A Treatment 

Improvement 

Protocol

Substance Abuse:

Clinical Issues in Intensive 

Outpatient Treatment

TIP

47

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov INTENSIVE

OUTPATIENT

TREATMENT

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857

Substance Abuse:

Clinical Issues in Intensive 

Outpatient Treatment

Robert F. Forman, Ph.D.

Consensus Panel Chair

Paul D. Nagy, M.S., LCAS, LPC, CCS

Consensus Panel Co-Chair

A Treatment 

Improvement 

Protocol

TIP 

47
Acknowledgments

Numerous people contributed to the development of this Treatment Improvement Protocol 

(TIP) (see pp. xi–xiv as well as appendixes C, 

D, and E). This publication was produced 

by JBS International, Inc. (JBS), under the 

Knowledge Application Program (KAP) 

contract numbers 270-99-7072 and 270-04-

7049 with the Substance Abuse and Mental 

Health Services Administration (SAMHSA), 

U.S. Department of Health and Human 

Services (DHHS). Christina Currier served as 

the Center for Substance Abuse Treatment 

(CSAT) Government Project Officer, and 

Andrea Kopstein, Ph.D., M.P.H., served as 

Deputy Government Project Officer. Lynne 

MacArthur, M.A., A.M.L.S., served as the JBS 

KAP Executive Project Co-Director. Barbara 

Fink, RN, M.P.H., served as the JBS KAP 

Managing Project Co-Director. Other KAP 

personnel included Dennis Burke, M.S., M.A., 

and Emily Schifrin, M.S., Deputy Directors for 

Product Development; Patricia A. Kassebaum, 

M.A., Senior Writer; Elliott Vanskike, Ph.D., 

Senior Writer/Publication Manager; Candace 

Baker, M.S.W., Senior Writer; Wendy Caron, 

Editorial Quality Assurance Manager; Frances 

Nebesky, M.A., Quality Assurance Editor; 

Leah Bogdan, Junior Editor; and Pamela 

Frazier, Document Production Specialist. In 

addition, Sandra Clunies, M.S., ICADC, served 

as Content Advisor. Dixie M. Butler, M.S.W., 

and Paddy Shannon Cook were writers.

Disclaimer

The opinions expressed herein are the views of 

the consensus panel members and do not necessarily reflect the official position of CSAT, 

SAMHSA, or DHHS. No official support of or 

endorsement by CSAT, SAMHSA, or DHHS 

for these opinions or for particular instruments, software, or resources described in this 

document is intended or should be inferred. 

The guidelines in this document should not be 

considered substitutes for individualized client care and treatment decisions.

Public Domain Notice

All materials appearing in this volume except 

those taken directly from copyrighted sources 

are in the public domain and may be reproduced or copied without permission from 

SAMHSA/CSAT or the authors. Do not reproduce or distribute this publication for a fee 

without specific, written authorization from 

SAMHSA’s Office of Communications. 

Electronic Access and Copies 

of Publication

Copies may be obtained free of charge from 

SAMHSA’s National Clearinghouse for 

Alcohol and Drug Information (NCADI), (800) 

729-6686 or (301) 468-2600; TDD (for hearing 

impaired), (800) 487-4889; or electronically 

through www.ncadi.samhsa.gov.

Recommended 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.

Originating Office

Practice Improvement Branch, Division of 

Services Improvement, Center for Substance 

Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 1 

Choke Cherry Road, Rockville, MD 20857.

DHHS Publication No. (SMA) 06-4182

NCADI Publication No. BKD551

Printed 2006
iii

What Is a TIP? .............................................................................................................................. ix

Consensus Panel .......................................................................................................................... xi

KAP Expert Panel and Federal Government Participants ........................................................ xiii

Foreword ......................................................................................................................................xv

Executive Summary .................................................................................................................. xvii

Chapter 1—Introduction ............................................................................................................... 1

Forces Affecting IOT and the Contents of This TIP .................................................................................. 2

Terminology and Definitions ....................................................................................................................... 3

Summary of This TIP .................................................................................................................................... 5

Chapter 2— Principles of Intensive Outpatient Treatment ........................................................... 7

Principle 1: Make Treatment Readily Available ........................................................................................ 8

Principle 2: Ease Entry ................................................................................................................................. 9

Principle 3: Build on Existing Motivation ................................................................................................. 9

Principle 4: Enhance Therapeutic Alliance ............................................................................................. 10

Principle 5: Make Retention a Priority .................................................................................................... 10

Principle 6: Assess and Address Individual Treatment Needs .............................................................. 11

Principle 7: Provide Ongoing Care ............................................................................................................ 11

Principle 8: Monitor Abstinence ............................................................................................................... 12

Principle 9: Use Mutual-Help and Other Community-Based Supports ................................................ 12

Principle 10: Use Medications if Indicated .............................................................................................. 13

Principle 11: Educate About Substance Use Disorders, Recovery, and Relapse ................................. 14

Principle 12: Engage Families, Employers, and Significant Others .................................................... 14

Principle 13: Incorporate Evidence-Based Approaches ......................................................................... 15

Principle 14: Improve Program Administration ...................................................................................................15

Chapter 3—Intensive Outpatient Treatment and the Continuum of Care ................................. 17

Overview of a Continuum of Care ............................................................................................................. 17

Conceiving of a Continuum of Care ........................................................................................................... 18

Key Aspects of IOT (Level II) ...................................................................................................................... 19

iii

Contents
iv

Key Aspects of Outpatient Treatment (Level I) ........................................................................................ 23

Continuing Community Care ..................................................................................................................... 24

Chapter 4—Services in Intensive Outpatient Treatment Programs ........................................... 27

Core Services ................................................................................................................................................ 27

Enhanced IOT Services ............................................................................................................................... 44

IOT Services: A Case Illustration ............................................................................................................... 46

Appendix 4-A. A Case Study of Intensive Outpatient Treatment .......................................................... 48

Appendix 4-B. Induction Protocol for Disulfiram ................................................................................... 56

Chapter 5—Treatment Entry and Engagement .......................................................................... 59

Elements of Engaging the Client in IOT ................................................................................................... 60

Collect Screening Information ................................................................................................................... 62

Assessing Barriers to Treatment ................................................................................................................ 64

Crises and Emergencies .............................................................................................................................. 67

Components of the IOT Admission Process ............................................................................................. 67

Sample Treatment Plans ............................................................................................................................ 76

Appendix 5-A. Substance Use History Form ............................................................................................ 84

Appendix 5-B. Instruments for Determining Substance-Related and Psychiatric Diagnoses ............ 85

Appendix 5-C. DSM-IV Criteria for Substance Dependence and Substance Abuse ............................ 87

Appendix 5-D. Supplements to the Six Assessment Domains in the ASI and Other Topics ................ 88

Chapter 6—Family-Based Services .............................................................................................. 93

Planning for Family Involvement .............................................................................................................. 94

Engaging the Family in Treatment ........................................................................................................... 95

Family Services ........................................................................................................................................... 98

Family Clinical Issues in IOT ................................................................................................................... 102

Appendix 6-A. Format and Symbols for Family Genogram ................................................................. 107

Appendix 6-B. Family Social Network Map ............................................................................................ 109

Appendix 6-C. Resources for Family-Based Services ............................................................................. 112

Chapter 7— Clinical Issues, Challenges, and Strategies in Intensive Outpatient Treatment ........ 115

Client Retention ......................................................................................................................................... 115

Contents
v

Relapse and Continued Substance Use .................................................................................................. 117

Substance Use by Family Members ......................................................................................................... 119

Group Work Issues ..................................................................................................................................... 120

Safety and Security .................................................................................................................................... 125

Client Privacy ............................................................................................................................................. 128

Clients Who Work ...................................................................................................................................... 130

Boundary Issues ......................................................................................................................................... 132

Appendix 7-A. Instruments for Assessing Relapse Potential ................................................................ 135

Chapter 8—Intensive Outpatient Treatment Approaches ........................................................ 137

12-Step Facilitation Approach ................................................................................................................. 138

Cognitive–Behavioral Approach .............................................................................................................. 140

Motivational Approaches ......................................................................................................................... 141

Therapeutic Community Approach ......................................................................................................... 142

The Matrix Model ...................................................................................................................................... 146

Community Reinforcement and Contingency Management Approaches ........................................... 148

Chapter 9— Adapting Intensive Outpatient Treatment for Specific Populations .............................153

Justice System Population ........................................................................................................................ 153

Women ........................................................................................................................................................ 157

Populations With Co-Occurring Psychiatric Disorders ......................................................................... 162

Adolescents ................................................................................................................................................. 171

Young Adults .............................................................................................................................................. 175

Chapter 10— Addressing Diverse Populations in Intensive Outpatient Treatment .................. 179

What It Means To Be a Culturally Competent Clinician ...................................................................... 180

Principles in Delivering Culturally Competent IOT Services ............................................................... 181

Issues of Special Concern ......................................................................................................................... 183

Clinical Implications of Culturally Competent Treatment .................................................................. 188

Sketches of Diverse IOT Client Populations ........................................................................................... 189

Appendix 10-A. Cultural Competence Resources .................................................................................. 197

Contents
vi

Exhibits

3-1 Goals, Duration, Activities, and Completion Criteria of Stage 1 .................................................. 21

3-2 Goals, Duration, Activities, and Completion Criteria of Stage 2 .................................................. 22

3-3 Goals, Duration, Activities, and Completion Criteria of Stage 3 .................................................. 25

3-4 Goals, Duration, Activities, and Completion Criteria of Stage 4 .................................................. 26

4-1 Core and Enhanced Services for IOT Programs ............................................................................. 28

4-2 Groups Conducted in Intensive Outpatient Treatment ................................................................. 29

4-3 Typical Sequence of Topics Addressed in Psychoeducational Group ......................................... 33

4-4 Case Management Services ................................................................................................................ 39

4-5 Examples of 24-Hour Crisis Coverage Implementation ................................................................ 41

4-6 Alternatives to Traditional 12-Step Groups .................................................................................... 43

4-7 Key Features of a Hospital-Based Suburban IOT Program .......................................................... 46

4-8 A Protocol for Ambulatory Detoxification and Disulfiram Induction ......................................... 56

5-1 Effective Interviewing Techniques .................................................................................................... 63

5-2 ABC Model for Psychiatric Screening .............................................................................................. 66

5-3 The Six Dimensions of the ASAM PPC-2R for Level II.1 IOT ...................................................... 69

5-4 Brief Screening Instruments That Assess Motivational Stage ....................................................... 70

5-5 Mild Withdrawal Symptoms for Four Drug Classes That Can Be Managed in Level II.5 

Ambulatory Detoxification ................................................................................................................ 71

Appendix A—Bibliography ........................................................................................................ 205

Appendix B—Urine Collection and Testing Procedures and 

Alternative Methods for Monitoring Drug Use ......................................................................... 237

Appendix C—Resource Panel .................................................................................................... 247

Appendix D—Cultural Competency and Diversity Network Participants ................................ 249

Appendix E—Field Reviewers .................................................................................................... 251

Index ......................................................................................................................................... 255

CSAT TIPs and Publications Based on TIPs ............................................................................ 265

Contents
Contents vii

6-1 Suggestions for Engaging Family Members at Intake ................................................................... 96

6-2 A Treatment Calendar for Family Members ................................................................................... 99

6-3 Social Network Grid Used in Conjunction With Network Map .................................................. 111

7-1 Examples of Immediate Safety Concerns and Counselor Responses ........................................ 126

8-1 Strengths and Challenges of 12-Step Approaches ........................................................................ 139

8-2 Strengths and Challenges of Cognitive–Behavioral Approaches ................................................ 141

8-3 Strengths and Challenges of Motivational Approaches ............................................................... 143

8-4 Strengths and Challenges of the Therapeutic Community Approach ....................................... 145

8-5 Strengths and Challenges of Matrix Model Treatment ................................................................ 147

8-6 Strengths and Challenges of Community Reinforcement and Contingency 

Management Approaches ................................................................................................................ 151

9-1 Core Treatment Needs and Service Elements for Women .......................................................... 160

9-2 SAMHSA’s Service Coordination Framework for Co-Occurring Disorders ............................... 164

9-3 The Family Intervention Program .................................................................................................. 174

9-4 Characteristics and Behaviors of Adolescents and Treatment Suggestions .............................. 176

B-1 Urine Toxicology Detection Periods for Different Substances .................................................... 240

B-2 Effectiveness of Drug Detection Methods That Use Different Biological Products .................. 243

ix

What Is a TIP?

Treatment Improvement Protocols (TIPs), developed by the Center for 

Substance Abuse Treatment (CSAT), part of the Substance Abuse and 

Mental Health Services Administration, within the U.S. Department of 

Health and Human Services, are best-practice guidelines for the treatment of substance use disorders. CSAT draws on the experience and 

knowledge of clinical, research, and administrative experts to produce 

the TIPs, which are distributed to facilities and individuals across the 

country. The audience for the TIPs is expanding beyond public and 

private treatment facilities to include practitioners in mental health, 

criminal justice, primary care, and other health care and social service 

settings.

CSAT’s Knowledge Application Program expert panel, a distinguished 

group of experts on substance use disorders and professionals in such 

related fields as primary care, mental health, and social services, works 

with the State Alcohol and Drug Abuse Directors to generate topics for 

the TIPs. Topics are based on the field’s current needs for information 

and guidance.

After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to be members of a resource panel that 

recommends specific areas of focus as well as resources that should be 

considered in developing the content for the TIP. These recommendations are communicated to a consensus panel composed of experts on 

the topic who have been nominated by their peers. Consensus panel 

members participate in a series of discussions. The information and 

recommendations on which they reach consensus form the foundation 

of the TIP. The members of each consensus panel represent substance 

abuse treatment programs, hospitals, community health centers, 

counseling programs, criminal justice and child welfare agencies, and 

private practitioners. A panel chair (or co-chairs) ensures that the contents of the TIP mirror the results of the group’s collaboration.
A large and diverse group of experts closely 

reviews the draft document. Once the changes 

recommended by these field reviewers have 

been incorporated, the TIP is prepared for 

publication, in print and on line. TIPs can be 

accessed via the Internet at www.kap.samhsa.

gov. The online TIPs are consistently updated 

and provide the field with state-of-the-art 

information.

Although each TIP strives to include an evidence base for the practices it recommends, 

CSAT recognizes that the field of substance 

abuse treatment is evolving, and research 

frequently lags behind the innovations pioneered in the field. A major goal of each TIP 

is to convey “front-line” information quickly 

but responsibly. For this reason, recommendations proffered in the TIP are attributed 

to either panelists’ clinical experience or the 

literature. If research supports a particular 

approach, citations are provided.

This TIP, Substance Abuse: Clinical Issues in 

Intensive Outpatient Treatment, was written 

to help clinicians address the expansion of 

intensive outpatient treatment (IOT) represented by the development and adoption of 

new approaches to treat a wider variety of 

clients. Researchers and clinicians have begun 

to question the acute care model of treatment 

for substance use disorders; this reexamination has led to a more robust collaboration 

between researchers and practitioners. The 

resulting focus on evidence-based treatment 

approaches informs most of the material 

in this TIP. The consensus panel presents 

14 guiding principles of IOT, supported by 

research and clinical experience. This TIP 

also situates IOT within the continuum of 

care framework established by the American 

Society of Addiction Medicine, including outpatient treatment and continuing community 

care. The volume describes the core services 

every program should offer, the enhanced 

services that should be available on site or 

through links with community-based services, 

and the process of assessment, placement, 

and treatment planning that helps clinicians 

address each client’s needs. Based on research 

and clinical experience, the consensus panel 

discusses major clinical challenges of IOT 

and surveys the most common treatment 

approaches used in IOT programs, including 

family-based services. More specialized sections address treatment of specific groups of 

clients: women; adolescents and young adults; 

persons involved with the criminal justice 

system; individuals with co-occurring disorders; racial and ethnic minorities; persons 

with HIV/AIDS; lesbian, gay, and bisexual 

individuals; persons with physical or cognitive disabilities; rural populations; individuals 

who are homeless; and older adults.

x What Is a TIP?
Chair

Robert F. Forman, Ph.D.

Clinical Scientist

Medical Affairs

Alkermes, Inc. 

Cambridge, Massachusetts

Formerly

Senior Investigator

Treatment Research Institute

Assistant Professor of Psychology in 

Psychiatry

School of Medicine

University of Pennsylvania

Philadelphia, Pennsylvania

Writer, chapters 1 and 2

Co-Chair

Paul D. Nagy, M.S., LCAS, LPC, CCS

Program Director

Duke Addictions Program

Clinical Associate

Department of Psychiatry and 

Behavioral Sciences

Duke University Medical Center

Durham, North Carolina

Writer, chapters 1 and 5

Consensus Panelists

Fred Andes, D.S.W., M.P.A., LCSW

Assistant Professor of Sociology

New Jersey City University

Jersey City, New Jersey

Writer, chapters 5 and 6

Margaret K. Brooks, J.D.

Consultant

27 Warfield Street

Montclair, New Jersey 

Writer, chapter 9

Frederick T. Chappelle, M.S.S.W., LCADC, 

CCS

Vice President and Financial Officer

Chappelle Consulting and 

Training Services, Inc.

Middletown, Connecticut 

Gerard J. Connors, Ph.D.

Director

Research Institute on Addictions

University of Buffalo

Buffalo, New York 

Writer, chapters 4 and 5

Anita L. Crawford

Chief Executive Officer

Roxbury Comprehensive Community 

Health Center

Roxbury, Massachusetts

Chris B. Farentinos, M.D., CADC II, 

NCDC II

Clinical Director

Change Point, Inc.

Portland, Oregon 

Writer, chapters 4, 7, 8, and 10

xi

Consensus Panel

This TIP is a consensus-based document, developed by the experts listed below. Although all 

panelists made significant contributions in the development of the TIP as a whole, some panelists took on the additional responsibility as writers for upfront development of particular 

chapters. Those chapters are listed after their names.
Marco E. Jacome, M.A., LPC,

CSADC, CEAP

Executive Director

Healthcare Alternative Systems, Inc.

Chicago, Illinois 

Writer, chapter 10

George Kolodner, M.D.

Medical Director

Kolmac Clinic

Silver Spring, Maryland 

Writer, chapter 4

Felicity L. LaBoy, Ph.D.

Clinical Coordinator

Dual Diagnoses Program

Substance Abuse Services

Bronx VA Medical Center

Bronx, New York

Writer, chapters 3, 4, and 9

Janice Ogden Lipscomb, M.S., ACADC

Director

Mental Health and Chemical Dependency 

Community Based Programs

Broadlawns Medical Center

Des Moines, Iowa

Writer, chapters 3 and 8

Mary E. McCaul, Ph.D.

Associate Professor

Psychiatry and Behavioral Sciences

Johns Hopkins University School of 

Medicine

Baltimore, Maryland

Writer, chapters 8 and 9

Elizabeth A. Peyton

Principal

Peyton Consulting Services

Newark, Delaware 

Writer, chapters 8 and 9

Richard A. Rawson, Ph.D.

Associate Director

UCLA Integrated Substance Abuse Programs

Los Angeles, California

Writer, chapter 2

Candace M. Shelton, M.S., CSAS, 

CADAC, CCS

Consultant

Tucson, Arizona

Writer, chapter 10

xii Consensus Panel
Barry S. Brown, Ph.D.

Adjunct Professor

University of North Carolina at Wilmington

Carolina Beach, North Carolina

Jacqueline Butler, M.S.W., LISW, LPCC,

CCDC III, CJS

Professor of Clinical Psychiatry

College of Medicine

University of Cincinnati

Cincinnati, Ohio 

Deion Cash

Executive Director

Community Treatment and Correction 

Center, Inc.

Canton, Ohio

Debra A. Claymore, M.Ed.Adm.

Owner/Chief Executive Officer

WC Consulting, LLC

Loveland, Colorado 

Carlo C. DiClemente, Ph.D.

Chair

Department of Psychology

University of Maryland Baltimore County

Baltimore, Maryland 

Catherine E. Dube, Ed.D.

Independent Consultant

Brown University

Providence, Rhode Island

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief, Services

Division of Clinical and Services Research

National Institute on Drug Abuse

Bethesda, Maryland

Michael Galer, D.B.A., M.B.A., M.F.A.

Chairman of the Graduate School of Business

University of Phoenix —Greater Boston Campus

Braintree, Massachusetts

Renata J. Henry, M.Ed.

Director

Division of Alcoholism, Drug Abuse, and 

Mental Health

Delaware Department of Health and 

Social Services

New Castle, Delaware 

Joel Hochberg, M.A.

