Quick Guide for Clinicians

U

Based on TIP 47

*Substance Abuse: Clinical Issues in Intensive Outpatient Treatment*

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

CONTENTS

Why a Quick Guide?

What Is a TIP?

Introduction

14 Principles of IOT

Intensive Outpatient Treatment and Continuing Care

Services in IOT Programs

Treatment Entry and Engagement

Family-Based Services

Clinical Issues, Challenges, and Strategies

Intensive Outpatient Treatment Approaches

Adapting Intensive Outpatient Treatment for Specific Populations

Addressing Diverse Populations

Ordering Information

Other Treatment Improvement Protocols

Quick Guide for Clinicians

Based on TIP 47

*Substance Abuse: Clinical Issues in Intensive Outpatient Treatment*

This Quick Guide is based entirely on information contained in TIP 47,
published in 2006. No additional research has been conducted to update
this topic since publication of TIP 47.

WHY A QUICK GUIDE?

This Quick Guide was developed to accompany *Substance Abuse: Clinical
Issues in Intensive Outpatient Treatment,* Number 47 in the Treatment
Improvement Protocol (TIP) Series published by the Center for Substance
Abuse Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA). This Quick Guide is based entirely on TIP 47
and is designed to meet the needs of the busy clinician for concise,
easily accessed how-to information.

The Quick Guide is divided into 12 sections (see *Contents*) to help
readers quickly locate relevant material. It will help clinicians make
informed decisions when treating clients in outpatient settings.

For more information on the topics in this Quick Guide, readers are
referred to TIP 47.

WHAT IS A TIP?

The TIP series has been in production since 1991. The series provides
the substance abuse treatment and related fields with consensus-based,
field-reviewed guidelines on substance abuse treatment topics of vital
current interest.

TIP 47, *Substance Abuse: Clinical Issues in Intensive Outpatient
Treatment*---

-   Addresses the expansion of intensive outpatient treatment (IOT)
    represented by the development and adoption of new approaches to
    treat a wide range of clients

-   Describes the core services every IOT program should offer, the
    enhanced services that should be available on site or through links
    with community-based services, and the processes of assessment,
    placement, and treatment planning that help counselors address each
    client's needs

-   Discusses major clinical challenges of IOT and surveys the most
    common treatment approaches used in IOT programs

-   Presents treatment strategies for specific groups including women;
    adolescents; criminal justice system clients; individuals with
    HIV/AIDS, co-occurring disorders, or physical or cognitive
    disabilities; racial and ethnic minorities; rural populations;
    people who are homeless; and older adults

-   Examines the complex issues facing IOT providers and offers
    analytical discussions and incisive opinions.

*See the end of this document for information on how to order TIPs and
other related products.*

INTRODUCTION

IOT is a multidimensional treatment modality that serves a variety of
clients. It recognizes substance abuse as a chronic disorder requiring
case management and the involvement of families, communities, and
mutual-help groups in ongoing care. The blending of evidence-based
interventions with community-based services has helped clinicians,
clients, and family members understand that substance use disorders have
complex biological, social, psychological, and spiritual dimensions. IOT
has the following features:

-   6--30 contact hours per week;

-   Step-up and stepdown levels of care that vary in intensity and
    duration;

-   A minimum duration of 90 days followed by outpatient continuing
    care;

-   Core services including---

> \- Comprehensive biopsychosocial assessment
>
> \- Group, individual, and family counseling
>
> \- Psychoeducational programming
>
> \- Integration into support groups
>
> \- Relapse prevention training
>
> \- Substance use screening and monitoring
>
> \- Vocational and educational services; and

-   Enhanced services including---

> \- Ambulatory detoxification
>
> \- Child care
>
> \- Outreach.

*For more detailed information, see TIP 47, pp. 1--6.*

14 PRINCIPLES OF IOT

The TIP consensus panel identified 14 principles integral to IOT:

1.  Make treatment available to a wide spectrum of clients;

2.  Make treatment access straightforward and welcoming;

3.  Build on existing motivation by using strategies that enhance client
    motivation;

4.  Enhance the therapeutic alliance by building trust between the
    counselor and client;

5.  Make client retention a priority;

6.  Assess the client's treatment needs and match services to the
    individual;

7.  Provide ongoing care through a chronic care model that adjusts to
    the client's needs;

8.  Monitor abstinence by recognizing the client's achieving and
    maintaining abstinence;

9.  Help clients integrate into support groups;

10. If indicated, use medications to manage co-occurring substance use
    and mental disorders;

11. Educate clients and family members about substance use disorders and
    recovery skills;

12. Include families, employers, and significant others in the treatment
    process;

13. Seek out and use evidence-based training and materials; and

14. Improve program administration.

*For more detailed information, see TIP 47, pp. 7--16.*

INTENSIVE OUTPATIENT TREATMENT AND CONTINUING CARE

The American Society of Addiction Medicine (ASAM) has established five
levels in a continuum of care for substance abuse treatment:

-   **Level 0.5:** Early intervention services;

-   **Level I:** Outpatient services;

-   **Level II:** Intensive outpatient/partial hospitalization services
    (subdivided into two levels: II.1 and II.5);

-   **Level III:** Residential/inpatient services (subdivided into four
    levels: III.1, III.3, III.5, and III.7); and

-   **Level IV:** Medically managed intensive inpatient services.

Key Aspects of IOT (Level II)

The amount of time that clients participate in IOT depends on individual
needs. State licensure bodies may require 9 treatment hours spread over
3 to 5 days. ASAM defines IOT as at least 9 hours of treatment per week
for adults. The minimum duration of IOT often is cited as 90 days. Any
setting that meets State licensure or certification criteria can provide
IOT.

IOT comprises two treatment stages: treatment engagement and early
recovery.

*Stage 1---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.

-   **Counselor activities---**

> \- Confirm diagnosis, eligibility, and appropriate placement in this
> level of care
>
> \- Assess biopsychosocial problems and match services to the most
> pressing problems
>
> \- Provide assessment feedback
>
> \- Explain program rules and expectations
>
> \- Address acute crises
>
> \- Resolve scheduling, payment, and counselor assignment issues
>
> \- Obtain medical and psychological diagnoses and treatment history,
> including pharmacotherapy
>
> \- Foster therapeutic alliances between client and counselor and
> client and group members
>
> \- Begin psychoeducational activities
>
> \- Identify sources of social support
>
> \- Initiate family contacts and education (with client's permission).

