teach new coping skills
~ Help identify unmet biopsychosocial needs
~ Assist locate community resources
~ Encourage support groups participation
~ Emphasize importance of spirituality/altruistic/values
~ Provide feedback on random drug test results as appropriate
~ Continue treatment plan implementation
Completion Criteria
~ Sustained recovery
~ Improved relationships
~ Improved coping/problem solving skills
~ Obtained drug-free, stable housing
~ Continued participation in support group
~ Obtained assistance with other problems
Stage 4: Continuing Community Care
~ Goals
~ Maintain wellness
~ Develop independence from treatment program
~ Maintain social and support network connections
~ Establish recreational activities
~ Duration—Years, ongoing

Counselor Activities
 Assist in developing a plan for continuing recovery
 Acquaint clients with local resources
 Encourage attendance at alumni or booster sessions
 Provide biannual checkups

 Completion criteria — Clients may need community support forever

Services (or Linkages) in IOT
~ Assessment
~ Treatment planning
~ Group and individual counseling
~ Psychoeducation
~ Pharmacotherapy
~ Drug testing/monitoring
~ Case management
~ Community based support groups

Services (or Linkages) in IOT Cont…
~ 24-Hour crisis coverage
~ Medical and dental treatment
~ Vocational and employment services
~ Wrap around services
Family Engagement
~ Reasons for resistance
~ Domestic violence
~ Shame
~ Fear of revealing family secrets
~ Resentments
~ Methods
~ Involve family in the intake (with permission)
~ Offer written invitations to participate
~ Family-only educational groups
Family Services
~ Family education
~ Multifamily groups
~ Family therapy
~ Individual
~ Couples
~ Child-focused
~ Family retreats
~ Support groups (Al-Anon, etc)
Family Clinical Issues
~ Trust reestablishment
~ Having fun
~ What do we tell the Jones’
~ Improving interpersonal communication
~ Re-establishing healthy boundaries
~ Resentment of the consuming nature of recovery
Client Retention
~ Understand treatment history
~ Use motivational techniques
~ Flexible scheduling
~ Use the group to engage client
~ Network with those involved in client’s recovery
~ Deliver services throughout treatment
~ Leave an open door/Don’t give up
Relapse Strategies
~ Educate families and clients about symptoms, causes, effects, interactions of:
~ co-occurring disorders
~ relapse
~ recovery
~ Identify relapse triggers and interventions early
~ Develop a relapse prevention plan
~ Use behavioral contracts
Withdrawn Clients
~ Discuss lack of participation with client
~ Assess for learning/cognitive disabilities
~ Pair clients with buddies (universally)
~ Incorporate buddy activities
~ Evaluate for mental health issues
~ depression, social phobia, etc.
~ Provide alternative methods for participation
~ Ensure an environment of safety
Clients Under the Influence
~ Assess client’s need for acute care or detoxification
~ Review rules with client
~ Instruct client to return when abstinent
~ Arrange for safe transportation home
~ Invite client to return to treatment
~ Discuss substance use during the next session
Treatment-Life Balance
~ Recovery is first priority
~ Not the time to make up for the past
~ Taking on too much
~ Ensure a balanced lifestyle
~ Treatment-Family-Work-Honey Do’s-Self
“Unavoidable” People Triggers
~ Identify high-risk situations
~ Distance from co-workers/family who trigger you
~ Role play effective communication and boundary setting skills
~ Transfer to another work environment

~ IOP has many challenges but provides flexibility
~ Use in conjunction with contracts/rewards, phased up/down approach
~ Integrate community resources to relieve some of the burden
~ See also TIP 46 Administrative Issues

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