President

Asher & Partners

Los Angeles, California

Jack Hollis, Ph.D.

Associate Director

Center for Health Research

Kaiser Permanente

Portland, Oregon 

Mary Beth Johnson, M.S.W.

Director

Addiction Technology Transfer Center

University of Missouri—Kansas City

Kansas City, Missouri 

Eduardo Lopez, B.S.

Executive Producer

EVS Communications

Washington, D.C.

Holly A. Massett, Ph.D.

Academy for Educational Development

Washington, D.C.

xiii

KAP Expert Panel and Federal 

Government Participants
xiv

Diane Miller

Chief

Scientific Communications Branch

National Institute on Alcohol Abuse and 

Alcoholism

Bethesda, Maryland

Harry B. Montoya, M.A.

President/Chief Executive Officer

Hands Across Cultures

Espanola, New Mexico

Richard K. Ries, M.D.

Director/Professor

Outpatient Mental Health Services

Dual Disorder Programs

Seattle, Washington

Gloria M. Rodriguez, D.S.W.

Research Scientist

Division of Addiction Services

New Jersey Department of Health 

and Senior Services

Trenton, New Jersey 

Everett Rogers, Ph.D.

Center for Communications Programs

Johns Hopkins University

Baltimore, Maryland 

Jean R. Slutsky, P.A., M.S.P.H.

Senior Health Policy Analyst

Agency for Healthcare Research and Quality

Rockville, Maryland 

Nedra Klein Weinreich, M.S.

President

Weinreich Communications

Canoga Park, California

Clarissa Wittenberg

Director

Office of Communications and Public Liaison

National Institute of Mental Health

Bethesda, Maryland

Consulting Members 

of the KAP Expert Panel

Paul Purnell, M.A.

Social Solutions, L.L.C.

Potomac, Maryland 

Scott Ratzan, M.D., M.P.A., M.A.

Academy for Educational Development

Washington, D.C. 

Thomas W. Valente, Ph.D.

Director, Master of Public Health Program

Department of Preventive Medicine

School of Medicine

University of Southern California

Alhambra, California

Patricia A. Wright, Ed.D.

Independent Consultant

Baltimore, Maryland

KAP Expert Panel and Federal Government Participants
Foreword

The Treatment Improvement Protocol (TIP) series supports SAMHSA’s 

mission of building resilience and facilitating recovery for people with 

or at risk for mental or substance use disorders by providing bestpractices guidance to clinicians, program administrators, and payers 

to improve the quality and effectiveness of service delivery and thereby 

promote recovery. TIPs are the result of careful consideration of all 

relevant clinical and health services research findings, demonstration 

experience, and implementation requirements. A panel of non-Federal 

clinical researchers, clinicians, program administrators, and client 

advocates debates and discusses its particular areas of expertise until 

it reaches a consensus on best practices. This panel’s work is then 

reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIPs’ panelists and reviewers bring to this highly participatory process have helped bridge the 

gap between the promise of research and the needs of practicing clinicians and administrators who serve, in the most current and effective 

ways, people who abuse substances. We are grateful to all who have 

joined with us to contribute to advances in the substance abuse treatment field.

Eric B. Broderick, D.D.S., M.P.H.

Acting Deputy Administrator

Assistant Surgeon General

Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

xv

xvii

This volume, Substance Abuse: Clinical Issues in Intensive Outpatient 

Treatment, and its companion text, Substance Abuse: Administrative 

Issues in Outpatient Treatment, revisit the subject matter of 

Treatment Improvement Protocol (TIP) 8, Intensive Outpatient 

Treatment for Alcohol and Other Drug Abuse, published in 1994 

(CSAT 1994c). When TIP 8 was published, one volume of about 100 

pages sufficed to address relevant topics in intensive outpatient treatment (IOT). Today, the same task requires two volumes, each devoted 

to a distinct audience, clinicians and administrators. The primary 

audience for this volume is clinicians working in IOT programs. 

The Changing IOT Landscape

Arnold M. Washton (1997) points out that the first large expansion of IOT took place during the 1980s, when White, middle-class 

individuals with cocaine addiction, many of whom were business 

professionals, sought treatment and did not want to take time away 

from work or face the stigma of checking into a residential treatment 

facility. A second expansion of IOT was ushered in by managed care 

with a focus on cost containment. Throughout the 1990s, IOT grew, 

becoming the dominant setting for most clients with substance use 

disorders. This growth was spurred by the expansion of IOT’s population from clients with a moderate range of problems to include 

clients who are homeless, adolescents, and persons with co-occurring 

mental disorders, all of whom formerly were considered too difficult 

for IOT programs to treat successfully. This expansion in clients and 

services means that IOT clinicians must keep abreast of a broadening array of treatment approaches and services provided beyond 

their programs. The current volume’s focus on clinicians reflects 

both the increased treatment options available and the expanded 

range of knowledge and skills required.

xvii

Executive Summary
xviii

Defining Substance 

Abuse Treatment and 

IOT

For most of the 20th century, substance 

abuse was considered an acute disorder. 

Viewing substance abuse more like pneumonia than like chronic diseases such as 

hypertension or diabetes had shaped the 

expectations and treatment choices of clinicians. As McLellan and colleagues (2000) 

point out, regarding substance abuse as a 

chronic disorder means realigning treatment and outcome expectations so that they 

resemble those for other chronic disorders. 

Today, many IOT programs are involved 

in treatment beyond the traditional 4 to 12 

weeks. Increasingly, IOT programs focus on 

ongoing care that addresses many areas of 

clients’ lives through case management and 

the involvement of other service providers 

and families and communities.

A parallel development has been the frequent application of research findings into 

practice in the field of substance abuse 

treatment. Research has yielded new understanding about the complexity of substance 

use disorders that takes into account biochemical processes, learning, spirituality, 

and environment. IOT programs are integral 

to the process of translating scientific findings into clinically effective treatments. The 

collaboration between research and practice 

has moved some treatments out of research 

centers and into IOT programs. Cognitive–

behavioral interventions, relapse prevention 

training, motivational enhancement, and 

case management are used in communitybased treatment settings as a result of the 

cross-fertilization of research and treatment. 

One result of the convergence of research 

and practice is the development of evidencebased principles that shape and guide 

substance abuse treatment. The consensus 

panel recommends 14 principles for IOT 

programs. These principles lay a theoretical 

foundation for discussions of IOT services, 

clinical challenges, and treatment approaches and adaptations. In their focus on client 

engagement and retention, individualizing 

treatment, using the entire continuum of 

care, and reaching out to families, employers, and the community, the 14 principles 

help define the IOT program’s contemporary 

role. 

Continuum of Care 

and IOT Services 

An IOT program is most effective at helping its clients if it is part of a continuum 

of care. The American Society of Addiction 

Medicine has established five levels of care: 

medically managed intensive inpatient, 

residential, intensive outpatient, outpatient, and early intervention. In addition, 

continuing community care (e.g., 12-Step 

support groups), which a client participates 

in after the conclusion of formal treatment, 

is another important level of service. A continuum of care ensures that clients can enter 

substance abuse treatment at a level appropriate to their needs and step up or down 

to a different intensity of treatment based 

on their responses. Clinicians enhance the 

capabilities of their programs when they are 

informed about and willing to refer clients to 

other treatment providers. Close monitoring 

of clients’ progress toward treatment goals 

is key to determining when they are ready 

for the next appropriate level of care. Any 

transition in treatment increases the likelihood that a client will drop out. A step-up 

or stepdown in treatment intensity in the 

same program or a referral to a nonaffiliated 

provider can be disruptive for the client. 

Mee-Lee and Shulman (2003) recommend 

that a continuum of care feature seamless 

transfer between levels, congruence in treatment philosophy, and efficient transfer of 

records. Clinicians need to be thoroughly 

familiar with local treatment options, including support groups, so that they can orient 

clients as the clients transition to new treatment situations.

Executive Summary 
xix

Services integral to all IOT programs are 

core services. The consensus panel believes 

that these core services, such as group and 

individual counseling, psychoeducational 

programming, monitoring of drug use, 

medication management, case management, medical and psychiatric examinations, 

crisis intervention coverage, and orientation to community-based support groups, 

are indispensable and should be available 

through all IOT programs. Additional services that are offered at the program site or 

through links with partner organizations are 

enhanced services. This concept is flexible, 

and what might be considered enhanced 

services for some programs may be essential 

services for a program with a different client 

population. (Clients whose first language is 

not English might need language classes to 

find work and participate in mutual-help 

groups, whereas a program that primarily serves native speakers would have little 

call for such a service.) Enhanced services 

include adult education classes, recreational 

activities, adjunctive therapies (e.g., biofeedback, acupuncture, meditation), child care, 

nicotine cessation treatment, housing, transportation, and food. 

Entry, Engagement, 

and Treatment Issues

Many clients who enter substance abuse 

treatment drop out in the early stages 

(Claus and Kindleberger 2002). Entry and 

engagement are crucial processes; how an 

IOT program addresses them can influence strongly whether clients remain in 

treatment. Client intake and engagement 

can involve contradictory processes such as 

collecting intake information from clients 

while initiating a caring, empathic relationship. Balancing administrative tasks and 

therapeutic intervention is a challenge clinicians face during a client’s first hours in 

an IOT program. To help clinicians achieve 

that balance, the consensus panel recommends assessing potential clients’ readiness 

for change and using strategies that motivate them to enter and continue treatment. 

Clinicians should begin to establish a 

therapeutic relationship as soon as clients 

present themselves for treatment. Any barriers to treatment must be addressed. Based 

on screening and assessments, clients should 

be matched with the best treatment modality and setting to support their recovery. An 

individualized treatment plan should be 

developed with the cooperation of the client 

to address the client’s needs.

Client retention is a priority throughout 

treatment. The consensus panel draws on 

research and the experience of practiced clinicians to address the issues of engagement 

and retention. Clients can become distracted 

from recovery if family members continue 

to use substances, boundaries between clients and staff are not established clearly, 

work conflicts with treatment, or they receive 

incompatible recommendations from different service systems. Clinicians need to know 

how to ensure the privacy of their clients and 

the safety and security of the program facility while maintaining open and productive 

therapeutic relationships with their clients. 

Clinicians also need to be familiar with common issues that can derail clients in group 

therapy such as intermittent attendance and 

other clients who are disruptive, ambivalent, 

or withdrawn. When clinicians understand 

and prepare for these problems, their clients 

have a better chance of being retained in 

and benefiting from treatment. A major factor in client retention is the quality of the 

relationship between client and counselor. 

The client is more likely to do well in treatment if a strong therapeutic alliance exists.

Treatment Approaches 

Used in IOT

IOT is compatible with different treatment 

approaches. Involving clients’ families 

in their recovery is an effective strategy. 

Substance-using behavior may be rooted 

in part in a client’s family history—whether 

family of origin or family of choice. Families 

Executive Summary 
xx

can play a crucial role in a client’s recovery. Providers should prepare for family 

involvement, education, and other services 

so that family members can support recovery. Family involvement in treatment has 

been linked to positive outcomes for clients 

in substance abuse treatment (Rowe and 

Liddle 2003). For IOT providers, adopting 

a family systems approach means including 

family members in every stage of treatment: 

the intake interview, counseling sessions, 

family dinners or weekends, and graduation celebrations. If family members are to 

support a client’s recovery, they must be disabused of unrealistic expectations and learn 

about relapse prevention. IOT providers 

should consider offering family education 

groups, multifamily groups, and family support groups. If family therapy (which in most 

States requires a licensed, master’s-level 

clinician) is warranted and an IOT clinic 

cannot offer it, referral relationships can be 

developed with an organization that provides 

individual family therapy, couples therapy, 

and child-focused therapy. 

Providers should be familiar with the 

strengths and challenges of different treatment approaches so they can serve their 

clients better by modifying and blending 

approaches as necessary. The 12-Step facilitation approach is common in the treatment 

environment. Twelve-Step-oriented treatment helps clients achieve abstinence and 

understand the principles of Alcoholics 

Anonymous and other 12-Step groups 

through group counseling, homework assignments, and psychoeducation. The 12-Step 

approach emphasizes cognitive, behavioral, 

spiritual, and health aspects of recovery 

and is effective with many different types of 

clients. 

Cognitive–behavioral therapy focuses on 

teaching clients skills that will help them 

understand and reduce their relapse risks 

and maintain abstinence. Clients must be 

motivated and counselors must be trained 

extensively for cognitive–behavioral therapy 

to succeed. 

Motivational approaches, such as motivational interviewing and motivational 

enhancement therapy, also rely on extensive 

staff training and high levels of client selfawareness. Through empathic listening, 

counselors explore clients’ attitudes toward 

substance abuse and treatment, supporting 

past successes and encouraging problemsolving strategies. These approaches are client 

centered and goal driven and encourage client self-sufficiency. 

Therapeutic community approaches are 

used most often in residential settings but 

have been adapted for IOT. In therapeutic 

community approaches, a structured community of clients and staff members is the 

main therapeutic agent—peers and counselors are role models, the work at the facility is 

used as therapy, and group sessions focus on 

self-awareness and behavioral change. The 

intensity of the treatment calls for extensive 

staff training and can result in high client 

dropout. However, therapeutic communities 

have proved successful with difficult clients 

(e.g., those with long histories of substance 

use and those who have served time in 

prison). 

The Matrix model integrates a number 

of other treatment approaches, including 

mutual-help, cognitive–behavioral, and motivational interviewing. A strong therapeutic 

relationship between client and counselor 

is the centerpiece of the Matrix approach. 

Other features are learning about withdrawal and cravings, practicing relapse 

prevention and coping techniques, and submitting to drug screens. 

Contingency management and community 

reinforcement approaches encourage clients to change behavior; these approaches 

reinforce abstinence by rewarding some 

behaviors and punishing others. Programs 

select a goal that is reasonable, is attainable, and contributes to overall treatment 

objectives and then reward small steps the 

client makes toward that goal. Contingency 

management and community reinforcement 

Executive Summary
xxi

approaches have been successful with clients 

who have chronic substance use disorders, 

when the costs for staff training and incentives can be addressed.

Treating Different 

Populations

Many of the approaches used in IOT programs were developed to treat substance 

use disorders in White, middle-class men. 

Adaptations to these approaches are necessary to treat a variety of clients such as those 

in the justice system, women, clients with cooccurring disorders, and adolescents. 

Increasing numbers of people with substance 

use disorders are involved with the justice 

system. Justice agencies and treatment providers need to work closely with each other, 

communicating clearly and coordinating 

their efforts. Cooperation of a different kind 

must exist between clinicians and clients. 

Therapeutic alliance is especially important 

when working with clients in the justice 

system who may have difficulty trusting a clinician and forming meaningful relationships 

outside the criminal environment. 

The number of treatment programs for 

women is increasing. These programs add 

enhanced services designed to address substance abuse in the context of pregnancy and 

parenting, self-esteem issues, and histories 

of physical, sexual, and emotional abuse. To 

treat women, clinicians often avoid confrontational techniques and focus on providing a 

safe and supportive environment with clearly 

established boundaries between client and 

counselor. 

Many people with co-occurring mental and 

substance use disorders are not receiving 

appropriate care (Watkins et al. 2001) and 

find themselves shuttling between psychiatric and substance abuse treatment, caught 

between two systems (Drake et al. 2001). 

Integrated treatment attends to both disorders together, adapts standard interventions 

to allow for clients’ cognitive limitations, and 

provides comprehensive services to care for 

both disorders. Programs that do not adopt 

an integrated approach are advised to coordinate services with mental health providers. 

A comprehensive approach to services also 

is important for adolescents who are using 

substances. Adolescents experience incredible upheaval in their lives and often need 

habilitation rather than rehabilitation. Many 

are in treatment for the first time and need 

to be oriented to treatment culture. Because 

adolescents often are living at home, family involvement is crucial. A behavioral 

contract—stipulating desired behaviors and 

rewards—and case management—addressing 

medical, social, and psychological needs—are 

also beneficial treatment tools.

IOT programs are being called on to serve 

an increasingly diverse client population. 

Almost one-third of Americans belong to an 

ethnic or racial minority group, and more 

than 10 percent of the U.S. population was 

born outside the country (Schmidley 2003). 

Although there is widespread agreement that 

clinicians should be culturally competent, 

no consensus exists about what cultural 

competence means. As a starting point, clinicians should understand how to work with 

someone from outside their own culture and 

strive to understand the specific culture of 

the client being served. Whereas the ability 

to treat clients from outside one’s culture 

is an extension of the skills of a good clinician, understanding the cultural context 

of individual clients is more demanding. 

Clinicians need to strike a balance between a 

broad cultural background and the specific 

cultural context of a client’s life; an observation that is applicable to a large group may 

be misleading or harmful if applied to an 

individual. 

For foreign-born clients, level of acculturation often is an issue. Most research shows 

that the more acculturated clients are, the 

more their substance use approximates U.S. 

norms. Programs that serve substantial numbers of foreign-born clients may consider 

Executive Summary 
xxii

offering language-specific programs and linking clients to language classes, job training, 

and employment services. Clients from other 

cultures may be averse to the emphasis on 

self-disclosure and self-sufficiency in substance abuse treatment. Counselors must be 

prepared to work within the client’s value 

system, which may be at odds with values 

promoted by the treatment program. 

Likewise, programs should ensure that program practices and materials do not pose 

a barrier to clients of non-Christian faiths. 

Many mutual-help programs have a strong 

Christian element; clients from other faiths 

should be informed of this orientation and 

provided with information about secular or 

religion-specific mutual-help groups. 

Other general guidelines for programs that 

treat clients from other cultures include 

assessing policies and practices to spot 

potential barriers for diverse clients, training staff members in cultural competence, 

providing materials at an appropriate reading level or translating materials into clients’ 

languages, and using outreach to promote 

awareness of the program. 

The consensus panel offers an extensive 

list of resources for further research as well 

as demographic, substance use, and treatment information on members of racial and 

ethnic groups; persons with physical or cognitive disabilities; persons with HIV/AIDS; 

persons who are lesbian, gay, or bisexual; 

rural populations; and homeless populations. These resources are found in appendix 

10-A.

Executive Summary 
1

The current volume addresses clinical issues and a companion volume, TIP 46, Substance Abuse: Administrative Issues in Outpatient 

Treatment (CSAT 2006f), discusses administration. Together, these 

TIPs break new ground as the first two-volume TIP issued by the 

Center for Substance Abuse Treatment (CSAT). This volume represents the most extensive discussion in a TIP of clinical issues for 

intensive outpatient treatment (IOT) programs.

Several developments in health care and the treatment of substance 

use disorders have prompted this full revision of TIP 8, Intensive 

Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT 

1994c). Since the original TIP was published, substantial changes 

have occurred in almost every aspect of how treatment services are 

conceptualized and delivered. By the late 1990s, IOT had moved 

from being a peripheral and relatively circumscribed clinical service, serving a small range of clients, to a robust, multidimensional 

treatment modality that plays a central role in the care of many 

individuals with substance use disorders. TIP 46, Substance Abuse: 

Administrative Issues in Outpatient Treatment (CSAT 2006f), provides 

a full history of IOT.

As with all TIPs sponsored by CSAT, this volume represents the 

thinking, experience, and work of a consensus panel. The rapidity 

of recent changes in the IOT field and the variety of challenges and 

opportunities that accompany them compelled this TIP’s consensus panel to draw on its clinical experience and current research to 

create a TIP that is both practical and evidence based. Substance 

Abuse: Clinical Issues in Intensive Outpatient Treatment examines 

significant and sometimes perplexing issues facing IOT providers 

and offers analytical discussions and incisive opinions. In writing 

the TIP, the consensus panel attempted to reflect the changes of the 

past decade and anticipate directions that IOT may take. 

In This 

Chapter...

Forces Affecting 

IOT and

the Contents of 

This TIP

Terminology and 

Definitions

Summary of

This TIP

1 Introduction
2 Chapter 1

Forces Affecting IOT 

and the Contents of 

This TIP

Chronic Disease Management

Recognizing that substance abuse is a chronic disorder similar to diabetes, hypertension, 

and asthma led the panel to question the 

acute care model of service delivery that 

has characterized substance abuse treatment for the past 50 years (McLellan et al. 

2000). Panel members felt strongly that 

IOT providers—like providers in the rest of 

the health care system—should rethink the 

acute care approach to treating substance 

use disorders. Increasingly, IOT programs 

are involved in substance abuse treatment 

beyond the initial 4 to 12 weeks. Much of the 

discussion in this volume is devoted to continuing care and to finding ways to include 

case management service providers, families, 

communities, and mutual-help groups in the 

ongoing care of individuals with substance 

use disorders.