-   **Completion criteria---**

> \- Completed assessment process and orientation
>
> \- Completed withdrawal from substance use
>
> \- Resolved immediate crises
>
> \- Established a treatment plan
>
> \- Attended scheduled sessions.

*Stage 2---Early Recovery*

-   **Goals---**

> \- Maintain 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 sustain abstinence
>
> \- Assist in identifying and developing strategies for relapse
> triggers
>
> \- Initiate random drug tests and provide rapid feedback of results
>
> \- Help clients and families integrate into mutual-help programs
>
> \- Assist in developing and strengthening positive social support
> networks
>
> \- Continue appropriate pharmacotherapy, medical, and psychiatric
> treatments.

-   **Completion criteria---**

> \- Sustained abstinence 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 a sober social support network
>
> \- Resolved medical, psychiatric, housing, and personal situations
> that may trigger relapse.

Key Aspects of Outpatient Treatment (Level I)

The goals of outpatient treatment are similar to those of IOT. Clients
who complete stages 1 and 2 of IOT step down to stage 3, maintenance.
Clients attend one or two treatment sessions per week.

*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 vocational, educational, and recreational needs
>
> \- Assist in locating community resources
>
> \- Encourage continuing work with support groups and sponsors
>
> \- Emphasize the importance of spirituality or altruistic values
>
> \- Provide feedback on random drug test results
>
> \- Continue appropriate pharmacotherapy, medical, or psychiatric
> assistance.

-   **Completion criteria---**

> \- Sustained abstinence
>
> \- Improved relationships
>
> \- Improved coping and problemsolving skills
>
> \- Obtained drug-free, stable housing
>
> \- Continued participation in a support group
>
> \- Obtained assistance with other problems.

Key Aspects of Continuing Community Care

Individuals may remain in this level of care for the rest of their lives
to remain abstinent and recover from relapses. A client's needs
determine this stage's duration and intensity.

*Stage 4---Continuing Community Care*

-   **Goals---**

> \- Maintain abstinence and a healthy lifestyle
>
> \- Develop independence from the treatment program
>
> \- Maintain social network connections
>
> \- Establish strong connection with support groups
>
> \- Establish recreational activities and develop new interests.

-   **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 for the
    rest of their lives.

Transitioning Between Stages

A transition plan helps the client move from one level of care to
another. To prepare an effective transition plan, the IOT counselor---

-   Engages clients in developing the plan early in IOT

-   Knows about community services and resources

-   Develops relationships with key agencies

-   Transfers clinical information to the new treatment program.

*For more detailed information, see TIP 47, pp. 17--26.*

SERVICES IN IOT PROGRAMS

-   **Group counseling.** Common IOT groups include psychoeducational,
    support, and family or couples groups. They provide venues for
    clients to practice new behaviors. For more on group therapy, see
    TIP 41, *Substance Abuse Treatment: Group Therapy.*

-   **Individual counseling.** Most individual counseling addresses the
    immediate problems stemming from substance use disorders, not
    underlying conflicts that may contribute to them.

-   **Psychoeducational programming.** Psychoeducational groups educate
    clients about substances and substance use disorders.

-   **Pharmacotherapy and medication management.** IOT programs that
    require attendance 3--5 times per week are ideal settings for
    identifying clients in need of pharmacotherapy and medication
    management.

-   **Monitoring alcohol and drug use.** When asked to report drug test
    results to the criminal justice system, employers, or child
    protective services, programs should tell clients that positive test
    results may trigger serious consequences.

-   **Case management.** Case managers provide social services and act
    as client advocates.

-   **Community-based support groups.** IOT counselors should introduce
    clients to the basic tenets of support groups and encourage
    participation in these meetings.

-   **24-hour crisis coverage.** Effective 24-hour coverage includes
    services that provide hotline advice or referrals and 24-hour
    detoxification.

-   **Medical treatment and psychiatric examinations/psychotherapy.**
    IOT programs should partner with medical and mental health providers
    for consultation on and referral for medical or psychiatric
    disorders.

-   **Vocational training and employment services.** Services on site or
    through case-managed referral are important for unemployed or
    underemployed individuals.

-   **Enhanced IOT services.** These include adult education,
    transportation, housing and food, recreation, adjunctive therapies,
    nicotine treatment, child care, and parenting training.

*For more detailed information, see TIP 47, pp. 27--57.*

TREATMENT ENTRY AND ENGAGEMENT

The admission process addresses early client attrition by assessing
readiness for change and establishing a collaborative relationship. The
counselor matches clients to the least intensive and restrictive
treatment setting and develops individualized interventions of variable
intensity. Treatment engagement is fostered by balancing the procedural
requirements of intake with an empathic response to clients.

Intake

The sandwich technique is a method of intake interviewing that helps
initiate a therapeutic relationship by "sandwiching" standard
assessments between two less formal discussions with clients. Before
conducting a formal assessment, the counselor---

-   Solicits the client's perceptions of problems that require treatment

-   Explores what the client expects from treatment

-   Supports the client's commitment to change

-   Offers hope that change is possible

-   Informally assesses the client's readiness to change.

The following information is often documented on the intake form:

-   Name, age, and gender;

-   The referral source;

-   The client's perspective on why treatment is needed and immediate
    crises;

-   Pertinent medical conditions;

-   Suicidal or other violent thoughts;

-   The client's usual residence;

-   Substance use disorder and severity; and

-   Length of time since the client's last substance abuse treatment.

Screening

Short screening instruments should be used to document a substance use
disorder that later may be confirmed with a diagnostic interview. Three
have shown high rates of accuracy:

-   CSAT's Simple Screening Instrument (reproduced in TIP 11, *Simple
    Screening Instruments for Outreach for Alcohol and Other Drug Abuse
    and Infectious Diseases*);

-   A combination of the Alcohol Dependence Scale and Addiction Severity
    Index-Drug Use Subscale (see appendix 5-B in TIP 47); and

-   Texas Christian University Drug Screen (see appendix 5-B in TIP 47).

The IOT Admission Process

Counselors must establish a client's eligibility before initiating
treatment. Biopsychosocial and multidimensional assessments should be
conducted, summarized, and presented to the client. The counselor should
then develop a treatment plan with the client.