Practice–Research 

Collaboration

In the past decade, emphasis on the blending of evidence-based interventions with 

community-based service delivery has 

increased. The longstanding divide between 

practitioners and researchers needed to be 

bridged. This disparity, described in the 

Institute of Medicine 1998 report, Bridging 

the Gap Between Practice and Research, 

was a major impetus behind the creation 

of the National Institute on Drug Abuse’s 

(NIDA’s) Clinical Trials Network and CSAT’s 

Addiction Technology Transfer Centers and 

Practice Improvement Centers. Research 

has resulted in new knowledge about how 

biochemical processes, learning, spirituality, 

and environment affect people who abuse 

substances. These advances may make it 

easier for clinicians, clients, family members, 

and the public to understand that substance 

use disorders are complex illnesses with 

important biological—as well as social, psychological, and spiritual—dimensions. IOT 

programs play a central role in translating 

scientific findings into clinically meaningful 

information and treatments.

The discussions of treatment and the clinical 

recommendations in this TIP are informed 

by the links between practice and research 

that are becoming the norm in the IOT field.

New Treatment Approaches

A growing interest in evidence-supported 

interventions has led practitioners to examine long-held assumptions about treatment 

and the recovery process. Several therapeutic 

approaches, previously applied primarily 

in university-based research centers, have 

begun to emerge as viable and effective 

interventions that can be implemented successfully in community-based treatment 

settings. Discussions on cognitive–behavioral 

interventions, relapse prevention training, 

motivational enhancement therapy, the 

use of incentives, and case management 

approaches have been incorporated into this 

TIP. Similarly, the TIP describes the benefits 

of integrating pharmacotherapies into IOT 

to help manage withdrawal and stabilize 

people with co-occurring disorders.

Convergence of Systems

Approximately 10 years ago, substance 

abuse treatment services were viewed widely 

as specialty services that interacted with a 

variety of other important stakeholders, such 

as the mental health, welfare, and criminal 

justice systems. A profound and important 

change affecting the delivery of IOT services 

is the convergence of these previously distinct 

systems and the substance abuse treatment 

system. The divisions among services have 

long been based on administrative convenience and funding streams, not the clinical 

needs of clients. Programs must be prepared 

to treat clients who simultaneously may be 

receiving public welfare, have children in 
Introduction 3

protective services, and be under criminal 

justice supervision. Each system may place 

substance abuse treatment requirements 

on the client, and, as a consequence, these 

systems can play an important role in supporting the goals of treatment. This TIP 

addresses the importance of simultaneously 

working with multiple systems.

Client and Program Diversity

IOT programs serve a greater variety of clients than they did when TIP 8 was published 

in 1994. The current volume makes a broader and deeper study of how individual 

differences affect treatment needs. Ten years 

ago IOT was offered primarily to privately 

insured clients with mild-to-moderate levels 

of dysfunction. Since then, IOT programs 

have adjusted their models to treat adolescents, clients who are homeless or 

economically disadvantaged, clients with 

mental disorders, clients involved with the 

criminal justice system, clients who are disabled, and those with other special needs 

once considered beyond the scope of IOT 

programs. Most programs also are responding to the needs of increasingly diverse racial 

and ethnic client populations. Many IOT 

programs now incorporate onsite ambulatory 

detoxification services, medication management, and infectious disease interventions.

Terminology and 

Definitions

IOT vs. IOP

Just as the treatment field has yet to settle 

on a commonly accepted name for itself (e.g., 

“substance abuse” versus “addiction” versus 

“substance use disorder” versus “chemical 

dependence”), there is also no agreed-on 

term to describe this intensive level of care. 

Because use of the terms “intensive outpatient treatment” and “intensive outpatient 

program” (IOP) varies by region, for the 

sake of consistency, the consensus panel 

agreed to use the 

term “intensive 

outpatient treatment” (“IOT”) to 

refer to this level of 

care instead of the 

equally acceptable 

term “intensive 

outpatient program.” Because 

of the variety of 

definitions applied 

by clinicians and 

researchers to “intensive outpatient treatment,” IOT studies cited in this volume also 

include day treatment, day hospital treatment, and partial hospitalization programs, 

in addition to IOT programs.

Outpatient Care vs. Aftercare 

vs. Continuing Care

The term “aftercare” is avoided throughout this TIP in favor of “continuing care.” 

Research literature occasionally uses the 

term “aftercare” when discussing traditional 

outpatient treatment that follows residential 

or intensive outpatient treatment. Others use 

the term “aftercare” when discussing clients’ 

participation in mutual-help groups after 

formal treatment is completed. In this volume, the term “continuing care” designates 

the mutual-help groups (including 12-Step 

and other support groups) available in the 

community after formal treatment ends. 

Even during the continuing community care 

phase or treatment, many clients return to 

the IOT clinic for occasional followup visits, 

similar to regular medical checkups for other 

chronic diseases.

Substance Abuse Treatment 

vs. Mutual-Help Groups 

The distinction between substance abuse 

treatment programs and mutual-help groups, 

such as 12-Step support groups, often is 

misunderstood by managed care organizations and the public. The American Medical 

Increasingly, IOT 

programs are involved 

in substance abuse 

treatment beyond the 

initial 4 to 12 weeks.
4 Chapter 1

Association (1998) 

has adopted a 

policy stating 

that clients with 

substance use disorders should be 

treated by qualified 

professionals and 

that mutual-help 

groups should 

serve as adjuncts 

to a treatment plan 

devised within the 

practice guidelines 

of the substance 

abuse treatment 

field. Likewise, the 

American Psychiatric Association, American 

Academy of Addiction Psychiatry, and 

American Society of Addiction Medicine 

(ASAM) have issued a joint policy statement 

that asserts that treatment involves at least 

the following (American Society of Addiction 

Medicine 1997):

A qualified professional is in charge of 

treatment.

A thorough evaluation is performed to 

determine the stage and severity of illness 

and to screen for medical and mental 

disorders. 

A treatment plan is developed.

The treatment professional or program 

is accountable for the treatment and for 

referring the client to additional services, if 

necessary.

The treatment professional or program 

maintains contact with the client until 

recovery is completed.

According to the policy statement adopted by 

these treatment professionals’ associations, 

mutual-help groups are an important component of treatment, but they cannot substitute 

for substance abuse treatment as outlined 

above. 

•

•

•

•

•

What Constitutes IOT?

Although IOT traditionally has consisted of 

at least 9 hours of treatment per week, usually delivered in three 3-hour sessions, some 

programs have substantially longer hours 

and others provide only 6 contact hours per 

week. The consensus panel agrees that a 

program that schedules treatment daily, for 

6 hours per day, should be considered a partial hospitalization program. But does such 

a program differ by kind or just by degree 

from an IOT program? At what point does 

an IOT service become a partial hospitalization program? Programs in which clients 

attend sessions 9 hours per week are clearly 

more intensive than once-a-week outpatient 

programs. But where does outpatient end 

and IOT begin? According to ASAM’s Patient 

Placement Criteria, IOT programs provide 

9 or more hours of structured programming 

per week; ASAM does not specify a minimum 

duration of treatment (Mee-Lee et al. 2001).

This TIP is intended to be equally useful 

to all IOT programs, regardless of the number of contact hours per week. But for the 

discussions and guidelines in this TIP to 

be meaningful, IOT must be delimited. The 

consensus panel agreed that IOT has the following features:

Contact hours per week: 6 to 30 

Stages: Stepdown and step-up stages of 

care that vary in intensity and duration

Duration: Minimum of 90 days followed 

by outpatient continuing care 

Core features and services:

Program orientation and intake

Comprehensive biopsychosocial 

assessment

Individual treatment planning

Group counseling

Individual counseling

Family counseling

Psychoeducational programming

Case management

Integration of clients into mutual-help 

and community-based support groups 

24-hour crisis coverage

•

•

•

•

–

–

–

–

–

–

–

–

–

–

...mutual-help groups 

are an important 

component of 

treatment, but they 

cannot substitute 

for substance abuse 

treatment...
Introduction 5

Medical treatment

Substance use screening and monitoring 

(urine or breath tests)

Vocational and educational services

Psychiatric evaluation and 

psychotherapy

Medication management

Transition management and discharge 

planning

Enhanced services:

Adult education

Transportation

Housing and food

Recreational activities

Adjunctive therapies

Nicotine cessation treatment

Child care

Parent skills training

Summary of This TIP

The following topics are covered in this 

volume:

Chapter 2—Principles of Intensive 

Outpatient Treatment presents 14 guiding principles of IOT and the research that 

supports them. The principles combine the 

findings of substance abuse research with 

the experiences of practiced clinicians. The 

principles are drawn from NIDA’s Principles 

of Drug Addiction Treatment (National 

Institute on Drug Abuse 1999), but the 

chapter focuses on issues that are critical to 

effective delivery of IOT services. 

Chapter 3—Intensive Outpatient Treatment 

and the Continuum of Care places IOT 

within a broad substance abuse treatment 

continuum that includes outpatient treatment and continuing community care. This 

chapter situates IOT within the framework 

of ASAM’s levels of care and discusses goals, 

intensity and duration of treatment, treatment setting, and stages for Level I and 

Level II care. The chapter discusses IOT 

as both an entry point for substance abuse 

treatment and a stepdown or step-up level 

–

–

–

–

–

–

•

–

–

–

–

–

–

–

–

of care for clients and addresses the importance of transitioning clients to continuing 

community care.

Chapter 4—Services in Intensive Outpatient 

Treatment Programs describes the core 

services a program should provide and 

enhanced services that often are delivered 

on site or through established links with 

community-based providers. Core services 

include group counseling and therapy, 

individual counseling, psychoeducational 

programming, pharmacotherapy and medication management, monitoring substance 

use, case management, 24-hour crisis coverage, induction into community-based 

support groups, medical treatment, psychiatric screening and therapy, and vocational 

training and employment services. Enhanced 

services include adult education, transportation, adjunctive therapies, and parenting 

classes.

Chapter 5—Treatment Entry and 

Engagement addresses the complex and 

critical processes of screening and diagnosis, 

placement, assessment, and treatment planning. The desired result of these processes is 

the client’s engagement in treatment at the 

appropriate level of care and the implementation of treatment that addresses his or her 

needs. This chapter discusses specific steps 

in the IOT admission process, including 

engaging and screening the client, assessing barriers to treatment, and attending to 

crises; it also illustrates them in two case 

studies.

Chapter 6—Family-Based Services discusses 

a family systems approach to IOT that 

acknowledges and supports the important 

role and influence of family members on 

treatment outcomes. The chapter includes 

goals and outcomes of family-based services 

and strategies for engaging families in treatment. The chapter also describes various 

types of family services (family education, 

multifamily groups, family therapy, retreats, 

support groups) and clinical issues that often 

arise when including families in treatment, 
6 Chapter 1

such as unrealistic expectations and sabotage of the client’s recovery.

Chapter 7—Clinical Issues, Challenges, and 

Strategies in Intensive Outpatient Treatment

looks at issues and problems that arise in 

clinical practice and offers solutions grounded in research and clinical experience. The 

chapter covers client retention, relapse and 

continued substance use, family members 

who abuse substances, group work issues, 

safety and security, client privacy, conflicting 

mandates, clients who work, and boundary 

issues.

Chapter 8—Intensive Outpatient Treatment 

Approaches provides detailed descriptions 

of established IOT program models and 

approaches. The chapter describes 12-Step 

facilitation, cognitive–behavioral, motivational, therapeutic community, Matrix 

model, and community reinforcement and 

contingency management approaches. 

The descriptions address the key aspects, 

research outcomes, and strengths and challenges of each approach.

Chapter 9—Adapting Intensive Outpatient 

Treatment for Specific Populations highlights the flexibility and adaptability of the 

IOT model to meet the diverse needs of specific populations: those involved with the 

criminal justice system, women, individuals 

with co-occurring disorders, and adolescents 

and young adults. The chapter provides a 

demographic overview of each group and 

discusses implications for IOT programming 

as well as clinical issues and strategies to use 

with each population. 

Chapter 10—Addressing Diverse Populations 

in Intensive Outpatient Treatment examines the importance of cultural competence 

to substance abuse treatment. Reviewing 

research that supports the need for individualized treatment, the chapter describes 

principles for the delivery of culturally competent services and explores topics of special 

concern: foreign-born clients, women from 

other cultures, and religious considerations. 

Sketches of diverse populations include 

Hispanics/Latinos; African-Americans; 

Native Americans; Asian Americans and 

Pacific Islanders; persons with HIV/AIDS; lesbian, gay, and bisexual individuals; persons 

with physical or cognitive disabilities; rural 

populations; individuals who are homeless; 

and older adults. The sketches describe each 

group’s demographic characteristics, statistics 

on substance use, clinical considerations, and 

implications for IOT. A chapter appendix 

contains an extensive list of resources on culturally competent treatment and on treating 

members of each population. 
7

In This 

Chapter...

Principle 1: Make Treatment 

Readily Available

Principle 2: Ease Entry

Principle 3: Build on 

Existing Motivation

Principle 4: Enhance 

Therapeutic Alliance

Principle 5: Make 

Retention a Priority

Principle 6: Assess and Address 

Individual Treatment Needs

Principle 7: Provide Ongoing Care

Principle 8: Monitor Abstinence

Principle 9: Use 

Mutual-Help and Other 

Community-Based Supports

Principle 10: Use 

Medications if Indicated

Principle 11: Educate About 

Substance Use Disorders, 

Recovery, and Relapse 

Principle 12: Engage Families, 

Employers, and Significant Others

Principle 13: Incorporate 

Evidence-Based Approaches

Principle 14: Improve Program 

Administration

2 Principles of Intensive 

Outpatient Treatment

This chapter 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 chapter 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.
8 Chapter 2

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. 

•

•

•

•

Comparing Inpatient Treatment With 

Intensive Outpatient Treatment

Several studies comparing intensive outpatient treatment with residential treatment have 

found no significant differences in outcomes (Guydish et al. 1998, 1999; Schneider et al. 1996). 

Finney and colleagues (1996), however, in a review of 14 studies, found that the available evidence tended to favor inpatient slightly over outpatient treatment. The consensus panel has 

concluded that clients benefit from both levels of care and that comparing inpatient with outpatient treatment is potentially counterproductive because the important question is not which 

level of care is better but, rather, which level of care is more appropriate at a given time for 

each client. Matching clients with enhanced services also improves client outcomes. McLellan 

and colleagues (1998) found that compared with control subjects, clients with access to case 

managers who coordinated medical, housing, parenting, and employment services had less 

substance use, fewer physical and mental health problems, and better social function after 

6 months. It is in the best interest of clients to have a broad continuum of treatment options 

available. Some clients entering IOT may be able to engage in treatment immediately, whereas 

others may need referral to a long-term residential program or a therapeutic community. Some 

clients can be detoxified successfully in an ambulatory setting, whereas others need residential 

services to complete detoxification successfully.
Principles of Intensive Outpatient Treatment 9

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 

•
10 Chapter 2

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 preadmission 

interviews (Martino et al. 2000), delivering 

phone reminders and mailed reminders, 

•

•

•

•
Principles of Intensive Outpatient Treatment 11

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 

The achievement 

and maintenance of 

therapeutic alliance 

are high priorities 

in treatment.
12 Chapter 2

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, 

BreathalyzerTM 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 
Principles of Intensive Outpatient Treatment 13

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 

Substance abuse 

is a chronic illness 

similar...to other 

chronic diseases such 

as asthma, diabetes, 

and hypertension.
14 Chapter 2

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. 

Ideally, IOTs 

should provide 

psychiatric evaluation 

and medication 

management on site.
Principles of Intensive Outpatient Treatment 15

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 EvidenceBased 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 evidencebased 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. Evidencebased 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 

•

•
16 Chapter 2

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.
17

Overview of a Continuum of Care

“Continuum of care” refers to a treatment system in which clients 

enter treatment at a level appropriate to their needs and then step 

up to more intense treatment or down to less intense treatment as 

needed. As outlined by Mee-Lee and Shulman (2003), an effective 

continuum of care features successful transfer of the client between 

levels of care, similar treatment philosophy across levels of care, 

and efficient transfer of client records. The American Society of 

Addiction Medicine (ASAM) has established five main 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 (Level 

II is subdivided into levels II.1 and II.5)

Level III: Residential/Inpatient services (Level III is subdivided 

into levels III.1, III.3, III.5, and III.7)

Level IV: Medically managed intensive inpatient services

These levels should be thought of not as discrete levels of care but 

rather as points in a continuum of treatment services (Mee-Lee and 

Shulman 2003).

From program to program, the treatment philosophy, services, settings, and client characteristics may vary for any given level of care 

because some aspects of treatment may be tailored to a specific 

population. For instance, a rural residential program primarily treating women who are alcohol dependent would be quite different from 

an urban residential program treating mostly men dependent on 

stimulants. Despite variability in the specific features of intensive 

outpatient treatment (IOT) or Level II care in programs across the 

country, the continuum of care model tries to ensure consistency 

throughout treatment and to ease the process of moving clients 

through treatment.

•

•

•

•

•

3 Intensive Outpatient 

Treatment and the 

Continuum of Care

In This 

Chapter...

Overview of a 

Continuum of Care

Conceiving of a 

Continuum of Care

Key Aspects of IOT 

(Level II)

Key Aspects 

of Outpatient 

Treatment (Level I)

Continuing 

Community Care 
18 Chapter 3

In addition to the levels of care described by 

ASAM, outpatient treatment can be broken 

down into four sequential stages that clients 

work through, regardless of the level of care 

at which they enter treatment:

Stage 1—Treatment engagement

Stage 2—Early recovery

Stage 3—Maintenance

Stage 4—Community support

These stages are discussed later in the chapter in the context of IOT and outpatient 

treatment.

Conceiving of a 

Continuum of Care

To reinforce the idea of a continuum of 

care, Mee-Lee and Shulman (2003) suggest 

that clinicians and administrators “envision admitting the client into the continuum 

through their program rather than admitting 

the client to their program” (p. 456). This 

early focus on moving the client along 

the continuum also 

prompts clinicians 

to look ahead to 

the next step in a 

client’s treatment. 

This, in turn, helps 

clinicians engage 

in the treatment planning that is integral not 

only to the client’s ongoing care but also to 

the transition from one level of treatment to 

the next.

IOT Programs and the 

Continuum of Care

IOT programs are diverse and flexible with 

respect to the spectrum, intensity, and duration of services and the settings in which 

services are delivered. They are, therefore, well suited to meet the varied needs 

of persons with substance use disorders. 

Conceptually, IOT is an intermediate level 

•

•

•

•

of ambulatory care that serves the following 

functions:

An entry point into substance abuse 

treatment. The client comes to the IOT 

program, an assessment reveals that the 

client would benefit from IOT (see chapter 5 of this TIP for placement criteria), a 

treatment plan is developed, and services 

are begun. 

A stepdown level of care. The client is 

transitioned to the IOT program from an 

inpatient or residential facility. In this 

case, the client may have been stabilized in 

a hospital facility or residential treatment 

program and now needs intensive treatment services to achieve or maintain abstinence as well as address other problems.

A step-up level of care. The client is 

referred to the IOT program if he or she 

has been unsuccessful in outpatient treatment or continuing community care and is 

assessed as needing an intensive and structured level of care to regain abstinence, 

work on relapse prevention skills, and 

address other issues. 

Assisting the Client Along the 

Continuum

IOT is part of a seamless continuum of levels 

of care. Moving the client along the continuum 

may require the IOT provider to refer the client to another treatment organization or may 

be the result of an internal transfer to another 

component of a comprehensive IOT program. 

Any change of setting, staff, or peers interjects a risk of the client’s dropping out of 

treatment. Experience suggests that the 

administrative paperwork and approvals 

needed to transfer a client between levels 

of care within the same organization can 

be accomplished with less disruption for the 

client than a referral to a new provider 

organization. Consequently, when referrals 

are made to a nonaffiliated provider 

•

•

•

IOT is part of a 

seamless continuum 

of levels of care.
Intensive Outpatient Treatment and the Continuum of Care 19

organization, coordination and case management needs increase. 

Key Aspects of IOT 

(Level II)

After considering IOT from the broad 

perspective of the continuum of care, it is 

necessary to look within Level II to understand IOT’s particular goals, intensity, 

duration, settings, and stages.

IOT Goals

Goals of IOT programs vary based on such 

factors as the treatment population, program 

comprehensiveness, and the program’s philosophy. Although programs differ, all IOT 

programs attempt to address the following 

general goals: 

To achieve abstinence

To foster behavioral changes that support 

abstinence and a new lifestyle 

To facilitate active participation in 

community-based support systems (e.g., 

12-Step fellowship)

To assist clients in identifying and addressing a wide range of psychosocial problems 

(e.g., housing, employment, adherence to 

probation requirements) 

To assist clients in developing a positive 

support network

To improve clients’ problemsolving skills 

and coping strategies

Intensity of Treatment 

Relative to traditional outpatient treatment, IOT provides an increased frequency 

of contact and services that respond to the 

chronicity and severity of substance use 

disorders and other problems experienced 

by clients. The actual number of hours and 

days per week that clients participate in IOT 

varies depending on individual client needs. 

State licensure bodies may require 9 treatment hours; ASAM defines IOT as 9 hours 

of treatment per week for adults (Mee-Lee et 

•

•

•

•

•

•

al. 2001). Although IOT programs generally 

provide structured programming for 9 hours 

or more per week spread over 3 to 5 days, 

some IOT programs provide fewer hours. The 

consensus panel recommends that the number of programming hours be 6 to 30 hours, 

based on client needs. Some clinicians find 

that more frequent, shorter visits are of greater benefit to the client than less frequent 

but longer sessions. However, some clients 

require longer treatment sessions, similar 

in intensity to partial hospitalization. More 

research is needed on optimal treatment 

intensity and factors to be considered in 

increasing or decreasing treatment intensity.

Duration of Treatment

The recommended minimum duration of 

the IOT phase often is cited as 90 days. 

Low-intensity outpatient treatment over a 

longer period may be a cost-effective means 

to enhance treatment outcomes because this 

approach is associated with less substance 

use and better social functioning in clients 

(Moos et al. 2001). Duration of treatment 

should be increased or decreased based on 

the client’s clinical needs, support system, 

and psychiatric status, among other factors. 

Longer duration of care is related to better 

treatment outcomes (Moos and Moos 2003).

Treatment Settings

IOT can be provided in any setting that 

meets State licensure or certification criteria 

(Mee-Lee et al. 2001). Programs offering IOT 

only and comprehensive programs offering 

several levels of care may differ in structures 

and services provided. IOT programs that are 

part of a large hospital setting can provide 

medical detoxification services, pharmacotherapy, and treatment for other medical 

and psychiatric conditions. IOT programs 

located in prison facilities treat offenders 

with alcohol and drug problems and successfully link offenders with stepdown services 

in the community on release. Other IOT 

programs may be located near vocational 
20 Chapter 3

training sites so that welfare recipients and 

others easily can attend both treatment and 

training sessions in homeless shelters and in 

modified therapeutic community programs.

Stages of Treatment

Within IOT or Level II care, treatment often 

is delivered in sequential stages, with service 

intensity and structure lessening as clients 

progress. As IOT services taper in intensity, 

the client assumes increasing responsibility 

and is provided less structure and supervision from treatment staff. IOT programs 

should have the flexibility to increase the 

intensity of services if the client’s lack of 

progress indicates such a need. 

Sequenced IOT can motivate clients, help 

them succeed in reaching recovery milestones 

and in meeting the criteria for completing 

a treatment stage, and provide an incentive 

for clients to grow and progress. Marking the 

passage from one IOT stage to the next with 

a celebration or ceremony also motivates 

clients. Sequenced stages allow complex 

information to be broken into small units 

that can be modified and made appropriate 

for each client’s cognitive and psychological 

functioning and stage of readiness.

IOT may be conceptualized as having two 

core stages, which correspond with the 

client’s progress in treatment: stage 1—treatment engagement and stage 2—early recovery. 

Definitions of IOT, such as those adopted by 

some States or health insurers, may include 

additional or fewer stages or may blend similar goals and services within different stages. 

Stage 1—Treatment 

engagement 

Goals and duration. One of the most 

critical tasks for the counselor and clinic is 

encouraging the client to remain in treatment. Many clients drop out of treatment 

after attending only a few sessions. During 

this initial stage, the counselor determines 

the client’s presenting problems with respect 

to substance abuse; physical, psychological, 

and social functioning; and social support 

network. Also, the counselor explains program rules and expectations and works to 

stabilize any crises. Exhibit 3-1 presents the 

goals, duration, counselor activities, and 

completion criteria of this stage of IOT.

Stage 2—Early recovery

Goals and duration. This stage is highly 

structured with educational activities, group 

involvement, and new behaviors to help the 

client develop recovery skills, address lapses, 

and build a substance-free lifestyle. Exhibit 

3-2 presents the goals, duration, counselor 

activities, and completion criteria of this 

stage of treatment.

Transition to Outpatient 

Treatment

Effective treatment in a continuum of 

care includes ongoing, less intensive, and 

tapered contact with treatment systems, 

much as with other chronic health conditions (McLellan et al. 2000). The client and 

counselor must prepare for the transition 

to less intensive treatment, a juncture that 

presents a high dropout risk. This stepdown 

level of care sometimes is provided as part of 

a comprehensive IOT program by the same 

staff and in the same facility. In other cases, 

clients are transferred through formal linkages to outpatient treatment delivered by a 

separate community-based program, often 

referred to as standard, traditional, or—in 

this TIP—simply outpatient treatment. 

Compatible models of care 

The consensus panel believes that, whenever possible, the client should be referred 

to an outpatient treatment program with a 

treatment model (e.g., 12-Step, cognitive–

behavioral, combined) that is compatible 

with that offered by the IOT program to 

ensure that the client is not confronted 

with significantly different treatment goals, 

approaches, and philosophies. If a client is 
Intensive Outpatient Treatment and the Continuum of Care 21

to be transferred to a program with a different philosophy, the client should be oriented 

to the differences so that the transition is not 

confusing and the client can benefit from the 

new program.

Exhibit 3-1

Goals, Duration, Activities, and Completion Criteria of Stage 1

Goals of the treatment engagement stage:

Establish a treatment contract with the counselor that specifies treatment goals, client 

responsibilities (e.g., attend group sessions, remain abstinent, submit urine samples), 

and the counselor’s efforts to help clients meet treatment goals and responsibilities.

Work to resolve acute crises.

Engage in a therapeutic alliance.

Prepare a treatment plan with help from the counselor.

Duration of the treatment engagement stage: A few days to a few weeks

Counselor activities of the treatment engagement stage:

Confirm diagnosis, eligibility, and appropriate placement in this level of care.

Assess biopsychosocial problems and match services to the most pressing problems.

Determine readiness for treatment.

Provide feedback about assessment findings and formulate an initial treatment plan 

and treatment contract. 

Explain program rules, expectations, and confidentiality regulations.

Address acute crises.

Manage withdrawal symptoms. 

Resolve scheduling, payment, and counselor assignment issues.

Obtain medical and psychological diagnoses and treatment, including 

pharmacotherapy.

Foster therapeutic alliances between client and counselor and client and 

group members.

Begin psychoeducational activities.

Identify potential sources of social support.

Initiate family contacts and education (with client’s permission). 

Completion criteria: Clinical indications that support the client’s transition from the 

treatment engagement stage to the early recovery stage include the client’s having

Completed the assessment process

Completed withdrawal from substance use

Resolved immediate crises

Completed orientation

Established a treatment plan

Attended scheduled sessions regularly

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22 Chapter 3

Exhibit 3-2

Goals, Duration, Activities, and Completion Criteria of Stage 2

Goals of the early recovery stage:

Maintain abstinence.

Demonstrate ability to sustain behavioral changes. 

Eliminate drug-using lifestyle and replace it with treatment-related routines and drugfree activities.

Identify relapse triggers and develop relapse prevention strategies.

Identify personal problems and begin to resolve them.

Begin active involvement in a 12-Step or other mutual-help program.

Duration of the early recovery stage: 6 weeks to about 3 months

Counselor activities of the early recovery stage:

Assist clients in following their individual plans to achieve and sustain abstinence.

Assist clients in identifying relapse triggers and developing strategies to avoid or cope 

with triggers.

Support evidence of positive change.

Initiate random drug tests and provide rapid feedback of results.

Assist clients in successfully integrating into a 12-Step fellowship or other mutual-help 

program.

Help clients develop and strengthen a positive social support network.

Encourage participation in healthful recreation and social activities.

Continue pharmacotherapy, if appropriate, and other medical and psychiatric 

treatments.

Offer education on topics such as hepatitis C and HIV infection, anger management, 

and parenting.

Continue assessments for other issues requiring intervention.

Educate clients and family members on addiction, the recovery process, and relapse.

Provide family and multifamily counseling.

Introduce families to 12-Step and other mutual-help programs appropriate for them; 

help families integrate into support groups.

Completion criteria: Clinical indications that support the client’s transition from the 

early recovery stage of IOT to the next level of care include the client’s having

Sustained abstinence for 30 days or longer 

Completed goals as indicated in the treatment plan

Created and implemented a relapse prevention and continuing care plan

Participated regularly in a support group 

Maintained a sober social support network

Obtained stable, drug-free housing

Resolved medical, psychiatric, housing, and peer situations that may trigger relapse

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Intensive Outpatient Treatment and the Continuum of Care 23

Transition planning

An individual transition plan helps the 

client transition from one level of care to 

another and provides an important link 

between his or her current treatment provider and the next. To prepare an effective 

transition plan, the IOT counselor can

Engage the client as an active participant 

in developing the plan early in IOT, including setting goals, establishing criteria for 

measuring progress, and identifying activities that will be part of ongoing treatment.

Maintain a working knowledge of the services and resources that are available in 

the community.

Develop strong working relationships with 

staff of key agencies (e.g., justice organizations, employers) to facilitate the transition, make special arrangements as needed, and eliminate unnecessary barriers for 

the client during transition.

Obtain the client’s written consent and 

arrange for the smooth and timely transfer 

of clinical information or documents to the 

new treatment program.

The panel recommends that the responsibility for client care be transferred clearly before 

a provider relinquishes clinical responsibility.

Key Aspects of 

Outpatient Treatment 

(Level I)

For clients who are stepped down from IOT, 

outpatient treatment offers the support they 

need to continue developing relapse prevention skills and resolving the personal, 

relationship, employment, legal, and other 

problems often associated with early recovery. 

Outpatient Treatment Goals 

The goals, strategies for treatment engagement, and recovery services of outpatient 

treatment are similar to those of IOT. 

However, the intensity and duration of the 

services differ from those provided in IOT. 

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Comparison of IOT and 

Outpatient Treatment

A study by McLellan and colleagues (1997) 

compared several components of 6 IOT programs and 10 outpatient treatment programs. 

Both types of programs provided group and 

individual abstinence counseling, relapse 

prevention programming, and drug and alcohol education. The IOT programs’ treatment 

duration ranged from 30 to 90 days, and they 

provided 3 to 5 sessions per week. Hours per 

session ranged from 3 to 6. The outpatient 

programs’ treatment duration ranged from 

45 to 60 days, and they provided 1 to 2 sessions per week. Hours per session ranged from 

1 to 2. Whereas the IOT programs provided 

more substance abuse counseling than the 

outpatient treatment programs, the outpatient 

treatment programs were more likely than 

IOT programs to offer medical appointments, 

family therapy sessions, psychotherapy, and 

employment counseling (McLellan et al. 1997). 

Although outpatient treatment duration is 

typically 60 days, it is suggested strongly that 

clients be scheduled for periodic followup sessions on a long-term basis. The best outcomes 

from treatment of substance use disorders 

have been seen in clients who participate in 

continuing care, such as methadone maintenance or Alcoholics Anonymous-style support 

programs (McLellan et al. 2000). Because the 

availability of funding for followup appointments varies, outpatient treatment programs 

might consider strategies for establishing a 

service model that supports the delivery of 

followup sessions.

Stepdown Treatment

Clients who have completed stages 1 and 2 

of their treatment at the IOT level of care 

can step down to outpatient treatment 

programs and enter stage 3—maintenance, 

having demonstrated a commitment to 

change, been stabilized, become abstinent, 

and developed relapse prevention skills. 
24 Chapter 3

Stage 3—Maintenance

Goals and duration. Stage 3—maintenance

helps the client build on gains made during 

stages 1 and 2. The goals, duration, counselor 

activities, and completion criteria of this stage 

of treatment are presented in exhibit 3-3.

Transfer to Continuing 

Community Care

Having completed stage 3 of their treatment, 

clients are discharged from formal treatment to continuing community care. Clients 

who remain within a system of ongoing 

care relevant to their needs are more likely 

to maintain their gains in abstinence and 

overall lifestyle changes. Participation in 

continuing community care is related to an 

increase in positive outcomes (Miller et al. 

1997; Ritsher et al. 2002). Continuing care 

planning is therefore a central task for IOT 

program staff whose clients remain in stepdown care within the program. IOT programs 

that refer clients to separate programs for a 

stepdown level of care must ensure, through 

their referral agreements and procedures, 

that the outpatient treatment program agrees 

to engage in continuing care planning.

Continuing community care in the form of 

12-Step support groups, faith fellowship, 

or other community-based organizations is 

sometimes neglected by treatment providers because of the difficulties of remaining 

engaged with clients after formal treatment 

is completed. Still, the benefits of carefully 

planning for transferring clients into community support groups are such that added 

attention should be given to these tasks. To 

ensure client access to a full continuum of 

care, treatment programs need to be aware 

of support groups and other community 

resources and introduce this information to 

clients early in the treatment process. Other 

key responsibilities for providers include 

ensuring transition of case management 

responsibilities, supporting clients’ early 

engagement in continuing community care, 

contributing to the expansion of community 

services, and encouraging clients who drop 

out to reengage with treatment.

Continuing 

Community Care 

Continuing community care following 

IOT and stepdown care is essential for all 

IOT clients, especially for those who may 

have other long-term psychiatric, social, or 

medical issues. The process of rebuilding 

a healthy, productive, and stable life takes 

years, and maintaining gains made over time 

may require continuous support for some 

individuals. 

Once the client maintains abstinence and 

has begun to address other serious problems 

that could threaten recovery, the client can be 

discharged into continuing community care. 

Stage 4—community support consists of the 

client’s participating in 12-Step or other mutualhelp groups and meeting with psychologists, 

case managers, or staff from community-based 

agencies, with limited support and involvement from the treatment program. 

Services in Continuing 

Community Care

As part of continuing care services, programs 

can sponsor alumni meetings and provide 

booster or checkup counseling sessions at 

the IOT or outpatient treatment facility. 

Periodic telephone contact also may be valuable (McKay et al. 2005). Other aspects of 

continuing care include involvement with 

selected community resources as needed, 

such as vocational training, recreational 

therapy, family therapy, or medical care.

Stage 4—Community support

Goals and duration. This stage is based on 

a detailed and individualized discharge plan 

for continuing recovery in the community 

using available resources. Exhibit 3-4 presents 

the goals, duration, counselor activities, and 

completion criteria of this stage.
Intensive Outpatient Treatment and the Continuum of Care 25

Exhibit 3-3

Goals, Duration, Activities, and Completion Criteria of Stage 3

Goals of the maintenance stage:

Solidify abstinence.

Practice relapse prevention skills.

Improve emotional functioning.

Broaden sober social networks.

Address other problem areas.

Duration of the maintenance stage: About 2 months to 1 year

Counselor activities of the maintenance stage:

Continue teaching and helping clients practice relapse prevention skills and refine 

plans to address relapse triggers.

Help clients acknowledge and quickly contain “slips” to keep them from becoming fullblown relapses.

Support clients as they work through painful feelings (e.g., sadness, anxiety, loneliness, 

shyness, shame, guilt).

Teach clients new coping and problemsolving skills that increase self-esteem and 

improve interpersonal relationships, including better communication skills, anger management skills, and making amends.

Help clients identify vocational or educational needs, improve work-related functioning, 

resolve family conflicts, and initiate new recreational activities.

Facilitate client linkages with community resources that foster clients’ interests and 

offer needed services for accomplishing life goals.

Assist clients in making and sustaining positive lifestyle changes.

Encourage continuing participation in support groups and ongoing work with a sponsor.

Emphasize the importance of spirituality or altruistic values that help clients see 

beyond themselves and work for community goals.

Continue monitoring random drug test results and providing feedback on results.

Continue pharmacotherapy, as needed, and other medical or psychiatric assistance.

Avoid complacency.

Completion criteria: Clinical indications that support the client’s transition from the 

maintenance stage to continuing care include the client’s having

Sustained abstinence (30 days or longer)

Improved relationships with family, friends, and significant others

Improved coping and problemsolving skills

Obtained drug-free, stable housing

Continued participation in a support group

Obtained ongoing assistance with other problems, if necessary

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26 Chapter 3

Intensity and Duration of 

Continuing Community Care

The duration of continuing community 

care varies for each individual. The chronic 

relapsing nature of substance use disorders 

often means that individuals may remain in 

this level of care for many months or years, 

relapse, return to outpatient treatment or 

IOT care, regain abstinence, and return to 

continuing community care. 

Exhibit 3-4

Goals, Duration, Activities, and Completion Criteria of Stage 4

Goals of the community support stage:

Maintain abstinence.

Maintain a healthy lifestyle.

Develop independence from the treatment program.

Maintain social network connections.

Establish strong connection with support groups and pursue healthy community activities.

Establish recreational activities and develop new interests.

Duration of the community support stage: Years, ongoing

Counselor activities of the community support stage:

Assist clients in developing a realistic, comprehensive, and individualized plan for continuing recovery.

Acquaint clients with local resources that allow them to

Sustain abstinence 

Continue participating in 12-Step or other mutual-help groups

Obtain medical or psychotherapeutic assistance as needed

Continue pharmacotherapy as needed

Start or continue vocational or educational training or other courses

Seek and obtain employment

Strengthen social support networks

Manage stress 

Prevent or respond to relapse

Enjoy abstinence

Provide information about and encourage attendance at alumni or booster sessions at 

the IOT or outpatient treatment program to review recovery status.

Provide a biannual checkup during which a comprehensive assessment is conducted of 

clients’ recovery and status. 

Completion criteria: Clients may need community support for the rest of their lives to 

remain abstinent or recover from relapses.

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27

A set of core services is essential to all intensive outpatient treatment 

(IOT) efforts and should be a standard part of the treatment package 

for every client. Enhanced services often are added and delivered 

either on site or through functional and formal linkages with 

community-based agencies or individual providers.

This distinction between core and enhanced services is somewhat 

flexible. What would be considered enhanced services for the general 

treatment population may be core services for a particular client 

group. For example, a program that serves primarily working mothers of young children may view providing child care and arranging 

transportation as core program elements. These same services are 

unlikely to be needed by most clients in an IOT program that treats 

mostly employed single men who do not have children living with 

them. 

This chapter describes many of the core and enhanced elements of 

IOT. Each description includes the purpose and the key aspects of 

the service. Exhibit 4-1 lists core and enhanced services for IOT programs. Some core services are discussed in other chapters, as noted 

in exhibit 4-1.

Core Services

Group Counseling and Therapy

Groups form the crux of most IOT programs. Several recent studies confirm that, for delivering relapse prevention training, a group 

approach is at least as effective as a one-on-one format (McKay et 

al. 1997; Schmitz et al. 1997). Group counseling allows programs to 

balance the cost of more expensive individual counseling services. A 

group approach supports IOT clients by

In This 

Chapter...

Core Services

Enhanced IOT 

Services

IOT Services: A 

Case Illustration

4 Services in Intensive 

Outpatient Treatment 

Programs
28 Chapter 4

Providing opportunities for clients to develop communication skills and participate in 

socialization experiences; this is particularly useful for individuals whose socializing 

has revolved around using drugs or alcohol

Establishing an environment in which clients help, support, and, when necessary, 

confront one another

Introducing structure and discipline into 

the often chaotic lives of clients

Providing norms that reinforce healthful 

ways of interacting and a safe and supportive 

therapeutic milieu that is crucial for recovery

Advancing individual recovery; group 

members who are further along in recovery 

can help other members

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Providing a venue for group leaders to 

transmit new information, teach new skills, 

and guide clients as they practice new 

behaviors

Types of groups

Most IOT programs place clients in several 

different types of groups during the course of 

treatment. Broadly speaking, these include 

psychoeducational, skills-development, support, and interpersonal process groups. 

These classifications are far from rigid; each 

type of group borrows ideas and techniques 

from others. Some IOT programs also add 

specialized groups and clubs for job-seeking 

or recreational activities. TIP 41, Substance 

•

Exhibit 4-1

Core and Enhanced Services for IOT Programs

Core IOT Services Provided On Site

Group counseling and therapy

Individual counseling

Psychoeducational programming

Pharmacotherapy and medication 

management

Monitoring alcohol and drug use

Case management

24-hour crisis coverage

Community-based support groups

Medical treatment

Psychiatric examinations and 

psychotherapy

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Vocational training and employment 

services

Family involvement and counseling*

Comprehensive biopsychosocial 

screening and assessment†

Program orientation and 

intake/admission†

Individual treatment planning and 

review†

Transition management and discharge 

planning‡

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*Discussed in chapter 6. †Discussed in chapter 5. ‡Discussed in chapter 3.