Treatment Planning

In planning treatment, counselors should---

-   Involve the client in developing the plan

-   Set unambiguous goals with criteria for accomplishment

-   Set sequence and target dates for goals and for reviewing and
    modifying the plan

-   Locate required resources, responsible persons, or activities.

*For more detailed information, see TIP 47, pp. 59--91.*

FAMILY-BASED SERVICES

A family can be considered anyone important to the client. This "family
of choice" can differ from the client's close relatives or "family of
origin."

Engaging the Family in Treatment

Family members may resist involvement in the client's treatment, or the
client may object to the family's involvement. The client may not want
family members to be involved because of domestic violence threats, fear
of revealing family secrets, or other reasons. Methods to help engage
families include using community reinforcement training interventions,
involving family members in the intake session, and offering written
invitations and incentives. If domestic abuse is suspected, clinicians
must assess the client and family carefully for any potential for
violence.

Family Services

-   **Family education groups** meet weekly for 2 to 3 hours, include
    between 10 and 40 individuals, and are facilitated by a clinician.

-   **Multifamily groups** provide family members with a support network
    and engage clients and families in group exercises.

-   **Family therapy** includes the following:

> *- Individual family therapy.* Helps family members look at their
> interactions and identify factors that contribute to substance use;
>
> *- Couples therapy.* Focuses on teaching partners to improve
> communication and work together in problemsolving; and
>
> *- Child-focused therapy.* Teaches parenting and problemsolving skills
> and provides information about normal childhood development.

-   **Family retreats** encourage families to take part in daylong
    education sessions and group activities.

-   **Support groups** for families meet weekly to provide support to
    family members as their loved ones complete their treatment.

Family Clinical Issues in IOT

Long-suppressed anger and other negative feelings may surface during
treatment. Families may also have unrealistic expectations. Counselors
should provide clear information about substance abuse and treatment.
Clients and family members must prepare for the possibility of relapse.
The client's abstinence can resolve some family problems but also may
raise new concerns about trust and how the family will be different.
Common questions that family members ask include the following:

-   **How do we reestablish trust?** The newly abstinent client may
    expect the trust of family members before they are willing to give
    it. Family members can agree to extend trust to the client
    incrementally, as the client remains abstinent.

-   **How do we have fun again?** New rituals can replace ones that
    involved substance use.

-   **What do we say to friends, neighbors, and associates?** Family
    members should practice appropriate responses to situations they are
    likely to encounter.

-   **First the bottle, now the meetings. Will it ever get better?**
    People in recovery often immerse themselves in recovery activities.
    Family members should be patient.

*For more detailed information, see TIP 47, pp. 93--113, and TIP 39,*
Substance Abuse Treatment and Family Therapy.

CLINICAL ISSUES, CHALLENGES, AND STRATEGIES

Client Retention

Counselors should strive to form good relationships with their clients.
Methods to improve client retention include the following:

-   **Learning the client's treatment history.** The counselor should
    understand why previous treatment was unsuccessful; if the client
    had been engaged and retained in treatment previously, the counselor
    should determine what made treatment appealing.

-   **Using motivational techniques.** The counselor should help clients
    identify life goals and how substance abuse interferes with them.

-   **Providing flexible schedules** to accommodate clients.

-   **Using the group to engage the client.** The counselor can
    encourage members to discuss prior treatment experiences, even if
    they were negative, and call one another for support.

-   **Increasing contact frequency during early treatment.** Even brief
    phone or e-mail contact can help clients through feelings of
    vulnerability and ambivalence common in early recovery.

-   **Using network interventions.** Counselors should work with
    individuals who are invested in the client's recovery.

-   **Delivering services throughout treatment.** Client dropout is more
    frequent during less rigorous program phases. Evening out the
    intensity of services can help retain clients.

-   **Never giving up.** The counselor should follow up with clients who
    dropped out.

Relapse and Continued Substance Use

Lapses are brief returns to substance use following a sustained period
of abstinence. They often occur in early months of treatment and can be
used as a therapeutic tool. Clients need relapse prevention strategies
to stop lapses from becoming relapses. Counselors can---

-   Educate clients and their families about addiction and recovery

-   Conduct an early assessment of relapse triggers

-   Develop a relapse prevention plan

-   Provide intensive monitoring and support

-   Evaluate and review all lapses

-   Use behavioral contracts.

Substance Use by Family Members

Substance use within the client's social network can threaten recovery.
The counselor can---

-   Stay alert for others using substances

-   Have the family and client sign an agreement stating that substances
    that will not be kept or consumed in the home

-   Assist in finding alternative housing

-   Provide treatment information to family members.

Group Work Issues

Clients are more likely to continue treatment when they feel supported
by the group. TIP 41, *Substance Abuse Treatment: Group Therapy,*
provides more information on therapeutic groups.

*Developing Group Cohesion*

Cohesive groups can contribute to recovery. Counselors can create group
cohesion by---

-   Creating group rituals

-   Instituting a program emblem

-   Exploring the group's response to clients who drop out

-   Encouraging identification with the program, not just the group

-   Maintaining effective group size (8--12 clients).

*Preparing Clients for Group*

Pregroup interviews allow the counselor to assess clients' treatment
readiness and shape their expectations of group. Programs can also post
group norms in meeting rooms.

*Working With Ambivalent Clients*

Ambivalent clients can compromise the group's progress. The counselor
can address ambivalence by discussing client behaviors individually, by
introducing theme-oriented information, or by focusing less on process
and more on content. Some clients may need to be moved to another group
or to individual therapy or be terminated from the program.

*Working With Clients Who Have Severe Mental Disorders*

Individuals with severe mental disorders may be disruptive in groups.
The counselor can coordinate treatment with the client's psychiatric
care provider and use the client's readiness to engage in group work as
a guide for group treatment. Staff members involved in group treatment
for these clients should have appropriate training and experience.

*Working With Disruptive Clients*

If a group member is impatient or restless or offends other members, the
counselor should review the group's rules and consequences of their
violation and then reassess the disruptive client's status. If
necessary, the counselor can hold an individual counseling session or
refer the client to a mental health professional.