Enhanced IOT Services

Delivered On Site or Via Functional Linkages

Adult education

Transportation services

Housing and food

Recreational activities

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Adjunctive therapies

Nicotine cessation treatment

Licensed child care

Parent skills training

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Services in IOT Programs 29

Abuse Treatment: Group Therapy (CSAT 

2005f), contains specific guidance on how to 

organize and conduct different types of 

groups in the context of a treatment program. Exhibit 4-2 highlights groups 

commonly conducted in IOT.

Exhibit 4-2

Groups Conducted in Intensive Outpatient Treatment

(continued)

Psychoeducational groups

These groups provide a supportive environment in which clients learn about substance 

dependence and its consequences. These time-limited groups may be initiated at the 

beginning of treatment. They feature

Low-key rather than emotionally intense environment.

Rational problemsolving mechanisms to alter dysfunctional beliefs and thinking 

patterns.

Various forms of relapse prevention and skills training. Didactic components often are 

supplemented by videos or slides to accommodate different learning styles.

Skills-development groups

These groups offer clients the opportunity to practice specific behaviors in the safety of 

the treatment setting. Common types of skills training include

Drug or alcohol refusal training. Clients act out scenarios in which they are invited to 

use substances and role play their responses.

Relapse prevention techniques. Using relapse prevention materials, clients analyze 

one another’s personal triggers and high-risk situations for substance use and determine ways to manage or avoid them.

Assertiveness training. Clients learn the differences among assertive, aggressive, and 

passive behaviors and practice being assertive in different situations.

Stress management. Clients identify situations that cause stress and learn a variety of 

techniques to respond to stress.

Support groups (e.g., process-oriented recovery groups)

These groups include clients in the same recovery stage—usually a middle to late phase 

of treatment—who are working on similar problems. Members focus on immediate issues 

and on

Pragmatic ways to change negative thinking, emotions, and behavior

Learning and trying new ways of relating to others

Tolerating or resolving conflict without resorting to violence or substance use

Looking at how members’ actions affect others and the function of the group

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30 Chapter 4

Key aspects of groups

Organization of groups. IOT programs 

often use open-ended heterogeneous groups 

that provide clinicians the flexibility of 

assigning new clients to ongoing groups. 

With the client census often difficult to 

predict from week to week, this flexibility permits immediate responsiveness to 

client needs. Members of open-ended heterogeneous groups have varying degrees of 

recognition and acceptance of their problems, and those on the road to recovery offer 

hope to those just beginning.

Although it may seem desirable to keep 

clients in the same group as they progress 

through the treatment process, the experience of the consensus panel has been that 

this is seldom possible because individuals 

have different responses to treatment and 

progress toward recovery at different rates. 

Hence, the composition of the group to which 

a client is initially assigned at admission is 

unlikely to remain constant throughout the 

treatment episode. Some clients progress rapidly to the next stage, whereas others need to 

cycle back to an earlier treatment intensity if 

they relapse or encounter other problems. 

IOT programs can organize homogeneous 

groups based on a therapeutically relevant 

issue for a subset of clients or based on 

demographic commonalities among clients. 

Therapeutically relevant issues that might 

call for single-issue groups include single 

parenting, HIV/AIDS, gender issues, drug 

of choice, or histories of physical violence 

and sexual abuse. Special groups based on 

demographic similarities include those for 

women, men, elderly persons, members of 

minority populations, clients with common 

socioeconomic or legal statuses, or clients 

who have particular professions or are unemployed. Clients in these homogeneous groups 

can use their common perspective as a basis 

for working together. Additional information 

associated with programming for diverse populations is presented in chapters 9 and 10.

Client-specific adaptations. Clients 

with temporary or permanent cognitive 

impairments, literacy deficits, or language 

problems need special attention or assignment to special groups. IOT programs should 

assess whether their treatment orientation 

and relapse prevention materials are appropriate for clients with cognitive impairments 

or learning disabilities. Chapter 10 provides 

additional information.

Exhibit 4-2 (continued)

Groups Conducted in Intensive Outpatient Treatment

Interpersonal process groups

Single-interest groups. These groups—usually organized at a later stage of treatment—

focus on an issue of particular significance to and sensitivity for group members. The 

issues include gender issues, sexual orientation, criminal offense, and histories of physical and sexual abuse.

Family or couples groups. These groups assist clients’ relatives and other significant 

individuals in learning about the detrimental effects of substance use on relationships 

and how these effects can be ameliorated or resolved. Additional information on family 

services is presented in chapter 6 and TIP 39, Substance Abuse Treatment and Family 

Therapy (CSAT 2004c).

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Services in IOT Programs 31

Clients not yet ready to pursue abstinence 

(those uninterested in change—precontemplators—or those thinking about a change in 

the near future—contemplators) often come 

to the program after being mandated to 

treatment by another agency. These clients 

could be assigned to a separate, pretreatment group in which counselors raise the 

clients’ awareness about substance use disorders through education and motivating 

interviews (Washton 2000).

Clients who should not participate in certain groups. Some clients should never be 

assigned to the same groups. Perpetrators 

and victims of domestic violence must be 

in separate groups. Neighbors, relatives, 

spouses, or significant others also should 

not be assigned to the same group (with the 

exception of family therapy). 

Clients who violate the principles of group 

therapy by failing to honor group agreements or dropping out continually and 

clients who cannot control their impulses 

might respond better to individual therapy.

Some socially anxious or very introverted 

clients cannot tolerate groups. These clients 

should be offered individual counseling until 

they are comfortable participating in group 

sessions (Hoffman et al. 2000) or lower 

intensity group sessions that focus on coping 

skills training (Avants et al. 1998). Some clients with severe psychiatric disorders, such 

as schizophrenia or antisocial personality 

disorder, may be unable to participate in 

groups and may be able to attend individual 

therapy only.

Duration and frequency of group sessions. IOT group counseling sessions often 

are scheduled for 90 minutes, although 

shorter and longer timeframes also are used. 

Psychoeducational group sessions often are 

only half that long (e.g., a 30-minute lecture 

followed by 15 minutes for questions) because 

they focus on instruction instead of interaction.

The American Society of Addiction 

Medicine’s (ASAM’s) definition of IOT 

requires participants to have a minimum of 

9 hours of therapeutic contact per week—at 

least in the initial treatment stage (Mee-Lee 

et al. 2001). A typical IOT program schedules 

3 hours of treatment on 3 days or evenings 

each week. This might entail 2 evenings 

of back-to-back 90-minute groups (one for 

members in the same recovery stage to share 

day-to-day concerns and the other to study 

a psychoeducational topic). A third evening 

might include 30 minutes of individual 

counseling, a 90-minute family session, and 

an hour-long skills training group. Some IOT 

programs meet 5 days or evenings per week.

IOT programs vary considerably in the anticipated length of stay or expected duration 

of active treatment. Many courses of treatment span 12 to 16 weeks before clients step 

down to a less intensive (maintenance) stage. 

Clients may remain in the maintenance 

phase for 6 months or more.

Group size and format. The optimal size of 

a group in most IOT programs is between 8 

and 15 members. Process-oriented groups 

may function more effectively if membership is limited to 6 to 8 members, whereas 

psychoeducational groups with considerable 

didactic content can be somewhat larger.

Most counseling guidelines suggest structuring group time (Mercer 2000; Owen 2000). 

Some groups use a “rule of thirds” wherein 

the first third of the session is used to solicit 

each member’s current issues or experiences, 

the second third is used to discuss a particular issue or skill, and the final third is used 

to sum up the meeting and assign an exercise (Kadden et al. 1995). Another approach 

uses a standard problemsolving process in 

which an issue of concern to the group is 

identified, a variety of solutions is offered, 

each option is explored, a decision is made 

about the course to follow, an action plan 

is developed, and affected group members 

agree to pursue this path and report the outcomes (Gorski 2000).

Many recovery groups have traditional 

opening and closing rituals that are meant 
32 Chapter 4

to increase members’ commitments to one 

another and to the group as a whole.

Group leaders’ roles and qualifications.

IOT programs usually specify the roles, 

responsibilities, qualifications, and personal characteristics of counselors who lead 

groups. Chapter 2 of TIP 46, Substance 

Abuse: Administrative Issues in Outpatient 

Treatment (CSAT 2006f), discusses these 

issues in detail.

Individual Counseling

In IOT programs, individual counseling is 

an important, supportive adjunct to group 

sessions but not the primary form of treatment. Whereas concurrent psychiatric 

interventions and addiction counseling are 

appropriate for clients with co-occurring 

substance use and mental disorders (CSAT 

1994b, 2005e; Daley and Thase 2002), most 

individual counseling in IOT programs 

addresses the immediate problems stemming 

from clients’ substance use disorders and 

their current efforts to achieve and maintain 

abstinence. Counseling typically does not 

address the client’s underlying, longstanding conscious and subconscious conflicts 

that may have contributed to substance 

use. Many of the readily available counseling manuals for substance abuse treatment 

have enhanced components for individuals 

or orient the entire approach to individual 

counseling (Kadden et al. 1995; Mercer and 

Woody 1999; Nowinski et al. 1992).

A 30- to 50-minute individual counseling session is typically a scheduled part of the IOT 

program and occurs at least weekly during 

the initial treatment stage. A client is assigned 

a primary counselor who strives to establish a 

close, collaborative therapeutic alliance.

An individual counseling session frequently 

follows a standard format. A counselor may 

ask the client about reactions to the recent 

group meeting, explore how the client spent 

time since the last session, ask how the client 

is feeling, inquire about drug and alcohol 

use, and ask whether there are any urgent 

issues. The counselor helps the client review 

reactions to recent group topics, reviews 

treatment plans and coping strategies, 

addresses fears and anxieties related to the 

change process, provides personalized feedback on urine toxicology and BreathalyzerTM

results, and probes into sensitive issues 

that are difficult to discuss in the group. 

Counselors also help clients access services 

they need that are outside the treatment 

program’s capabilities and plan the transition to another level of care or discharge. A 

counseling session usually ends with a summary of the client’s plans and a schedule for 

the next few days (Carroll 1998; Gorski 2000; 

Mercer 2000).

Psychoeducational 

Programming

Psychoeducational groups are more didactic than process-oriented recovery groups 

and involve a straightforward transmission 

of facts. The counselors who deliver these 

services need to be knowledgeable about 

the subject matter. They also need to know 

where and how to obtain additional information to support their presentations and 

give members of the group other references 

and resources. These sessions, like recovery groups, stimulate discussion that helps 

participants relate the topic to personal 

experience and foster emotional and behavioral change (Washton 2000).

Exhibit 4-3 lists typical topics that are covered in psychoeducational groups and the 

treatment stage at which they are introduced.

Pharmacotherapy and 

Medication Management

Pharmacotherapy and medication management are critical adjuncts to effective 

substance abuse treatment that should not 

be ignored or separated from other therapies, 

psychosocial supports, and behavioral contingencies. Medications target only specific and 
Services in IOT Programs 33

limited aspects of substance use disorders. 

Pharmacotherapy, by itself, does not change 

lifestyles or restore the damaged functioning 

that accompanies most drug dependence.

IOT programs that require attendance 3 to 5 

days per week are ideal settings for identifying clients in need of medication, initiating 

medication regimens, and monitoring clients’ compliance. IOT programs should give 

serious consideration to providing pharmacotherapy and medication management 

services

To provide ambulatory detoxification and 

relief of withdrawal symptoms for some 

clients

•

Exhibit 4-3

Typical Sequence of Topics Addressed in Psychoeducational Group

Treatment 

engagement

Understanding motivation and committing to treatment 

Counteracting ambivalence and denial

Determining the seriousness of the drug or alcohol problem

Conducting self-assessment, setting goals, and self-monitoring progress

Overcoming common barriers to treatment

•

•

•

•

•

Early

recovery

Learning about biopsychosocial disease and recovery processes 

Understanding the effect of specific drugs and alcohol on the brain 

and body

Placing symptoms of substance use disorders in the context of other 

behavioral health problems

Learning about early and protracted withdrawal symptoms for specific 

drugs and alcohol

Knowing the stages of recovery and the client’s place in the continuum 

of care

Learning strategies for quitting and finding the motivation to stop 

Minimizing risks of HIV/AIDS, hepatitis C, and sexually transmitted 

diseases (STDs)

Identifying high-risk situations that are cues or triggers to substance 

use: people, places, and things

Identifying peer pressures and compulsive sexual behavior as triggers

Understanding cravings and urges, learning to extinguish thoughts 

about substance use, and coping with cravings

Structuring personal time 

Coping with high-risk situations

Understanding abstinence and the use of prescription and over-thecounter medications

Understanding the goals and practices of various 12-Step or other 

mutual-help groups

Identifying and using positive support networks

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

(continued)
34 Chapter 4

To prevent relapse by reducing craving, by 

potentially precipitating an aversive reaction, or by blocking the reinforcing effects 

of drugs

To reduce the medical and public health 

risks from use or injection of illicit drugs 

with medical maintenance

To ameliorate the underlying psychopathology that may contribute to substance 

use disorders

To monitor treatment of some medical 

conditions associated with substance use 

disorders

•

•

•

•

Ambulatory detoxification 

ASAM criteria (Mee-Lee et al. 2001) include 

provisions for ambulatory detoxification 

when specific program and environmental 

supports are in place for persons who are 

at low risk for severe withdrawal. IOT programs should have written medical protocols 

or guidelines for specific detoxification 

procedures, as well as formal affiliations 

with appropriate general medical and psychiatric treatment facilities and laboratory 

testing and toxicology services. (This TIP is 

not intended to provide detailed information about detoxification and the medical 

management of detoxification. For more 

Exhibit 4-3 (continued)

Typical Sequence of Topics Addressed in Psychoeducational Group

Maintenance and 

continuing care

Understanding the relapse process and common warning signs 

Identifying tools to prevent relapse 

Developing personal relapse plans

Counteracting euphoria and the desire to test control 

Improving coping and stress management skills

Learning anger management and relaxation techniques

Enhancing self-efficacy for handling risky situations

Responding safely to slips and avoiding escalation 

Finding recovery resources

Structuring leisure time and finding recreational activities 

Knowing the importance of personal health: diet, exercise, 

hygiene, and checkups

Taking a personal inventory 

Handling shame, guilt, depression, and anxiety 

Understanding family dynamics: enabling and sabotaging behaviors

Rebuilding personal relationships 

Understanding sexual dysfunction and healthy sexual behavior

Developing educational and vocational skills

Learning daily living skills: money management, housing, 

and legal assistance

Embracing spirituality and recovery and finding meaning in life 

Recognizing grief and loss and the relationship to substance use

Learning about parenting: basic needs of children and their 

developmental stages and developmental tasks

Maintaining balance in life

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•
Services in IOT Programs 35

information on detoxification see appendixes 

4-A and 4-B and chapter 5 of this volume 

and TIP 45, Detoxification and Substance 

Abuse Treatment [CSAT 2006e]).

IOT programs can institute ambulatory 

detoxification safely for appropriate clients 

if they

Make arrangements for immediate and 

continuous supervision or consultation by 

a qualified physician, with provisions for 

hospitalization or alternative detoxification, if necessary.

Have medically trained staff (e.g., registered nurses, nurse practitioners, licensed 

practical nurses, physician’s assistants) on 

site to conduct initial physical examinations, obtain medical histories, inform clients about medication effects, adjust dosages, and monitor clients for several hours 

or longer each service day.

The consensus panel recommends that family members be involved in monitoring and 

reporting adverse events for the client undergoing detoxification.

Using the CIWA-Ar scale. The Clinical 

Institute Withdrawal Assessment–Alcohol, 

Revised (CIWA-Ar) scale commonly is used 

to determine which clients who are alcohol 

dependent can receive ambulatory detoxification and which should be referred for 

inpatient care. The CIWA-Ar can be administered reliably in a few minutes by a staff 

member with a minimum of 3 hours of 

training (for more information about the 

CIWA-Ar, see chapter 5).

Some disagreement exists among physicians 

about the cutoff points on the CIWA-Ar for 

conducting ambulatory detoxification or 

referring a client for inpatient care. Many 

physicians seem to concur that clients with 

scores of 20 or higher should be treated in 

an inpatient medical facility. Other experienced addiction specialists find that clients 

with scores up to the low 20s can be managed safely in an outpatient setting with 

proper monitoring, supervision of medi-

•

•

cations, and other supports (see the case 

illustration and appendix 4-A). Medical staff 

members in IOT programs must use their 

best judgment or rely on the program’s written procedures.

The CIWA-Ar also is used to monitor the client’s response to administered medications 

at 30- to 60-minute intervals. Symptomtriggered doses are given only when trained 

staff members observe withdrawal signs of 

a specified intensity. Appropriate use of the 

CIWA-Ar has been shown to reduce both 

the numbers of clients receiving withdrawal 

medications and the amount of medication administered (Reoux and Miller 2000; 

Wiseman et al. 1998). The instrument has 

been adapted for monitoring benzodiazepine 

withdrawal (Busto et al. 1989) and for assessing opioid withdrawal (Bradley et al. 1987). 

(See chapter 5 for information about other 

screening instruments.)

Detailed guidelines and resources regarding 

ambulatory detoxification are available in 

TIP 24, A Guide to Substance Abuse Services 

for Primary Care Clinicians (CSAT 1997a), 

and TIP 45, Detoxification and Substance 

Abuse Treatment (CSAT 2006e). Internet 

resources include articles from the American 

Family Physician (www.aafp.org), ASAM 

materials such as Principles of Addiction 

Medicine (www.asam.org), and Detoxification 

Clinical Practice Guidelines developed by the 

New South Wales Health Department (www.

druginfo.nsw.gov.au/home). 

Pharmacotherapies for 

addiction

Research supports the effectiveness of 

medication-assisted treatment for alcohol 

and opioid addiction. Despite promising leads, extensive laboratory research, 

and many clinical trials, no compelling 

evidence exists of effective medications 

for treating dependence on cocaine and 

other stimulants, marijuana, inhalants, or 

hallucinogens.
36 Chapter 4

Preventing relapse to alcohol. Disulfiram 

(Antabuse®) and naltrexone (ReVia®) have 

been used successfully to assist clients who 

are alcohol dependent with avoiding relapse. 

An IOT program is an ideal setting to initiate disulfiram treatment because doses are 

effective for 3 days. Clients can receive their 

doses during a session, with double doses or 

take-home doses provided for the weekends. 

Early research studies suggested that naltrexone did not reduce the frequency of alcohol 

use relapses but appeared to shorten the 

duration of relapse and to lessen the amount 

of alcohol drunk during a relapse episode 

(O’Malley et al. 

1992; Volpicelli et 

al. 1992). However, 

recent data suggest 

that naltrexone 

might be ineffective 

in limiting drinking for men with 

chronic, severe 

alcohol dependence (Krystal et al. 

2001). Clinicians 

who are interested 

in naltrexone for 

clients who use 

alcohol are referred 

to TIP 28, Naltrexone and Alcoholism 

Treatment (CSAT 1998c).

Acamprosate (Campral®) was approved by 

the U.S. Food and Drug Administration in 

2004 for postwithdrawal maintenance of 

alcohol abstinence. In nearly two decades of 

use in Europe, acamprosate has been found 

to be safe and effective for treating alcohol 

dependence (Mann et al. 2004; Tempesta 

et al. 2000). Treatment with acamprosate 

has been shown to decrease the amount, 

frequency, and duration of alcohol consumption in clients who relapse to alcohol use 

(Chick et al. 2003; Tempesta et al. 2000) 

and to reduce cravings, even in clients who 

resume drinking (CSAT 2005a). 

Medication maintenance for opioid 

dependence. Clients dependent on opioids, 

who frequently do not respond to other 

forms of substance abuse treatment, can be 

maintained effectively on certain longer acting opioid medications that enable them to 

function productively. These opioid medications include methadone, buprenorphine, 

and levo-alpha acetyl methadol (LAAM). 

(Although LAAM is still approved by the U.S. 

Food and Drug Administration for treatment 

of certain clients dependent on opioids, the 

U.S. manufacturer of LAAM ceased producing it in 2005.)

Treatment with methadone and LAAM currently must take place in specially approved 

and licensed programs or, under special circumstances, in a physician’s office. Because 

new clients must attend these programs 

a minimum of 5 days a week, methadone 

maintenance programs are ideal settings 

for introducing many components of IOT 

programming.