*Working With Quiet, Withdrawn Clients*

Clients are reluctant to participate in group sessions for many reasons,
including resentment at being in treatment, depression, and denial.
Counselors can---

-   Ask clients individually why they are reticent and discuss options

-   Assess language and comprehension skills and move a client to an
    appropriate group

-   Pair clients to encourage acceptance and participation

-   Contract with a client to increase participation step by step

-   Refer a client for psychiatric evaluation.

*Responding to Intermittent Attendance*

Clients who miss sessions may jeopardize the group's trust. The
counselor should address any barriers to attendance as well as assess
each client's readiness for change. If necessary, clients can be
assigned to another group with which they have more in common.

Safety and Security

*Drug Dealers or Gang Members at the Facility*

IOT programs should post signs prohibiting loitering, drug-related
activity, and unauthorized persons on site. Some clients may be
reluctant to break ties with substance-using acquaintances and may need
the counselor's encouragement and program's rules to end harmful
associations.

*Stalking, Domestic Violence, and Threats Against Clients*

IOT programs can take the following steps to ensure client and staff
safety:

-   Ask clients about restraining orders or threats. Staff members have
    a duty to warn if danger is imminent and confidentiality regulations
    are met. Chapter 7 of TIP 47 provides more information;

-   Intervene early to deescalate potentially violent situations;

-   Place violence-related information in case records and help clients
    create a personal safety plan. TIP 25, *Substance Abuse Treatment
    and Domestic Violence,* provides a sample plan;

-   Require clients to sign a no-contact agreement that forbids contact
    with a batterer;

-   Assist clients in obtaining a civil protection order; and

-   Connect clients with community services that address domestic
    violence.

*Treating Violent Clients*

IOT staff can take the following steps when treating violent clients:

-   Have all new clients sign a code of conduct stating that acts of
    violence result in termination;

-   Notify supervisors and law enforcement if a threat to safety exists
    or a crime is being committed; and

-   For clients mandated to treatment, follow steps prescribed in the
    agency agreement. TIP 44, *Substance Abuse Treatment for Adults in
    the Criminal Justice System,* provides more information.

*Clients Arriving Under the Influence of Drugs*

Arriving under the influence indicates that a substance use disorder is
active and requires an alternative treatment plan. Counselors should---

-   Assess the client's need for acute care or detoxification

-   Review the rules with the client

-   Instruct the client to return when abstinent

-   Arrange for safe transportation home

-   Write or call the client to invite him or her to return to treatment

-   Discuss the substance use during the next session.

Client Privacy

Federal confidentiality regulations do not permit providers to reveal
information about a client unless the client signs a release. IOT staff
members must consult a list of client-approved individuals before
they---

-   Acknowledge that a client is a program participant

-   Share any information

-   Transfer a phone call to the client

-   Take a message for the client.

Clients' spouses, partners, or acquaintances may want to anonymously
inform IOT providers about continued substance use. The counselor can
respond by speaking with the client during individual counseling and
revising the treatment plan if necessary.

Knowledge of HIV Status Withheld From Partner

During treatment a counselor may learn that a client has not informed a
partner of his or her HIV-positive status. The following strategies
reduce this risk and maintain client confidentiality:

-   Ensure that the client is aware of how HIV/AIDS is transmitted;

-   Discuss feelings of fear, embarrassment, and guilt about revealing
    HIV status to a partner;

-   Include information about HIV transmission in educational material
    for family members;

-   Help the client and partner discuss the issue and refer the client
    to HIV/AIDS counseling; and

-   Encourage the client to participate in a support group and provide a
    referral.

Helping Clients Balance Work and Treatment

Individuals who enter IOT may face conflicts with work, especially if
the employer is unaware that the employee is in treatment. Counselors
should encourage clients to make treatment and recovery their first
priority and should be flexible with treatment schedules.

Once in treatment, clients sometimes try to make up for past actions by
taking on additional tasks. Counselors should remind the client that
recovery is the first priority and encourage the client to balance the
activities undertaken, suggesting that there will be time to address
past mistakes when recovery is solidly underway.

Clients, Co-Workers, and Employers

Clients who have used substances with coworkers may find it difficult to
renegotiate these relationships. Options for addressing these issues
include---

-   Helping the client identify circumstances that increase the risk of
    relapse

-   Encouraging the client to distance himself or herself from
    co-workers who use substances

-   Using role plays to practice responding to treatment questions and
    substance use invitations

-   Encouraging the client to transfer to another work environment.

If an employer referred the client to treatment, the employer may expect
information about the client's readiness to resume work duties. IOT
counselors cannot determine a client's fitness for work; only the
employer can determine this. With the client's consent, counselors can
inform the employer about treatment progress. Counselors can also refer
the employer to drug-free workplace information available on the
Internet (www.workplace.samhsa.gov) and negotiate with the employer for
continuing treatment.

Workplace drug testing is mandatory for some private-sector workers. If
one of these employees is mandated to treatment, the counselor must
inform the employer in writing of assessment results and treatment
recommendations.

Boundary Issues

Clients and staff members become involved on intellectual, emotional,
and spiritual levels. This can lead to behaviors that challenge
boundaries between and among staff and clients.

*Clients Giving Gifts to Staff*

IOT programs should develop rules that limit gifts to items that can be
shared by staff members and clients. Inappropriate gifts should be
refused politely. Most programs prohibit gifts that---

-   Exceed a certain value

-   Are not the result of a religious or cultural tradition

-   Are offered in anticipation of special treatment

-   May cause confusion about the counselor--client relationship.

*Socializing Among Clients*

Some programs encourage clients to support one another outside the
program; others discourage outside contact. Most IOT programs have rules
regarding dating and other client pairings that could undermine
treatment.

*Socializing Between Clients and Staff*

To safeguard the therapeutic relationship, IOT programs typically
prohibit staff--client relationships outside treatment. Consequences for
violations include reprimand, probation, and dismissal. In some cases,
the staff member must be reported to the licensing or certification
board.

*Counselors With Dual Roles*

IOT counselors who are members of mutual-help groups must maintain
boundaries between their professional life and their own recovery. A
counselor cannot be a client's sponsor. Counselors should avoid meetings
attended by current or former clients. If this is not possible, the
counselor should avoid sharing personal issues at the meeting. Large
cities have "counselor only" meetings that are not listed in
directories.