Buprenorphine alone and a 

buprenorphine-naloxone combination are 

alternative medications for maintenance 

of individuals dependent on opioids. 

Buprenorphine was approved by the U.S. 

Food and Drug Administration in 2002 

for the treatment of opioid dependence 

and is scheduled as a Class III narcotic. 

Buprenorphine can be dispensed or prescribed by physicians in office-based 

practices or in health care facilities that are 

not specially licensed, provided they obtain 

a waiver from the Substance Abuse and 

Mental Health Services Administration. IOT 

programs with a physician on staff or readily 

available are eligible to dispense or prescribe 

buprenorphine. Buprenorphine is safer for 

treating opioid dependence than methadone 

or LAAM because it is more difficult to overdose (Jaffe and O’Keefe 2003; Johnson et al. 

2003) and, in combination with naloxone, 

reduces the risk of diversion (Johnson and 

McCagh 2000; Mendelson and Jones 2003). 

TIP 40, Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of Opioid 

Addiction (CSAT 2004a), provides more 

information. Information about Web-based 

and onsite training about buprenorphine 

Whenever 

medication is used to 

support abstinence, 

clients need to be 

educated about the 

drug prescribed. 
Services in IOT Programs 37

can be obtained by clicking on Medication 

Assisted Treatment on the CSAT Web site 

(buprenorphine.samhsa.gov/training_main.

html). TIP 43, Medication-Assisted Treatment 

for Opioid Addiction in Opioid Treatment 

Programs (CSAT 2005b), offers guidance 

about methadone, LAAM, and opioid 

pharmacotherapy.

Co-occurring disorders. Many clients who 

enter substance abuse treatment have cooccurring mental disorders. ASAM patient 

placement criteria recommend that individuals with moderate-severity disorders be 

treated in IOT programs that are designed 

primarily for clients who abuse substances; 

the placement criteria also recommend 

that IOT programs be capable of coordination and collaboration with mental health 

services. These programs can provide psychopharmacologic monitoring, psychological 

assessment and consultation, and treatment 

of substance use disorders to clients with 

moderate-severity mental disorders. Clients 

with symptomatic, high-severity psychiatric 

diagnoses should be treated in programs that 

treat co-occurring disorders by integrating 

mental health and substance use treatment 

and that have cross-trained staff (Drake et al. 

1998b; Ries et al. 2000). (Moderate-severity 

co-occurring mental disorders include stable 

mood or anxiety disorders. High-severity 

disorders include schizophrenia, mood disorders with psychotic features, and borderline 

personality [Mee-Lee et al. 2001].) Chapter 9 

provides additional information on treating 

individuals with co-occurring disorders. TIP 

42, Substance Abuse Treatment for Persons 

With Co-Occurring Disorders (CSAT 2005e), 

also addresses this issue.

Clinical strategies and approach. 

Whenever medication is used to support 

abstinence, clients need to be educated 

about the drug prescribed. It is important 

for clients to understand

Expected effects of the drug prescribed, 

interactions with other licit and illicit 

drugs, and adverse reactions that should 

be reported at once to the medical staff

•

Side effects and how they can be ameliorated (e.g., laxatives for the commonly 

experienced constipation produced by 

methadone)

Cross-tolerance and synergistic or other 

interactive effects when mixed with other 

drugs, especially drugs for such chronic 

conditions as high blood pressure, diabetes, high cholesterol, and asthma

The time usually needed for the full effect of 

medications, such as antidepressants, to be felt

The way in which a medication is introduced 

and explained can affect clients’ willingness 

to comply with the dosing schedule and their 

chances of receiving its full benefits. When 

clients begin a medication regimen, it may 

be useful to hold educational groups for 

clients and their family members. Accurate 

information can be imparted, and the questions of both clients and their families can 

be answered. If clients are given take-home 

doses, the inclusion of family members in 

such educational groups may be helpful for 

encouraging compliance with the medication 

protocol.

Medication-assisted IOT programs must 

build time into the treatment schedule for 

administering medications, monitoring the 

effects, and providing appropriate education 

about medications. The program can schedule the administration of medications to 

minimize the effect of withdrawal symptoms 

on the client’s participation in psychosocial 

treatment and to maximize treatment attendance and retention.

Infectious diseases. Of paramount concern 

is encouraging client compliance with medication regimens to treat, control, or cure 

infectious diseases. Several TIPs address 

this issue, including TIP 6, Screening for 

Infectious Diseases Among Substance Abusers

(CSAT 1993b); TIP 18, The Tuberculosis 

Epidemic: Legal and Ethical Issues for 

Alcohol and Other Drug Abuse Treatment 

Providers (CSAT 1995c); and TIP 37, 

Substance Abuse Treatment for Persons With 

HIV/AIDS (CSAT 2000c).

•

•

•
38 Chapter 4

Monitoring Alcohol 

and Drug Use

Routine monitoring of clients’ illicit drug 

and alcohol consumption to determine 

whether the selected therapy is having the 

desired effect is a standard part of all IOT 

programs. Some programs rely on clients’ 

self-reports. However, most programs use 

objective tests of biological specimens—usually urine samples, but also breath, saliva, 

sweat, blood, or hair samples. The results of 

these scientifically established procedures 

help program staff members reliably and 

accurately monitor a client’s treatment 

course, recognize clients’ success in remaining abstinent, and increase the accuracy of 

clients’ self-reporting. Monitoring drug and 

alcohol use helps clinicians determine the 

need for treatment plan modifications, helps 

families reestablish trust, helps clients avoid 

slips or lapses, and discourages them from 

substituting a different drug or alcohol for 

their primary drug of choice.

Testing in the IOT program is designed to 

deter clients from using substances, not to 

punish or induce shame and guilt. Programs 

might use drug-free urine test results as a 

contingency for receiving specified rewards, 

reinforcing desired behaviors rather than 

punishing continued drug use (see Budney 

and Higgins 1998).

When programs are asked to report urine 

test results to the criminal justice system, an 

employer, or a children’s protection agency, 

it is important to consider the negative effect 

reporting can have on treatment. Knowing 

that a positive test result may lead to punishment can inhibit a client’s forthrightness 

in self-disclosure and encourage treatment 

dropout. Clients need to be informed fully 

that their test results will be disclosed and 

that testing positive may trigger serious consequences (CSAT 2004b).

Procedures for collecting and testing urine 

and a chart showing cutoff times for detecting various drugs are provided in appendix 

B (page 237). (Note: Alcohol is hard to test 

for because it may be eliminated from the 

client’s system rapidly.) Appendix B lists 

methods and screening tests for detecting 

alcohol and illicit drugs, using a number of 

tests in addition to urinalysis.

Case Management

Individuals who abuse substances are likely 

to have significant and interrelated problems in addition to their use of psychoactive 

substances. Services to address these needs 

often are fragmented across many agencies. 

Services may be difficult to access without 

the assistance of a case manager who is 

knowledgeable about service providers and 

can help clients access these services (exhibit 

Qualifications and Roles of Case Managers

Many IOT programs hire professionally trained case managers, such as social workers or 

counselors whose sole function is case management. Other IOT programs may expect treatment counselors to assume case management responsibilities as well as counseling duties. 

In some programs, peer counselors or indigenous workers augment the work of professional 

staff members.

Case managers in IOT programs develop and maintain an accurate list of local and regional 

services that clients may need.

Case managers facilitate transfers to other treatment services as dictated by the clients’ needs. 

Case managers in IOT programs participate in developing written memorandums of understanding and interagency agreements to ensure that these documents specify services offered, 

staff qualifications, number of available slots, costs, lines of authority, and referral procedures. 

•

•

•

•
Services in IOT Programs 39

4-4). Case managers help clients identify and 

prioritize needs that cannot be met by the 

IOT program and access and participate in 

additional services to meet those needs.

Examples of client populations that might be 

aided by case management services include 

pregnant women, people who are homeless, 

clients with HIV/AIDS and other serious 

medical conditions, people with severe mental disorders, long-term welfare enrollees, 

people with physical disabilities, and people 

involved in the criminal justice system.

IOT programs—particularly those serving publicly funded clients—need to have 

detailed, up-to-date resource directories or 

formal arrangements with the following 

types of local services: 

Social service and child welfare agencies

Vocational rehabilitation 

Training and employment assistance 

programs

Preventive health care; inpatient, outpatient, and community health care services 

(e.g., visiting nurses; home health aides; 

physicians; specialty programs for HIV/

AIDS, hepatitis C, STDs, or tuberculosis 

[TB]; and prenatal and pediatric care)

Inpatient and outpatient psychiatric treatment and mental health services

Recovery support groups

•

•

•

•

•

•

Exhibit 4-4

Case Management Services

Functions

Provide a core set of social services that includes assessment, planning, linkage, monitoring, and advocacy. 

Provide the client with a single contact person who is responsible for finding and mobilizing needed resources, negotiating formal systems, and bartering informally with 

other service providers to gain access to appropriate services.

Respond to client’s needs, tailoring resources to the individual rather than fitting the 

client into existing services.

Intervene with many systems and providers on behalf of the client.

Operate in the community and transcend facility boundaries.

Focus on pragmatic, immediate ways to meet needs (e.g., clothing, shelter).

React sensitively and competently to clients’ ethnic, gender, and cultural differences.

Models

Single agency model. Case managers personally establish relationships with counterparts in other agencies to find and access services for individual clients.

Informal partnership model. Staff members from several agencies link into collaborative teams or networks that consult about individual cases and share services.

Formal consortium model. Case managers and service providers are joined through 

written agreements or contracts that define roles, responsibilities, shared services, and 

costs. This model usually is organized by a lead agency that has primary responsibility 

and receives most or all of the funding.

•

•

•

•

•

•

•

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•
40 Chapter 4

Faith-based institutions appropriate for 

the client population

Food banks and clothing distribution 

centers 

Recreational facilities and programs of 

many types

Adult education programs, including 

instruction in adult literacy and English as 

a second language

Child care 

Parent training programs 

Volunteer transportation services 

Family therapy and couples counseling 

Housing resources, including U.S. 

Department of Housing and Urban 

Development Section 8 housing, shelters 

for homeless persons and battered women, 

and recovery houses

Legal assistance

Providers of heavily used services should be 

visited by IOT staff members to maintain 

close working relations.

Research outcomes and 

findings

Several studies suggest that case management services increase client retention, 

improve clients’ occupational and social 

functioning, and ameliorate their psychiatric 

symptoms (Siegal et al. 1996, 2002). Case 

management services have been found to be 

a low-cost enhancement that improve client 

retention in some publicly funded, mixedgender substance abuse treatment programs 

(Schwartz et al. 1997). A study by McLellan 

and colleagues (1998) provides support for 

adding case management services to IOT 

programs. This study evaluated the effectiveness of case-managed social services added 

to public-sector substance abuse treatment 

programs that served inner-city clients who 

were severely impaired. Case management 

consisted of coordinating and expediting clients’ use of medical screening, employment 

counseling, drug-free housing, parenting 

classes, and recreational and educational 

services. Clients who received enhanced 

services had significantly better treatment 

•

•

•

•

•

•

•

•

•

•

outcomes than clients in traditional outpatient treatment. The investigators concluded 

that both addiction-focused services and 

supplemental social supports are necessary 

for effective, long-term rehabilitation.

In another study, case management for 

pregnant women enrolled in specialized 

women’s outpatient substance abuse treatment included regular phone calls and home 

visits, written referrals to social service agencies, staff advocacy for clients’ with social 

service agencies, and free transportation 

to and from treatment. Case management 

and transportation services were significant 

predictors of retention in drug treatment 

(Laken and Ager 1996). In a followup 

study, treatment retention was associated 

with decreased drug use and increased 

infant birth weight (Laken et al. 1997). 

TIP 27, Comprehensive Case Management 

for Substance Abuse Treatment, provides 

detailed information (CSAT 1998a).

24-Hour Crisis Coverage

Many clients in IOT programs develop 

problems that require immediate attention 

outside working hours. Arrangements are 

needed for 24-hour, 7-day-a-week coverage by 

trained personnel (exhibit 4-5). The benefits 

of this coverage include reducing unnecessary hospitalizations and providing fail-safe 

options for clients and families to head off 

crises.

IOT programs should ensure that clients are 

aware of the afterhours coverage and that 

the coverage is listed in published materials. Clients need clear, written instructions 

regarding emergencies—whether to go immediately to a hospital or to call 911.

Community-Based Support 

Groups

IOT programs should foster active participation in community-based 12-Step and other 

mutual-help groups as part of the treatment 

process. This effort is extremely important 
Services in IOT Programs 41

for clients because formal substance abuse 

treatment is a relatively brief step in the long 

journey to recovery. In addition, clients need 

to develop a support network of positive role 

models and friends who can help guide their 

continuing recovery. Support groups serve as 

an important adjunct to structured therapy. 

At a minimum, clients need to be introduced 

to the basic tenets of a 12-Step or similar 

mutual-help group. Most IOT programs 

encourage participation in group meetings 

and give clients options about the type of 

community-based group they can attend.

Key aspects of community 

support groups 

An IOT program often can facilitate voluntary attendance in support groups by helping 

clients understand more about local support groups through group discussion and 

individual counseling. At a minimum, IOT 

programs should give clients a thorough 

introduction to mutual-help programs, help 

clients overcome any resistance by encouraging their attendance with other group 

members or program alumni, and leave the 

decision about joining a group to the clients. 

Programs also can invite support groups to 

hold open meetings on site; these meetings 

allow clients to become familiar with the format of Alcoholics Anonymous (AA), Narcotics 

Anonymous (NA), Cocaine Anonymous (CA), 

or other groups.

Counselors should be familiar with the differences between various support groups in 

the community and help their clients select 

an appropriate group meeting to attend. 

Counselors should match clients with groups 

attended by persons who have similar social, 

ethnic, economic, and cultural backgrounds 

and experiences. The substances clients 

abuse, as well as other factors, also may 

affect the match (Forman 2002).

The 12-Step fellowship

Twelve-Step fellowships are the most commonly recognized and widely attended 

groups for continuing recovery support. 

Involvement in 12-Step groups such as 

AA, NA, or CA is correlated positively with 

both retention in treatment and abstinence 

(Fiorentine 1999). Twelve-Step groups 

include a spiritual focus, espouse principles 

of conduct, and provide ongoing support for as long as an individual wishes to 

participate.

Twelve-Step groups are available throughout the country. There are different types 

of meetings (e.g., open speaker meetings, 

Exhibit 4-5

Examples of 24-Hour Crisis Coverage Implementation

Hotline services. In some programs, afterhours calls are forwarded to a hotline or 

other crisis intervention service. This service can provide advice and referrals or, if indicated, can contact an IOT program staff member.

Oncall clinicians. A few large IOT programs that serve a particularly troubled population (e.g., persons with severe co-occurring mental disorders) may have rotating, oncall 

clinicians who answer and screen inquiries.

Agreement with 24-hour professional service providers. In some areas, afterhours 

calls to the IOT program are transferred to a detoxification or inpatient rehabilitation 

unit that is staffed 24 hours a day.

•

•

•
42 Chapter 4

Step meetings, open and closed discussion 

meetings). Basic AA texts include Alcoholics 

Anonymous (the “Big Book”), Twelve 

Steps and Twelve Traditions, and Living 

Sober. Basic texts of NA include Narcotics 

Anonymous and It Works: How and Why.

Information about AA and fellowship 

meetings is available from the General 

Services Offices of Alcoholics Anonymous 

(www.gso.org) and from World Services, 

Inc. (www.alcoholics-anonymous.org). 

Information on AA meetings can be obtained 

from the central offices in each State and 

the District of Columbia. A list of contacts 

in the central offices can be found at www.

aa.org/en_find_meeting.cfm. The Narcotics 

Anonymous Meeting Search function at 

www.na.org helps people locate an NA meeting throughout the United States and its 

territories. The CA Web site provides contact 

information for meetings throughout the 

United States, Canada, and Europe (www.

ca.org/phones.html). Nowinski and colleagues (1992) and Daley and colleagues 

(1999) also offer guidance on conducting 12-

Step-oriented counseling.

Some clients may be more comfortable in 

12-Step groups that have been adapted to 

meet participants’ needs. Depending on the 

geographic location, there may be gay- and 

lesbian-identified groups, women’s groups, 

groups for people who are hearing impaired, 

men’s meetings, Spanish-language meetings, 

meetings for agnostics, young people’s meetings, and beginners’ meetings.

Special 12-Step groups have been organized 

by people with both substance use and 

psychiatric disorders (see chapter 9). These 

groups have been shown to reduce substance 

use and increase compliance in clients taking 

prescribed medications (Laudet et al. 2000a).

Alternatives to communitybased 12-Step groups

Community support groups exist for clients 

who may be uncomfortable with traditional 

12-Step groups (see exhibit 4-6). 

Medical Treatment

Many IOT clients enter treatment with undiagnosed or untreated medical conditions 

that require immediate and continuing care 

by a physician. All IOT programs need to 

have preplanned arrangements with a community health center or a local hospital that 

can handle any overdose or withdrawalrelated emergencies. Relationships need to 

be in place with medical providers that will 

test for and treat infectious diseases, including STDs, HIV infection, TB, hepatitis B and 

C, and other health conditions. Programs 

serving women who are pregnant or of childbearing age need to have arrangements in 

place for obstetric and gynecological care.

Psychiatric Examinations and 

Psychotherapy

IOT programs need to evaluate clients’ mental and psychiatric status and to refer those 

with signs and symptoms indicating that a 

thorough evaluation is warranted. Chapter 

5 provides guidance on conducting psychological evaluations. Chapter 9 discusses the 

needs of persons in IOT with co-occurring 

psychiatric disorders; additional information is provided in TIP 42, Substance Abuse 

Treatment for Persons With Co-Occurring 

Disorders (CSAT 2005e). Ideally, IOT programs have relationships with mental health 

centers and with individual psychiatrists for 

consultation and referral.

Vocational Training and 

Employment Services

Unemployment or underemployment is often 

a problem for individuals in early recovery. 

Clients entering IOT programs often have 

issues that impede their ability to be employed 

fully, such as limited formal education, poor 

work readiness, and skill deficits. Few IOT programs are prepared to address these barriers 

to employment; hence, specialized vocational 

and employment counseling and related services on site or through case-managed referral 

are an optimal part of an IOT program.
Services in IOT Programs 43

IOT programs need to stay abreast of local 

vocational training and employment 

resources and to develop relationships 

with these agencies and with individual 

counselors at these agencies. Many communities offer specific vocational resources 

for persons with disabilities, veterans, 

women, criminal justice clients, and other 

Exhibit 4-6

Alternatives to Traditional 12-Step Groups

Self-Management and Recovery Training (www.smartrecovery.org) groups were developed during the 1980s as alternatives to the 12-Step model. These groups address recovery within a cognitive–behavioral framework. Preliminary studies suggest this approach 

can be a viable alternative for individuals who are reluctant to attend 12-Step meetings, 

although further study is needed (Connors and Dermen 1996; Godlaski et al. 1997). 

Atheists and agnostics are less likely than clients who describe themselves as spiritual 

or religious to initiate and sustain AA attendance. However, clients who identify themselves as atheist and agnostic and who persist in AA attendance show no difference in 

days abstinent or drinking intensity when compared with clients who identify themselves as spiritual or religious (Tonigan et al. 2002; Winzelberg and Humphreys 1999).

Secular Organizations for Sobriety (www.secularhumanism.org) and Save Our Selves 

(www.secularsobriety.org) promote individual empowerment, self-determination, and 

self-affirmation and offer groups for women and members of minority groups in addition to open groups.

A variety of support groups can be accessed through national organizations such as 

Women for Sobriety, Inc. (www.womenforsobriety.org), the Women’s Action Alliance, 

the Institute on Black Chemical Abuse (www.aafs.net/ibca/ibca.htm), the National 

Black Alcoholism and Addictions Council (www.nbacinc.org), the Hispanic Health and 

Human Services Organization, the Hispanic Health Council (www.hispanichealth.com), 

and the National Association of Native American Children of Alcoholics.

Clients who are former inmates may respond positively to community-based support 

services that address their special needs. Programs such as the Fortune Society (www.

fortunesociety.org) and the Safer Foundation, which provide assistance to former 

inmates, are located in several large cities.

Religious institutions are frequently a significant community-based support system for 

many recovering individuals, particularly within African-American communities (CSAT 

1999b). Many IOT programs encourage interested clients to become involved with community religious groups. For example, JACS (Jewish Alcoholics, Chemically Dependent 

Persons, and Significant Others) helps members reconnect with one another and 

explore resources within Judaism that enhance recovery.