*For more detailed information, see TIP 47, pp. 115--136.*

INTENSIVE OUTPATIENT TREATMENT APPROACHES

IOT programs modify and blend multiple treatment approaches. Resources
are on pages 137 and 138 of TIP 47.

12-Step Facilitation Approach

The 12-Step facilitation approach is based on the Alcoholics Anonymous
(AA) concept that alcoholism is a primary, progressive disease with
biological, psychological, and spiritual features. The 12-Step
facilitation approach to treatment involves helping clients understand
AA principles, work through the 12 Steps, achieve abstinence, and become
involved in community-based 12-Step groups. Substance use is seen as a
disease marked by denial and loss of control. Group work focuses on
accepting the disease and taking responsibility for recovery. Emphasis
is on writing journals, reading 12-Step literature, and adopting
spiritual values. Staff members who are not in recovery should
familiarize themselves with 12-Step literature and with the
characteristics of local meetings. The strengths and challenges of
12-Step facilitation are as follows:

-   **Strengths---**

> \- Provides meetings that are free, widely available, supportive, and
> specialized
>
> \- Emphasizes an array of recovery tasks in cognitive, spiritual, and
> health realms
>
> \- Is effective with clients from diverse backgrounds.

-   **Challenges---**

> \- Can be difficult to monitor clients' compliance with assigned step
> tasks
>
> \- May be difficult for some clients to accept emphasis on a higher
> power
>
> \- May be difficult for small communities to support 12-Step meetings
> or meetings for those with co-occurring disorders.

Cognitive Behavioral Approach

Cognitive behavioral therapy (CBT) is based on the theory that most
emotional and behavioral reactions are learned and that new reactions
can be taught to help clients maintain abstinence. Clients learn to
recognize substance abuse triggers and learn strategies for
counteracting them. Many CBT programs also encourage 12-Step
participation. The strengths and challenges of CBT are as follows:

-   **Strengths---**

> \- Engages clients in therapy and learning
>
> \- Is described in numerous manuals
>
> \- Is suitable for diverse clients with histories of substance abuse
>
> \- Provides structured methods for understanding and preparing for
> relapse triggers and situations.

-   **Challenges---**

> \- May require adjustments for clients with poor cognitive skills
>
> \- Requires counselor training
>
> \- Requires clients be motivated to complete extensive homework
> assignments
>
> \- Was developed as an individual counseling approach.

Motivational Approaches

Motivational approaches include motivational interviewing (MI) and
motivational enhancement therapy (MET). They acknowledge that substances
have rewarding properties that can disguise their hazards and long-term
negative effects. MI is a directive counseling strategy designed to
reduce ambivalence toward treatment. It is frequently paired with
problemsolving strategies that build on past successes. In MET,
counselors act as coaches rather than authority figures. They provide
feedback about results on standardized assessments and discuss clients'
responses to this feedback. The strengths and challenges of MI and MET
are as follows:

-   **Strengths---**

> \- Are client centered and relevant to clients' interests
>
> \- Focus on realistic goals
>
> \- Encourage self-efficacy and self-sufficiency
>
> \- Emphasize positive support that does not undermine or elicit anger
> from clients
>
> \- Do not require that staff members achieve specific educational
> levels.

-   **Challenges---**

> \- Rely on clients' capabilities and self-awareness
>
> \- Are incompatible with common problem-oriented assessment
> instruments
>
> \- Require staff training and supervision
>
> \- May be difficult to combine with disease- or therapeutic
> community-oriented approaches that expect adherence to program-imposed
> rules
>
> \- Were developed as individual approaches (their effectiveness for
> use with groups is unproved)
>
> \- Do not specify session content.

Therapeutic Community Approach

Therapeutic communities (TCs) use the "community as method" approach, in
which the whole treatment community is the therapeutic agent. The TC
model considers substance use a disorder of the whole person and
recovery a developmental process entailing mutual help and social
learning. Treatment is organized into phases. Many clients served by TCs
have histories of severe substance use disorders and criminal behavior,
so TCs strive to habilitate, rather than rehabilitate, clients. TCs
focus on all aspects of the client's life, featuring a structured day
and peers who confront negative behaviors in a supportive milieu. The
strengths and challenges of TC approaches are as follows:

-   **Strengths---**

> \- Are effective for people with long histories of substance
> dependence and antisocial behavior
>
> \- Are effective in teaching clients how to achieve goals
>
> \- Can reduce recidivism among clients who have served time in prison.

-   **Challenges---**

> \- May be too confrontational for some clients
>
> \- Require staff training
>
> \- Can pose difficulties for clients with co-occurring disorders
>
> \- May require time to find an effective mix of clinicians and
> recovering staff.

The Matrix Model

The Matrix model integrates several techniques (CBT, 12-Step, MET) and
emphasizes group work over individual sessions. A primary therapist or
counselor coordinates the client's treatment, and the client--family
relationship is critical. The following structured groups are central:

-   **Early recovery groups** meet during the first month of treatment
    and focus on teaching clients cognitive tools for managing cravings
    and structuring time;

-   **Family education sessions** focus on the biology of addiction,
    conditioning and addiction, and addiction's effects on the family;

-   **Relapse prevention groups** focus on cognitive and behavioral
    change; and

-   **Social support groups** help clients pursue drug-free activities
    and develop friendships not focused on drug use.

The strengths and challenges of the Matrix model are as follows:

-   **Strengths---**

> \- Integrates a CBT approach with family involvement, psychosocial
> education, 12-Step support, and urine testing
>
> \- Follows a manual that provides specific instructions and exercises
>
> \- Has been used widely and effectively with people dependent on
> stimulants.

-   **Challenges---**

> \- May require modification of material for clients with impaired
> cognitive functioning
>
> \- Requires special staff training and supervision
>
> \- May not appeal to all clients
>
> \- May not allow for treatment of other non-drug-specific problems.

Community Reinforcement and Contingency Management Approaches

Community reinforcement (CR) and contingency management (CM)
interventions are based on operant conditioning. Effective CR and CM
programs use incentives (e.g., vouchers for food or entertainment) to
reward clients for attaining a desired goal (e.g., having a negative
drug test). Rewards are tailored to clients' responses and program
capacities. More frequent reinforcers, even if small, have a greater
effect than larger, more remote rewards. The strengths and challenges of
CR and CM are as follows:

-   **Strengths---**

> \- Reduce drug use significantly when incentives are used
>
> \- Combine readily with other psychosocial interventions and
> pharmacotherapies
>
> \- Can be implemented with low-cost incentives such as donated goods
> or services
>
> \- Are effective in reducing drug use and increasing treatment
> compliance
>
> \- Have extensive scientific support in laboratory and clinical
> studies.

-   **Challenges---**

> \- May be difficult to keep clients from returning to baseline drug
> use rates when incentives are terminated
>
> \- Can be labor intensive and require staff training and frequent
> client attendance
>
> \- Require sufficiently large rewards to have continuing appeal
>
> \- Have been studied using small samples that incurred large costs for
> incentives
>
> \- May be difficult to acquire required resources

\- Do not emphasize importance of long-term supports.

*For more detailed information, see TIP 47, pp. 137--152.*

ADAPTING INTENSIVE OUTPATIENT TREATMENT FOR SPECIFIC POPULATIONS

Justice System Population

The justice system population is overwhelmingly male and younger than
the general population. It is also more likely than the general
population to have problems related to employment and finances; housing
and transportation; education; co-occurring disorders; and HIV/AIDS,
tuberculosis, or hepatitis C.

Offenders who are compelled to participate in treatment include the
following:

-   Offenders referred to treatment in lieu of incarceration;

-   Offenders discharged from residential treatment who need continuing
    treatment;

-   Offenders who need treatment and are placed under community
    supervision; and

-   Offenders who are incarcerated.

*Rules for Offenders in Treatment*

Some justice system policies and sanctions may conflict with treatment
principles. IOT program staff and justice system partners must agree on
consequences for alcohol use or lapses in abstinence, discharge
criteria, and the use of drug-testing results.

*Communication Between Systems*

IOT programs should designate point-of-contact personnel for all justice
system referrals. Clients must sign confidentiality forms stipulating
information that can be shared between systems. All agreements between
the IOT program and justice system need to be formalized in a memorandum
of understanding that includes the following:

-   Each partner's responsibilities;

-   Consequences for noncompliance;

-   The types, content, and schedule of reporting; and

-   Definitions of critical incidents that require the IOT program to
    notify the justice agency.

*Staff Training*

Staffs in both systems need cross-training that includes each system's
philosophy, approach, goals, objectives, and boundaries. Treatment
providers need information about the justice system's structure,
operations, and security concerns. Justice system personnel need
information about substance use disorders and the components of
treatment.

Women

Compared with men, women usually begin substance use later and enter
treatment earlier. The following issues are of particular concern when
treating women:

-   **Violence.** Women with substance use disorders are more likely
    than men to have been abused as children and more likely than other
    women to be victims of domestic violence;

-   **Mental disorders.** Women have higher rates of psychiatric
    comorbidity than do men;

-   **Parenting issues.** Women often are children's sole caretakers and
    may fear losing custody;

-   **Welfare issues.** In some States, failure to participate in
    treatment may jeopardize benefits;

-   **Pregnancy.** Substance use during pregnancy can result in
    neurologically damaged, low-weight, and premature babies; and

-   **Relationships.** A woman's substance use often is influenced by
    her partner.

*Barriers to Treatment Entry and Retention*

Barriers that affect a woman's treatment entry and retention include
fear of retribution from an abusive spouse or partner, gender
insensitivity in treatment programs, lack of affordable or reliable
child care, and ineligibility for treatment medications if pregnant.

*Entry and Assessment*

A woman entering treatment may respond better if the intake counselor is
a woman. Staff members need to be patient during intake, understanding
that for many women it is empowering to decide when to provide
information and how much to provide. Female clients need careful
assessments for psychiatric disorders and history of childhood trauma
and adult victimization.

*Clinical Issues and Strategies*

Women-only groups may be advantageous for female clients. Other core
clinical issues that should be addressed in IOT for women include the
following:

-   **Relationships with family and significant others.** Provide family
    or couples counseling;

-   **Feelings of low self-esteem and self-efficacy.** Address in group
    and individual counseling and identify and build on the client's
    strengths;

-   **History of physical, sexual, and emotional abuse.** Avoid using
    confrontational techniques and hold individual and group therapy
    sessions or refer for treatment;

-   **Psychiatric disorders.** Refer for or provide evaluation and
    treatment of psychiatric disorders, medication management, and
    therapy;

-   **Parenting, child care, and child custody.** Hold parenting
    classes, develop substance abuse prevention services for children,
    provide or arrange licensed child care (including a nursery for
    young children and afterschool programs for older children), and
    assist with Head Start enrollment;

-   **Medical problems.** Refer for medical care including reproductive
    health; and

-   **Gender discrimination and harassment.** Ensure that the program
    has policies against harassment.

*Staff Training*

Staff members should be trained about the assessment and ramifications
of sexual, physical, and emotional abuse. Staff should understand and
enforce sexual harassment rules.

Populations With Co-Occurring Psychiatric Disorders

Treating clients with co-occurring disorders often is complicated by the
presence of interacting symptoms. Coordination between mental health and
substance abuse systems is crucial. Long-term approaches seem to be more
effective than short-term acute care. Clients with psychotic conditions
might pose insurmountable challenges for most IOT programs.

*Integrated Treatment*

Integrated treatment considers both disorders to be chronic, primary,
biologically based mental illnesses but assumes that comprehensive,
conjoint treatment can reduce symptoms of both disorders effectively.
Integrated treatment usually involves intensive case management and a
long treatment period. It may not be feasible for all IOT programs.

*Core Service Elements*

-   **Screening.** All clients need to be screened for co-occurring
    psychiatric disorders.

-   **Assessment.** Assessment should be performed by a clinician
    trained in both areas or by clinicians from each field as soon as it
    is possible to distinguish substance-induced from independent
    conditions.

-   **Treatment engagement.** Providing continuous support, assisting
    with immediate needs, and helping clients access services can
    improve client retention.

-   **Treatment planning.** Psychiatric status, social support, housing,
    medication adherence, and symptom management must be considered when
    making a treatment plan.

-   **Referral.** Clients with psychiatric disturbances that require
    secure inpatient treatment, 24-hour medical monitoring, or
    detoxification should be referred for appropriate care.