Some IOT programs run support groups for former clients on an indefinite basis. 

Generally, participation in these alumni groups does not require payment to the IOT 

program. The groups often are supported at minimal cost by the program as part of a 

continuum of care for clients who successfully complete treatment. Typical support provided by the IOT program for alumni groups includes meeting space, refreshments, and 

promotion of the group to clients. Some clients attend both 12-Step meetings and other 

support groups.

•

•

•

•

•

•
44 Chapter 4

groups. TIP 38, Integrating Substance Abuse 

Treatment and Vocational Services (CSAT 

2000a), presents more information.

Enhanced IOT Services

Adult Education

Clients who have educational deficits need 

encouragement to enroll in local adult education classes, literacy programs, or general 

equivalency diploma programs. Those who do 

not speak English well should be encouraged 

to attend English-as-a-second-language courses. 

If a sufficient number of clients do not have 

high school diplomas or use a language other 

than English at home, an IOT program might 

recruit volunteers to conduct classes on site.

Transportation Services

The transportation needs of clients may be 

met in several ways, including providing public transportation tokens or passes. This simple 

accommodation should be considered by all 

programs that serve low-income clients as a way 

to encourage retention in treatment. Alternatives 

that are likely to involve insurance liability 

include using staff or volunteers to drive vans.

Housing and Food

Housing programs in many cities provide 

room and board for recovering persons. These 

recovery homes usually are not licensed treatment facilities but rather are financially 

self-sustaining organizations that offer housing 

for a limited time. The homes often are established or staffed by recovering individuals and are 

available for a nominal weekly or monthly rent.

The ground rules for residence are 

abstinence, regular rent payments, and 

appropriate conduct. Some recovery houses 

require attendance at house meetings and 

community-based 12-Step meetings. Some 

recovery houses actively encourage ongoing 

substance abuse treatment and employment 

by the end of the first 30 days of residence. 

Other group-living houses are available to 

special populations, such as persons infected 

with HIV or individuals with psychiatric 

diagnoses, and professional staff members 

usually are in residence or readily available.

Many temporary shelters for homeless persons 

offer recovery support or more formal and staged 

substance abuse treatment. The Salvation Army, 

for example, operates halfway houses or supportive living residences for recovering persons. 

Some shelters for homeless people also incorporate short-term recovery support. Homeless 

populations and other low-income clients in IOT 

programs may need the assistance of food banks 

or access to surplus food that may be supplied 

by local merchants or other community agencies.

Recreational Activities

Organized recreational activities can be a valuable part of treatment, helping clients find 

healthful, substance-free interests to replace a former focus on substance use. Scheduled exercise 

(including walking, sports, weight training, and 

aerobics) has been shown to be an important 

aspect of substance abuse treatment (Kremer et 

al. 1995). Exercise can relieve underlying depression and anxiety (Paluska and Schwenk 2000). 

Organized sports, games, arts and crafts, and 

walks can have therapeutic benefits.

Adjunctive Therapies

Groups in which clients use various nonverbal, 

creative media (e.g., music, dance, drama, crafts, 

and arts such as painting, drawing, sculpture, 

and collage) can be therapeutic and helpful to 

recovery. Other alternative therapies that might 

help clients include acupuncture and stress 

reduction by means of biofeedback therapy 

(Richard et al. 1995).

Various forms of meditation (mindfulness, 

visualization, breath meditation, and transcendental meditation) have been used to 

treat diseases such as cancer and AIDS 

(Marlatt and Kristeller 1999). As an adjunct 

to substance abuse treatment, meditation 

can be used with the goal of reducing the 
Services in IOT Programs 45

frequency and intensity of cravings and 

improving clients’ emotional and psychological function (CSAT 1994a). Meditation 

is consonant with the philosophy of AA and 

other 12-Step support groups (CSAT 1999c). 

Nicotine Cessation Treatment

Clinical experience indicates that the 

majority of people who are drug or alcohol dependent also smoke cigarettes. More 

people in this group die from tobacco-related 

causes than from their alcoholism or drug 

dependence (Hurt et al. 1996). Despite 

the health risks associated with smoking, 

substance abuse treatment staff members 

persistently believe that smoking cessation 

may be detrimental to clients’ abstinence 

from other drugs. However, believing that 

the best time to quit smoking would be during treatment was the main factor in clients’ 

accepting nicotine cessation treatment at 

admission to substance abuse treatment 

(Seidner et al. 1996). In one study, fewer 

than 10 percent of clients objected to a clinic’s smoking ban when nicotine replacement 

therapy was available along with substance 

abuse treatment (Zullino et al. 2003). 

The relapse rate for smokers in the general 

population who are trying to quit is high. 

Frank and colleagues (1991) found that fewer 

than 4 percent of smokers who succeed in 

quitting did so with the help of a physician. 

Smokers who are trying to quit achieve the 

highest success rates when they participate in 

behavioral therapy in combination with nicotine replacement therapy (Glover et al. 2003). 

These findings suggest that IOT programs are 

good settings for smoking cessation efforts 

because they offer a structured environment 

in which clients’ efforts to quit smoking can 

be supported by behavioral and medicationassisted interventions and other clients. Strong 

associations have been shown between reductions in cigarette smoking and reductions 

in other substance abuse during treatment 

(Kohn et al. 2003; Shoptaw et al. 2002).

Nicotine replacement is available in prescription (inhaler, spray) and nonprescription (gum, 

patch) forms. Clients may need to try several 

different products of the same type (e.g., different brands or dosages of gum) or try different 

delivery mechanisms before they find a product that works for them. Researchers have 

found that inhalers, sprays, gum, and patches 

are more effective than placebo in helping 

clients quit smoking (Schmitz et al. 1998). The 

antidepressant medications bupropion and 

nortriptyline have shown promise in diminishing cravings for nicotine and improving 

quit rates, probably because they help alleviate depression—a major cause of relapse (da 

Costa et al. 2002; Richmond and Zwar 2003).

Licensed Child Care

IOT programs that serve women who have 

young children should have appropriate childcare facilities on site or nearby to facilitate 

the mothers’ participation in treatment. For 

liability and therapeutic reasons, childcare 

arrangements should be provided by licensed 

childcare professionals, not by untrained 

counselors or volunteers. IOT programs 

should check with their county government or 

Single State Authority about local regulations.

Parent Skills Training

Many clients need to learn parenting skills, 

children’s developmental stages, and appropriate disciplinary strategies for each stage. 

Parents also may benefit from practical 

information about obtaining vaccinations, 

diets for youngsters, listening skills, and 

attention-increasing activities that prepare 

toddlers for school. Training in parenting 

skills is essential for parents who have survived emotional, physical, and sexual abuse 

in their own childhoods. Without intervention, these clients may perpetuate this type 

of harmful behavior with their own children.

IOT programs can help enroll clients’ young 

children in Head Start programs (where 

available) and facilitate their attendance 

(visit the Web site of the National Head 
46 Chapter 4

Start Association, www.nhsa.org). Focus on 

Families, a training program for parents in 

opioid treatment programs, has involved parents successfully in treatment, decreased their 

use of illicit substances, and reduced the risk 

factors and enhanced the protective factors 

for future drug use among their children; 

however, few significant changes have been 

seen in children’s behavior at 1-year followup 

(Catalano et al. 1997, 1999). Information 

about Strengthening American Families and 

other age-specific model parent and family 

training programs evaluated by the Office of 

Juvenile Justice and Delinquency Prevention 

can be found at www.strengtheningfamilies.

org. Information about programs, such as 

the National Center on Substance Abuse and 

Child Welfare and Starting Early, Starting 

Smart, that focus on children and families 

in the context of substance abuse prevention 

and treatment can be found at www.samhsa.

gov/Matrix/programs_children.aspx. 

IOT Services: A Case 

Illustration

Exhibit 4-7 describes a suburban, hospitalbased IOT program, and appendix 4-A 

(starting on page 48) presents a case study 

illustrating the treatment course for one of 

its clients. This IOT program offers comprehensive services for diverse groups of 

clients. The treatment philosophy integrates 

the disease concept of chemical dependence 

with cognitive–behavioral approaches, motivational counseling, and the principles of 

12-Step fellowship programs and similar 

mutual-help community support groups. 

The facility is located within a hospital but 

has a separate entrance. It is close to public transportation and has ample parking. 

The reception room feels welcoming, and 

rooms for group sessions are furnished with 

upholstered couches and chairs, soft lighting, and pleasant artwork. Several group 

rooms double as offices for the counselors 

and onsite medical staff. This IOT program 

serves clients who are dependent on a variety of substances. Many clients have both 

substance use and mental disorders. The 

programming and schedules are sufficiently 

flexible to serve the needs of professionals, 

blue-collar workers, students, single-parent 

families, stay-at-home parents, and retirees.

Exhibit 4-7

Key Features of a Hospital-Based Suburban IOT Program

(continued)

Qualified medical staff members make the initial assessment of applicants’ withdrawal 

potential; these medical staff members prescribe and dispense medications for symptomatic relief and monitor clients’ reactions for up to 10 hours. 

Medications can be administered on site.

Staff members provide continuing assessment of other potential psychiatric problems 

that may contribute to clients’ substance use disorders; a psychiatrist in the hospital’s 

psychiatric unit is available for medication evaluation and monitoring when needed.

Whenever possible, family members (with the consent of the client) are involved in the 

initial assessment, treatment planning, and psychoeducational activities.

•

•

•

•
Services in IOT Programs 47

Exhibit 4-7 (continued)

Key Features of a Hospital-Based Suburban IOT Program

Randomized, monitored urine testing is used as a clinical tool for deterring clients’ use 

of mood-altering substances.

Clients are expected but not required to participate in 12-Step fellowships or other 

mutual-help groups early in treatment.

Clients attend groups for both therapeutic and educational purposes. Most therapy 

groups are co-led by two counselors. Group members examine the ways in which their 

thoughts, emotions, and behaviors contribute to, or detract from, a satisfying lifestyle 

or recovery. The clinician is responsible for ensuring a psychologically and physically 

safe environment that provides support and maintains therapeutic pressure for positive change. Counselors are flexible in setting limits; they maintain order while allowing 

spontaneity and growth. The emphasis is on giving all group members an opportunity 

to participate as equals. 

Three 3-hour IOT sessions are organized into sequential groups. Issues identified during the first highly structured group are explored in depth during the second, less 

structured group therapy session. The third, didactic group session can be tailored to 

particular issues identified during the therapeutic discussions or to the basic interests 

of the group. These sessions, which use lectures and videos as well as written materials, 

address an array of topics, including basic information about alcohol and drugs, the 

12 Steps of AA or NA fellowships and other support groups, and a cognitive–behavioral 

relapse prevention approach.

The client’s transition from the rehabilitation (early recovery) to the continuing care 

(maintenance) phase of treatment is carefully planned so that the client continues with 

the rehabilitation group while “trying out” the continuing care group. The client usually knows several members of the new group and, sometimes, a co-leader of the new 

group. The group meets in the facility in which earlier treatment was conducted and 

the structure of the sessions is similar to that of the primary treatment phase. Step-up 

care is used flexibly so that clients who have relapsed move to a more structured schedule until they are restabilized.

Programming is structured to respond to individual client needs, including a variable, 

rather than a fixed, length of stay.

Three levels of IOT services are offered in overlapping phases to reduce attrition and 

facilitate long-term recovery:

Partial hospitalization (ASAM Level II.5) for up to 10 hours per day for medically 

monitored ambulatory detoxification.

Intensive outpatient (ASAM Level II.1) for 3 hours per day for rehabilitation. Clients 

initially are seen 5 days per week. The frequency gradually is tapered to once weekly 

for a total of 10 to 30 sessions, depending on clinical need. Separate individual and 

family sessions also are scheduled.

Nonintensive outpatient (ASAM Level I) once weekly for 2 hours for continuing care 

for up to 2 years. 

•

•

•

•

•

•

•

–

–

–
48 Chapter 4

Appendix 4-A. A Case Study of Intensive 

Outpatient Treatment

Case Presentation Commentary

Initial Contact

Tom, a 45-year-old African-American 

accountant, has been referred to the 

program by his supervisor through his company’s employee assistance program (EAP) 

because of repeated Monday-morning tardiness and complaints by co-workers that his 

work is increasingly “sloppy” and he often 

smells of alcohol.

Because the referral was initiated by an 

EAP, it is important for staff members 

to stay in close contact with the EAP 

representative.

An EAP representative telephoned and made 

an appointment for Tom for 9 a.m. the next 

day. Tom has health insurance, has not had 

previous treatment, and is married with a 

family. Tom was asked to invite his wife to 

come with him.

A trained intake worker screens all applicants to ascertain their eligibility and 

whether there is any psychiatric or medical 

emergency that cannot wait for a regularly 

scheduled appointment.

Stage 1: Treatment Engagement

During the intake interview, Tom reports 

that he has been drinking “about a six 

pack” of beer daily for the past 5 years, with 

“maybe 10 or 15 beers” on weekend days. He 

denies other drug use and any major problems, although he was charged with driving 

while intoxicated (DWI) 2 years ago, at 

which time his blood alcohol level (BAL) was 

.22 mg/dl. He says he was “put out” that the 

judge sent him to alcohol education classes 

and AA meetings, even though he “wasn’t 

really drunk or unable to drive.” His doctor told him at his last checkup about a year 

ago that his liver function tests were slightly 

elevated and he should stop drinking.

Family members are invited to participate in 

intake interviews. 

Many treatment applicants initially minimize the extent or intensity of substance use 

and associated problems. However, Tom 

clearly has a substance use disorder that is 

affecting his functioning. 

After confidentiality regulations are 

explained, Tom consents to the program’s 

requesting a transcript of the records of his 

DWI charge and his involvement with the 

alcohol education classes. His claim of not 

really being drunk despite a .22 mg/dl BAL 

suggests a high tolerance.

He also agrees that his internist can be 

asked to forward medical records and conduct additional tests or examinations, if they 

are indicated.

Tom says he stopped drinking for a while but 

started again and hasn’t been back to see the 

doctor since then. When asked about this 

period of abstinence, Tom says it probably 

lasted 4 months and that he felt

Tom’s history indicates that his drinking 

may be complicated possibly by underlying 

depression, even though he blames others 

for his return to alcohol and does not, apparently, yet see his drinking as a problem. 
Services in IOT Programs 49

Case Presentation Commentary

depressed during that time. “It’s hard having 

a teenage daughter,” he offers as an excuse 

for drinking again. He says it was pretty easy 

to stop drinking then and would be now. He 

claims he has no withdrawal symptoms and is 

“healthy as a horse.” 

He agrees, however, to participate in the program because his job is in jeopardy.

When asked about Tom’s drinking, his wife, 

Gloria, reports that he actually consumes 

11⁄2 to 2 six-packs a day and 20 or more 

beers per day on weekends. She’s certain of 

this because she “picks up after him every 

night” after he falls asleep in his chair. She’s 

been complaining and worrying about Tom’s 

drinking for years and begged him to get 

help. She reports that his teenage daughter complains of how “mean” he gets when 

drinking. There has been no violence, but he 

shouts at the girl a lot. Gloria observes that 

Tom has “terrible shakes” in the morning 

until he has a beer. She recalls that he was 

pretty blue and unhappy when he stopped 

drinking and “couldn’t sleep, either.” She 

has begged him to go back to the doctor and 

says Tom never mentioned his “liver problems” to her before. 

Ambulatory Detoxification

Gloria provides a more accurate description 

of Tom’s drinking pattern and confirms both 

his physiological dependence and the possibility of underlying depression. She appears 

to be supportive of her husband although 

distressed by his continued drinking and its 

effects on the family.

Asked to stretch out his arms, Tom has slight 

but visible tremors in his hands and fingers. 

A Breathalyzer test at 9 a.m. yields a reading 

of .10 mg%, indicating his BAL last night at 

9 p.m. when he drank his last beer was an 

estimated .34 mg%.

The estimated BAL for last night is consistent with the DWI report and documents a 

high tolerance.

Tom is asked to submit an observed urine 

sample.

He is assigned a counselor who performs 

a thorough assessment. Over the next few 

weeks, the counselor and Tom develop a 

treatment plan.

All newly admitted clients provide a urine 

sample.

The counselor administers the CIWA-Ar, and 

a physician’s assistant conducts a brief exam 

and draws blood for new liver function tests. 

The counselor discusses the results of the 

assessments with Tom and Gloria and clearly 

explains Tom’s assessed need for

Staff members determine that Tom can be 

detoxified safely on an outpatient basis. He 

agrees to remain on site during the day for 

monitoring, and he has a responsible wife 

who can drive him home and monitor him.
50 Chapter 4

Case Presentation Commentary

supported detoxification and the program’s 

ambulatory detoxification process. The 

counselor also discusses the program’s policy 

of encouraging all clients to begin taking 

disulfiram as soon as possible. The counselor 

ascertains that no contraindications exist for 

Tom, explains the mechanism by which disulfiram works, and provides Tom and Gloria 

with written information. Tom agrees to 

begin taking disulfiram once the medication 

is approved by his physician.

Tom is given 50 mg of chlordiazepoxide 

(Librium®) that will be repeated every hour 

until he appears mildly sedated. He takes 3 

doses on the first morning.

Clients with CIWA-Ar scores in the low 20s 

have been detoxified successfully with this 

protocol in this setting.

Tom attends his first group meeting in the 

morning. In the afternoon when there are 

no group meetings, Tom watches TV, reads, 

or sleeps in a lounge chair in a quiet room 

where he can be observed by the medical 

staff. 

At 2 p.m., when his regularly monitored BAL 

reaches 0, Tom is given 125 mg of disulfiram. 

(For this program’s protocol, see appendix 

4-B.)

By 4 p.m., Tom is feeling very anxious again 

and is given another 50 mg of chlordiazepoxide, which relieves his symptoms. He is asked 

to sit through another 3-hour evening group 

session and have his wife pick him up at 8:30 

p.m. when the program closes.

Immediate introduction to group treatment 

on the day of admission circumvents resistance to treatment beyond detoxification. It 

also allows group members to see the client 

at his worst so he cannot deny the severity of 

his withdrawal reactions once he is sober.

As he leaves for home, Tom is given three 

50 mg doses of chlordiazepoxide to be taken 

hourly at bedtime until he falls asleep. He 

and Gloria are reminded that he has disulfiram in his system and should not drink.

Clients are given 50 mg doses of take-home 

chlordiazepoxide for up to 3 nights, but the 

medication is under the control of a responsible family member. The number of pills 

supplied should be monitored carefully. If 

the client has a history of dependence on 

sedatives, such medications are not appropriate for unmonitored administration.

The next morning, Tom reports that he 

needed only two doses of chlordiazepoxide 

to sleep, and he returns the extra dose. He is 

given another 125 mg of disulfiram. He is not 

given chlordiazepoxide during the second
Services in IOT Programs 51

Case Presentation Commentary

day but is given two more 50 mg doses for 

the second night. He needs only one and 

returns the other. On the third night, Tom 

takes home one dose of chlordiazepoxide but 

returns it the next day.

Stage 2: Early Recovery

On the third day, Tom returns to his fulltime job. Because Tom works days, he is 

scheduled for the evening program, which 

he will attend on the next 5 weekdays for 3 

hours each session. He will be scheduled for 

one individual session with his primary counselor each week. In addition to providing 

treatment planning and individual counseling, his counselor will provide ongoing case 

management. The hospital’s social workers 

are available to assist the counselor with 

Tom’s case management needs if necessary.

Clients who work days attend evening sessions. The 3-hour psychoeducational group 

sessions have a standard format: the first 

hour consists of a structured group during 

which each of the 6 to 14 members is asked 

individually to report significant emotional 

or behavioral events since the last meeting (e.g., moods, sleep patterns, activities, 

AA attendance, stress, cravings); a second 

hour is devoted to a modified form of group 

therapy that focuses on issues of particular 

relevance to members and encourages their 

interactions; and a third hour consists of 

didactic instruction on such relevant topics 

as medical aspects of addiction and relapse 

prevention techniques. All nondidactic 

groups are co-led by trained staff.

On the third day, a staff member gives Tom 

a prescription for 250 mg daily of disulfiram 

to fill at the hospital pharmacy. He will selfadminister disulfiram at the start of each 

evening’s group session. He will receive a 

double dose on Fridays to last through the 

weekend.

All clients who abuse alcohol are encouraged 

to take disulfiram throughout the rehabilitation phase. It has been found to be a useful 

adjunct for helping all clients who drink—

whatever other drugs they use—to achieve 

and maintain abstinence.