*Mental Health Care*

IOT programs that serve clients with co-occurring psychiatric disorders
should include mental health specialists on the treatment team. An
onsite psychiatrist can overcome problems of offsite referral.
Alternatively, providers can establish a working relationship with a
mental health care provider. Providers can---

-   Arrange appointments with a mental health care provider

-   Become familiar with psychotropic medications, their indications,
    and side effects

-   Instruct the client on the importance of complying with the
    medication regimen

-   Report symptoms and behavior to the prescribing psychiatrist

-   Use peer groups to monitor and support proper use of medication

-   Monitor side effects.

*Modified Program Structure*

Separate treatment tracks for clients with co-occurring disorders allow
clients to be grouped together to address common issues in group
sessions. Using staged approaches provides successive interventions
geared to the client's current stage of recovery and addresses levels of
severity of the co-occurring disorders.

*Therapeutic Relationship*

Counselors should monitor psychiatric symptoms and assist clients in
solving external problems. Because confrontational approaches may be
ineffective or harmful, counselors can be assertive but remain empathic
by presenting straightforwardly to the client his or her conflicting
thoughts and behaviors. TIP 42, *Substance Abuse Treatment for Persons
With Co-Occurring Disorders,* provides more guidance.

*Group Treatment*

Group treatment can increase abstinence rates and decrease the need for
hospitalization. Groups for these clients should be small and use short
sessions with focused directional techniques. Counselors should
communicate in a simple, concrete, and repetitive manner and affirm
accomplishments rather than use disapproval or sanctions. Examples of
groups for clients with co-occurring disorders include psychoeducational
groups, medication management groups, and social skills training groups.

*Mutual-Help Groups in the Community*

Dual recovery organizations include---

1.  Double Trouble in Recovery
    ([www.doubletroubleinrecovery.org](http://www.doubletroubleinrecovery.org/))

2.  Dual Disorders Anonymous

3.  Dual Recovery Anonymous
    ([www.draonline.org](http://www.draonline.org/))

4.  Dual Diagnosis Anonymous (www.ddaworldwide.org).

*Family*

Clients with co-occurring disorders often have unsatisfactory family
relationships. Psychoeducational groups for family members combine
information, guidance, and support.

*Continuing Care*

People with co-occurring disorders have two chronic conditions, often
require long-term care that supports their progress, and can respond
quickly to a relapse of either disorder.

*Cross-Training*

Cross-training helps staff members from both fields reach a common
approach for treating clients with co-occurring disorders. The
Mid-America Addiction Technology Transfer Center's curriculum promotes
cross-disciplinary understanding. More information is at www.mattc.org.

Adolescents

Adolescents experience many developmental changes and may require
habilitation rather than rehabilitation. They may have short attention
spans, limited future perspectives, and limited abilities to think
abstractly. They may also require parental consent for treatment.
Adolescents can come to IOT through parental request, school referral,
or juvenile justice system mandate. Unlike adult clients, adolescents
are likely to be entering treatment for the first time.

*Assessment*

Information to gather for assessment includes---

-   School records, class schedule, and school involvement

-   Relationships with peers and family members

-   Mental and physical health status

-   History of abuse and trauma

-   Involvement with the juvenile justice system.

Special attention should be paid to family assessment and should
include---

-   Financial and housing status

-   Substance use history and treatment episodes

-   Mental and physical health

-   Family problems with violence

-   Family involvement in the legal system

-   Family strengths and resources.

Assessment for psychiatric disorders and risk of suicide is crucial.
More than half of adolescents with substance use disorders also have
co-occurring psychiatric disorders.

*Family Involvement*

IOT providers treating adolescents should work with the family as much
as possible. TIP 39, *Substance Abuse Treatment and Family Therapy,*
provides more information. Counselors can---

-   Emphasize the importance of family members in recovery

-   Require that a family member accompany the adolescent to the intake
    interview

-   Encourage family attendance at the program's family education and
    therapy sessions

-   Have family members help develop and reinforce the behavioral
    contract (see below).

Family-based treatment approaches include multidimensional family
therapy, multisystemic therapy, family CBT, and adolescent community
reinforcement.

*Behavioral Contract*

The clinician works with the adolescent and the family to develop and
commit to a contract that specifies treatment goals, unacceptable
behaviors, and rewards and consequences. The conditions in the contract
help the adolescent and the family understand the treatment process.

*Case Management*

When treating adolescents, case managers monitor school performance;
coordinate medical health, mental health, and social services; and work
with juvenile justice. Caseloads should be limited to 8 to 10
adolescents per staff member.

*Group Work Strategies*

Groups should consist of adolescents of the same age and gender with
similar levels of motivation for change. Structured discussions appear
more successful than open-ended sessions.

*Clinical Considerations*

Not all adolescents who use substances are dependent. Prematurely
diagnosing adolescents is counterproductive, and many adolescents
respond poorly to confrontational techniques. MI, MET, and CBT models
are useful. Common issues in adolescent treatment and practical
suggestions for resolving them include the following:

-   **Inconsistent ability for abstract thinking.** Limit abstract,
    future-oriented activities, use mentors, and avoid scare tactics and
    labels;

-   **Impulsive and short attention spans.** Practice activities to
    teach self-control skills;

-   **Vulnerability to peer influence.** Help establish positive peer
    groups and develop skills in resisting negative peer pressure;

-   **Frequent emotional fluctuations.** Validate feelings, acknowledge
    pressures of adolescence, and help improve stress management skills;

-   **Lack of involvement in healthy recreational activities.** Help
    develop daily schedules and find new recreational activities; and

-   **Tendency toward pessimistic or fatalistic attitudes.** Recognize
    fatalist attitudes and validate anger or perceived obstacles to
    success but challenge clients to think positively.

*Staff Training*

IOT program staff members need to practice empathy and set boundaries.
Counselors should know what substances adolescents use as well as
current slang and the effects of any new drugs. They should also have
knowledge of the school system and understand family dynamics.

Young Adults

Young adults may be ready for placement in an adult group. The following
issues are relevant:

-   **Education and employment.** Educational and job skill levels need
    to be addressed;

-   **Family roles.** Some clients may have family responsibilities and
    need assistance with child care and parenting skills;

-   **Separating from parents.** Young adults often require life skills
    development;

-   **Peer relationships.** Some clients may need help in developing
    healthy peer networks;

-   **Mentoring.** Positive adult role models can provide meaningful
    examples; and

-   **Community service.** Young adults in treatment should be
    encouraged to participate in community or faith-based events.

*For more detailed information, see TIP 47, pp. 153--177.*

ADDRESSING DIVERSE POPULATIONS

Treatment providers increasingly serve diverse populations. Treating a
client from outside the prevailing U.S. culture involves understanding
the client's culture and mediating among it, U.S. culture, and the
treatment culture.

What It Means To Be Culturally Competent

The Surgeon General's report *Mental Health: Culture, Race, and
Ethnicity* concludes that the gap between research and practice is worse
for minorities than for the general public. The culturally competent
provider is responsible for ensuring that treatment is effective for
diverse clients. Information on diverse populations can be found in the
resources listed in appendix 10-A of TIP 47.

Delivering Culturally Competent IOT Services

Cultural observations that may be accurate when applied to a group can
be misleading and harmful when applied to an individual. Clinicians
should seek a balance between understanding clients in the context of
their culture and seeing clients as merely an extension of their
culture.

*Differences in Worldview*

U.S. culture tends to be more materialistic and places greater value on
individual achievement and being future oriented than other cultures.
Other cultural issues include the following:

-   **Holistic worldview.** Many cultures see all of nature as an
    intertwined whole. Becoming healthy entails reconnecting with the
    larger universe;

-   **Spirituality.** Spiritual beliefs should be recognized;

-   **Community orientation.** Many cultures are oriented to the
    collective good of the group;

-   **Extended families.** IOT programs must employ a flexible
    definition of family;

-   **Communication styles.** Cultural misunderstandings can be
    misinterpreted as personal violations of trust or respect and can
    prevent clients from receiving appropriate care;

-   **Multidimensional learning styles.** Many cultures do not believe
    that written information is more reliable than oral information. The
    authority of the speaker may be of great importance;

-   **Respect and dignity.** Treating others in an informal, friendly
    way---which is acceptable in the United States---may be viewed by
    other cultures as disrespectful; and

-   **Attitudes toward help from counselors.** Many cultures prefer to
    handle problems within the extended family and may be reluctant to
    accept help from a therapist.

*Foreign-Born Clients*

Refugees often have experienced severe trauma before arriving in the
United States. Other clinical issues include mistrust of authority,
extreme stigma, and the client's level of acculturation. IOT providers
can better serve foreign-born clients by visiting community refugee and
immigrant organizations. Providers can also set up IOT groups in the
immigrants' native language. Language-specific programs should---

-   Translate or adapt program documents and contact information

-   Address important issues faced by immigrants

-   Use general terminology, avoiding words that are difficult to
    understand or translate

-   Familiarize clients with the existence of social and educational
    services

-   Make English-language services available to clients who are
    motivated to learn English.

*Women From Other Cultures*

Immigrant women face the same barriers that American women face but have
the added barrier of being cultural outsiders. Women raised in
male-dominated cultures are often passive and selfless. Counselors may
want to push women toward independence but should be aware that this may
not be personally or culturally desirable. Effective treatment programs
seek to enhance women's economic autonomy. Other services should include
domestic violence intervention, multidisciplinary meetings with
caregivers, and parenting classes.

*Religious Orientation*

IOT providers must ensure that their program welcomes people from all
faiths and that no treatment practices are a barrier to those from
non-Christian religions. Providers can promote religious acceptance
within the program by learning religious customs and seeking support
from religious leaders.

Clinical Implications of Culturally Competent Treatment

To ensure culturally competent treatment, a program should---

-   Assess its policies posing barriers to treating diverse populations

-   Ensure that staff receive training in the cultural beliefs of client
    populations

-   Incorporate clients' family and friends into treatment

-   Provide appropriate program materials in clients' first languages

-   Hire staff and board members from the diverse groups the program
    serves

-   Incorporate elements from the culture of the populations being
    served

-   Partner with agencies and groups that deliver community services

-   Use a motivational framework for treatment.

For demographic sketches of the following populations, see pages
189--196 in TIP 47:

-   Hispanics/Latinos;

-   African Americans;

-   Native Americans;

-   Asian Americans and Pacific Islanders;

-   Persons with HIV/AIDS;

-   Lesbian, gay, and bisexual clients;

-   Persons with physical and cognitive disabilities;

-   Rural populations;

-   Homeless populations; and

-   Older adults.

*For more detailed information, see TIP 47, pp. 179--204.*

ORDERING INFORMATION

TIP 47

*Substance Abuse: Clinical Issues in Intensive Outpatient Treatment*

TIP 47--RELATED PRODUCTS

KAP Keys for Clinicians Based on TIP 47

Do not reproduce or distribute this publication for a fee without
specific, written authorization from the Office of Communications,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services.

Easy Ways to Obtain Free Copies of All TIP Products:

1.  Call SAMHSA's National Clearinghouse for Alcohol and Drug
    Information (NCADI) at 800-729-6686, TDD (hearing impaired)
    800-487-4889.

2.  Visit NCADI's Web site at
    [www.ncadi.samhsa.gov](http://www.ncadi.samhsa.gov/).

3.  Access TIPs online at
    [www.kap.samhsa.gov](http://www.kap.samhsa.gov/).

OTHER TREATMENT IMPROVEMENT PROTOCOLS (TIPS) THAT ARE RELATED TO THIS
QUICK GUIDE

TIP 25: *Substance Abuse Treatment and Domestic Violence* (1997)
**BKD239**

TIP 31: *Screening and Assessing Adolescents for Substance Use
Disorders* (1999) **BKD306**

TIP 32: *Treatment of Adolescents With Substance Use Disorders* (1999)
**BKD307**

TIP 39: *Substance Abuse Treatment and Family Therapy* (2004) **BKD504**

TIP 41: *Substance Abuse Treatment: Group Therapy* (2004) **BKD507**

TIP 45: *Detoxification and Substance Abuse Treatment* (2006) **BKD541**

TIP 46: *Substance Abuse: Administrative Issues in Outpatient Treatment*
(2006) **BKD545**

See above for ordering information for all TIPs and related products.

DHHS Publication No. (SMA) 07-4233

Printed 2007