When told that his initial urine came back 

positive for marijuana, Tom acknowledges that 

he smoked a joint with friends last weekend. To 

deter further use of illicit substances, he must 

now submit observed urine samples frequently 

and randomly. His counselor also informs Tom 

that his liver function test results are back 

and that his levels are elevated. The counselor 

schedules an appointment for Tom to meet with 

a physician to discuss the implications of these 

results.

The reasons and circumstances for Tom’s 

use of marijuana—as well as alcohol—will 

be explored in the group. The program has 

a policy of total abstinence from all moodaltering drugs, and clients are expected to 

report any use of prescription or other substances before they are discovered by urine 

toxicology studies.

After five sessions, Tom’s schedule is tapered 

to 4 evenings a week because he seems to be 

responding well to the group and is participating actively. He got through 1 weekend
52 Chapter 4

Case Presentation Commentary

without too much difficulty and reports 

sleeping well and attending two AA meetings per week with a buddy from work. At 

the end of the second week, Tom reports 

that both his wife and daughter are proud of 

him—everything seems rosy.

During the third week of treatment, however, Tom begins feeling depressed—with 

early morning wakening and loss of appetite. 

When a score of 25 on the Beck Depression 

Inventory reveals that he is moderately 

depressed, Tom’s counselor meets with him 

and assures him that it is not unusual for 

people in early recovery to feel depressed 

and to have trouble sleeping. They discuss some things Tom can do to manage his 

depression, such as starting a moderate 

exercise program. The counselor gives Tom 

a relaxation tape that he can use at night to 

help him fall asleep easier and encourages 

him to report any new symptoms or worsening of his depression immediately.

Although it is not uncommon for psychiatric symptoms to emerge within the first few 

weeks of abstinence, clients may experience 

protracted abstinence withdrawal, which 

can cause similar symptoms. This program’s 

policy is to manage mild-to-moderate symptoms nonmedically at first and to monitor 

the client carefully. Depending on the severity of the symptoms, an immediate referral 

for medication management of depression or 

for an appointment with a psychiatrist could 

be appropriate.

Tom also reports having some “really good” 

family times at baseball games over the weekends. He’s pleasantly surprised at what a 

nice kid his daughter can be, although he’s 

had a few arguments with her about the TV 

shows she prefers and the boy she has been 

dating. Gloria has been coming regularly to 

the relatives’ support group and attended an 

Al-Anon meeting last week.

Tom’s wife and daughter are encouraged 

to attend a weekly support group for relatives and significant others. This relatives’ 

support group meets separately for 2 hours, 

and then participants join the clients for the 

third hour of didactic substance abuse education. No additional charges are incurred 

for family members’ attendance at support 

groups. Relatives also are encouraged to 

attend Al-Anon or Alateen meetings.

Nevertheless, at 5 weeks into treatment Tom 

reveals to his counselor that he and his wife 

are increasingly in conflict, but he’s uncomfortable discussing his marital problems in 

group. With Tom’s permission, the counselor 

schedules several sessions with Tom and his 

wife to discuss these issues and assess the 

need for referral for marriage counseling.

During individual sessions, the counselor 

continues to assess clients’ personal problems, helping them sort out issues related 

to their clients’ (and their families’) early 

adjustment to a recovery lifestyle. The counselor may need to address a client’s issues 

of shame, guilt, sexual functioning, or childhood trauma if these issues appear to be 

interfering with the client’s recovery.

Tom reports increasing feelings of sadness, 

irritability, and lack of energy. He says he 

has tried to exercise more, with some success, but often is “too tired.” He has used the 

relaxation tape every night and says that it

The counselor continues to assess and monitor other medical or psychiatric conditions 

that may require more a detailed evaluation, 

counseling, or referral to outside resources.
Services in IOT Programs 53

Case Presentation Commentary

helps “sometimes” but that he still is having 

significant problems sleeping. He has missed 

two group sessions in the last 2 weeks and 

is participating less in the group sessions he 

does attend. Tom’s counselor schedules an 

appointment for Tom with the program’s 

psychiatrist for further evaluation.

The psychiatrist meets with Tom and decides 

that Tom’s current level of depression should 

be managed medically. He prescribes antidepressant medication and discusses with Tom 

possible side effects and when he can expect 

to begin feeling the effects of the medication. 

The psychiatrist schedules followup appointments with Tom.

Tom continues to attend group sessions 4 

days a week for another 4 weeks. By 3 weeks 

after starting the antidepressant he is participating actively, reports feeling much better, 

and is positive about his recovery. He attends 

AA three times a week and has a sponsor. He 

reports that he has not used marijuana, and 

urinalysis supports his self-report.

At this point, program staff members assess 

that Tom is progressing well enough to step 

down his group treatment to two times per 

week and individual counseling to every 

other week.

The program’s consulting psychiatrist is 

readily available to meet with Tom and 

assess his need for medication. The psychiatrist meets regularly with Tom to monitor 

his medication and answer any questions he 

may have.

Stage 3: Maintenance

In week 11, while participating in the rehabilitation phase, Tom begins attending a 

2-hour continuing care group that meets 

in the same facility once a week in place of 

one of his rehabilitation phase groups. He is 

assigned to a group of mostly other professional people. Tom already knows a few of 

the members who transitioned earlier from 

the rehabilitation group; his counselor is a 

co-leader of the new group. The meeting format is familiar, consisting of group therapy 

but no more didactic presentations. The 

break between the two parts of the meeting 

becomes a time for group members to talk

A 2-week overlap between early recovery 

and maintenance groups eases the transition to the longer term, stepdown treatment 

phase at the same site. If possible, clients are 

placed in more homogeneous groups whose 

members have similar interests and values. 

Bonding and trust among group members 

become important in this phase as participants give one another constructive feedback 

and model techniques of daily living that 

prevent relapse.

At the point of transition to the maintenance 

phase, Tom has been abstinent for more
54 Chapter 4

Case Presentation Commentary

frankly and share perspectives about the 

therapeutic process. After 2 weeks of overlap, Tom steps down to attending only the 

once-per-week maintenance group. At this 

point, Tom is given his disulfiram prescription to take on his own at home.

Tom adjusts well to his continuing care group 

and attends regularly for about 2 months. 

When he catches a bad cold, however, he 

calls in sick—just before the Christmas 

holidays. After Tom misses another session 

without reporting in—and his wife also stops 

coming to the relatives’ support group— 

Tom’s counselor telephones him at home.

than 10 weeks, has started a regimen of antidepressant medications, has attended AA 

meetings regularly, has learned a great deal 

about alcoholism and substance abuse, and 

has begun to identify and understand the 

emotional triggers for his drinking and the 

negative influence that a circle of friends at 

work has on him. He is trying to implement 

several important lifestyle changes and has 

taken on more responsibility for his own 

recovery.

Tom acknowledges that he has “slipped” and 

has been drinking on a daily basis for 7 days. 

He stopped taking disulfiram about a month 

after he joined the continuing care group, 

thinking he could “handle it.” He has drifted 

away from AA meetings. Now, Tom says, 

he has missed the last 2 days of work and is 

afraid his supervisor suspects the reason. 

Tom promises to return to the program the 

next day with his wife to discuss what to do. 

After Tom acknowledges that he has “messed 

up” because of overconfidence and the 

stress of the holidays, he is returned to the 

rehabilitation phase, attending 4 evenings a 

week and taking disulfiram again at the start 

of each session. He is expected to continue 

attending his weekly continuing care group, 

resume attending AA meetings, and reconnect with his sponsor.

It is not unusual for clients to relapse, at 

least briefly, after they are comfortable, 

think they no longer need treatment, and 

stop believing recovery is a lifelong process. 

This is a predictable event, especially among 

people who are in treatment for the first 

time. It can be difficult for them to accept 

that a substance use disorder is a chronic 

condition, requiring lifelong care.

The intensity and duration of the response 

to a slip or relapse—a return or step-up to the 

rehabilitation phase—depend on a client’s 

reactions. Each client must understand how 

and why the relapse occurred and not blame 

others. Clients should be acknowledged 

for interrupting their relapse quickly and 

returning to treatment voluntarily. This can 

mark a turning point in clients’ understanding of their condition and recovery needs.

After Tom attends 11 of the 3-hour rehabilitation sessions over a period of 3 weeks, 

program staff members agree that Tom is 

“back on track” with an increased appreciation for the long road of recovery. He returns 

to his regular schedule of weekly continuing 

care group and AA meetings.

Stage 4: Discharge to Continuing 

Community Care

The program covers the costs of this more 

intensive relapse intervention as part of its 

regular charges.

Planning for discharge begins early in the 

continuing care process. After 3 months in

Although treatment may continue at the program for as long as 11⁄2 to 2 years, only a
Services in IOT Programs 55

Case Presentation Commentary

the continuing care group, Tom’s primary 

counselor refers him to a local psychiatrist 

for continued medication management. Tom 

is asked to prepare a plan for maintaining 

his recovery following discharge from treatment. He reports the following plans for 

ongoing community care to members of his 

group for their approval:

minority of clients actually stay that long.

Other clients leave earlier—on average, after 

about 25 weeks of continuing care. They 

are, however, encouraged to announce their 

plans in advance and receive clinician and 

group member endorsement. The goal is for 

them to leave with a realistic plan for 

ongoing recovery.

Continue to attend AA meetings four to five 

times weekly and maintain regular contact 

with his sponsor.

Encourage Gloria to continue attending AlAnon meetings.

Join an AA club’s bowling league team as a 

substitute for occasional “nights out” with 

rowdy drinking buddies at work who also 

smoke pot.

Continue to attend the church that he and 

Gloria have joined and continue to participate in a couples group that is part of 

their pastoral counseling services—with 

the understanding that referral to a private 

therapist may be indicated.

Continue his antidepressant medication 

and meet regularly with his psychiatrist for 

medication management.

Consider courses he might take that would 

qualify him for a promotion to a supervisory position at work. 

After 6 months of continuing care, Tom is discharged from active treatment. He will receive 

support calls every 6 months for 3 years.

•

•

•

•

•

•
56 Chapter 4

After detoxification, some IOT clients benefit 

from receiving drugs that help them remain 

abstinent and resist relapse. Disulfiram 

is appropriate for clients who are alcohol 

dependent, including clients whose alcohol 

dependence is combined with cocaine use and 

methadone clients who have alcohol problems.

Disulfiram interferes with the normal 

metabolism of acetaldehyde, an intermediary product in the oxidation of alcohol, and 

precipitates an unpleasant physical reaction 

if alcohol is consumed within 12 hours to 

7 days (depending on dose) after taking the 

drug. Within several minutes of a person’s 

drinking alcohol, the disulfiram reaction 

begins, with facial flushing followed by 

throbbing headache, tachycardia, increased 

respirations, and sweating. Nausea and vomiting usually occur within 30 to 60 minutes, 

sometimes accompanied by hypotension, 

dizziness, fainting, and collapse. The whole 

reaction can last for 1 to 3 hours and is sufficiently unpleasant to discourage most clients 

from drinking while taking disulfiram.

Some physicians recommend waiting 4 to 

5 days after a client is alcohol free before 

initiating disulfiram treatment (CSAT 

1997a). The Physicians’ Desk Reference

(2003) instructs physicians not to administer disulfiram until 12 hours after the last 

drink. The IOT consensus panel finds that 

careful monitoring of clients’ BALs achieves 

the same effect—assurance that no alcohol 

exists in the system. Exhibit 4-8 outlines the 

protocol for ambulatory detoxification and 

disulfiram induction. Low doses (125 mg) 

of disulfiram can be administered as soon 

as a client’s BAL reaches zero—usually on 

the day of admission. The consensus panel 

recommends that clients who are alcohol 

dependent receive disulfiram as soon as they 

are detoxified rather than jeopardize their 

abstinence by waiting for a liver function test 

to be conducted. If needed, testing for liver 

Appendix 4-B. Induction Protocol for Disulfiram

Exhibit 4-8 

A Protocol for Ambulatory Detoxification and Disulfiram Induction

Source: G. Kolodner, M.D., personal communication, 2003.

First day: Chlordiazepoxide 50 mg hourly until anxiety is relieved—50 mg to 300 mg

When BAL = 0: Disulfiram 125 mg*

First night: Chlordiazepoxide 50 mg at bedtime;† repeat hourly x 2 until asleep (3 

doses provided)

Second day: No medication

Second night: Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if not asleep (2 

doses provided)

Third night: Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if not asleep (2 

doses provided)

*Disulfiram is dispensed only at the clinic.

†All unused chlordiazepoxide doses must be returned to the clinic the following morning.
Services in IOT Programs 57

impairment can be done during the 2 to 3 

weeks after starting disulfiram.

Dosage Levels

Some experienced clinicians prefer to prescribe low doses of disulfiram (125 mg) for 

most clients because at this dose the reaction 

to drinking is not as potent or potentially 

dangerous as it would be at a higher dose. 

Other physicians use an initial dose of 250 

to 500 mg of disulfiram. Lower doses are 

appropriate for persons who have some liver 

impairment, small women, and elderly persons. Although no studies exist regarding the 

optimal length of disulfiram treatment, some 

clients have taken the drug for as long as 16 

years (CSAT 1997a). Compliance beyond the 

active treatment phase, however, is a major 

problem.

Episodic use of disulfiram is an effective strategy for clients who want to guard 

against drinking in situations that carry a 

high risk for alcohol consumption. These 

situations might be special events or celebrations where most people are consuming 

alcohol or meetings with friends who are former drinking buddies.

Contraindications and Cautions

Disulfiram is contraindicated for clients with 

acute hepatitis, severe myocardial disease or 

coronary occlusion, chronic lung disease or 

asthma, psychoses, or sensitivity to disulfiram or its derivatives used in pesticides and 

rubber vulcanization. Disulfiram is not prescribed for pregnant women or clients who 

have had a previous allergic reaction. Women 

of childbearing age are warned to use contraception while taking disulfiram because the 

medication might endanger a fetus.

Clients who take phenytoin (Dilantin®), 

isoniazid, or warfarin (Coumadin®) should 

be warned that disulfiram might intensify 

the effects of those medications, requiring 

a reduction in the disulfiram dose. Clients 

taking disulfiram should not take metronidazole (Flagyl®). They should avoid inadvertent 

exposure to the alcohol contained in many 

cough medicines and mouthwashes or emitted by alcohol-based solvents in a closed 

area. Consumption of food that contains 

liquor or wine usually does not cause a 

problem if the alcohol has been evaporated 

during the cooking process. Clients should 

report any allergic reaction in the form of an 

itchy rash, which usually can be controlled 

by lowering the dosage or administering an 

antihistamine.

Monitoring Procedures

Clients taking disulfiram should be monitored a minimum of every 4 months to 

ascertain whether any allergic hepatitis 

requires immediate discontinuation of 

the drug. Other potentially adverse effects 

include optic neuritis, peripheral neuritis, 

polyneuritis, and peripheral neuropathy. 

Mild reactions to the initiation of disulfiram, 

such as headaches and drowsiness, usually 

are transient and dissipate spontaneously 

within a few weeks.

59

5 Treatment Entry 

and Engagement

Entry into intensive outpatient treatment (IOT) for a substance use 

disorder is a complex and critical process for both the client and 

the program. Clients’ motivations to change range from outright 

resistance to eager anticipation. An IOT program’s intake process, 

from initial contacts through ongoing assessments and treatment 

planning, strongly influences whether clients complete admission procedures, select appropriate interventions, and engage in 

treatment.

Early attrition of clients is a pervasive problem in substance abuse 

treatment (Claus and Kindleberger 2002). To address this problem, 

the consensus panel recommends the following in the admission 

process: 

Assessing a person’s readiness for change and applying appropriate strategies to motivate the client to enter and participate in 

treatment

Establishing a collaborative relationship between the clinician and 

client from the start

Identifying and overcoming barriers that discourage the client 

from engaging in treatment

Matching clients to the least intensive and restrictive treatment setting that can support recovery effectively

Developing individualized interventions of variable intensity and 

duration that meet each client’s needs, rather than fitting the person into a predefined program

More is being learned about the complicated interrelationships 

among substance abuse and many other biopsychosocial factors, 

including mental disorders, child abuse and neglect, domestic violence, issues related to physical and cognitive functioning, history of 

trauma, poverty, criminal activities, skill deficiencies, and infectious 

diseases. Many screening and assessment instruments are available 

to ascertain the presence of these factors.

•

•

•

•

•

In This 

Chapter...

Elements of 

Engaging the Client 

in IOT

Collect Screening 

Information

Assessing Barriers 

to Treatment

Crises and 

Emergencies

Components of 

the IOT Admission 

Process

Sample Treatment 

Plans
60 Chapter 5

A major challenge of the admission process 

is to balance a rapid and empathic response 

to a client’s request for treatment with the 

need to obtain information about many 

aspects of the client’s life that can affect the 

treatment response. The need for detailed 

assessment information must not 

impinge on the 

main admission 

activities: to engage 

the individual in 

treatment, ameliorate immediate 

crises, and remove 

barriers to treatment. Attention 

needs to be given 

to clinicians’ interviewing styles and the program’s intake 

procedures, as well as to the content and 

sequence of the screenings or assessments 

conducted. 

Elements of Engaging 

the Client in IOT

The acknowledgment that the provider 

shares responsibility with the client for 

the client’s motivation to change and 

commitment to treatment marks a fundamental shift in substance abuse treatment. 

Treatment engagement can be fostered by

Providing a positive, welcoming 

environment

Adopting effective initial response 

procedures

Preparing for and conducting supportive, 

productive intake interviews

Program Surroundings

The physical layout and ambience of the 

IOT program can influence a person’s commitment to the treatment process (Grosenick 

and Hatmaker 2000).

•

•

•

Create a welcoming 

environment

Programs should do everything possible 

to make the waiting area welcoming and 

comfortable. Staff members or others can 

provide current magazines and recovery literature. A television set can show instructive 

videos. Toys (games, paper and crayons) can 

be provided for small children who accompany potential clients. A bathroom, public 

telephone, and source of water should be 

accessible and clean. A vending machine is 

desirable if people spend much time in this 

space. 

The Americans with Disabilities Act guarantees equal access to treatment for clients 

with disabilities. All program staff members 

should anticipate clients’ needs, be mindful of physical barriers that limit access to 

or use of the program’s facilities, and be 

prepared to make accommodations. Stairs, 

cluttered areas, narrow hallways, doorknobs, 

and even deep pile carpet may restrict the 

movements of clients who use crutches or 

wheelchairs. Clients with disabilities may 

require assistance in arranging transportation and may require more time to get from 

place to place when they are at the treatment 

facility. 

Ensure availability

The facility where new clients are admitted 

should be accessible by public transportation and be open during hours that are 

convenient for them. Information about the 

program should be available by telephone. 

An answering service can provide an ongoing 

message about the program’s location, access 

by public transportation, parking availability, hours of operation, and when a staff 

member is available to answer questions. 

This information also can be listed on a 

program Web site and posted on the clinic’s 

front door.

Abruptness or 

rudeness on the 

part of staff...can 

result in no-shows or 

early dropout.
Treatment Entry and Engagement 61

Communicate cultural 

competence

Often the first thing potential clients notice 

is whether the program seems receptive to 

their ethnic, cultural, or gender identity. 

Posters and pictures of populations served 

by the program, reading materials in various languages, posted announcements of 

workshops and community activities that 

address topics of interest, and staff members who can communicate in the potential 

clients’ languages as well as empathize with 

different cultural attitudes are some accommodations that IOT programs can provide. 

Chapters 9 and 10 discuss other aspects of 

serving diverse populations; chapter 4 of TIP 

46, Substance Abuse: Administrative Issues in 

Outpatient Treatment (CSAT 2006f), discusses how administrators can prepare programs 

for cultural diversity; and the forthcoming TIP Improving Cultural Competence in 

Substance Abuse Treatment (CSAT forthcoming a) addresses this issue as well. 

Reinforce privacy and 

confidentiality

All staff members need to be mindful of clients’ privacy. Clients should never be greeted 

by name in public areas. All interviews need 

to be conducted in a private room. To ensure 

privacy, the intake worker provides the client 

with any forms that need to be completed 

and walks with the individual to a private 

area where the client can fill out the forms. 

It may be necessary to arrange for an interpreter to translate conversations and forms. 

Extensive telephone interviews should be 

conducted from a private or soundproof 

office so that those in the waiting room do 

not overhear conversations.

Initial Response Procedures

An IOT program should review its initial 

response procedures to make sure that it 

receives potential clients in a welcoming way.

Ensure a rapid response

A review of initial response procedures 

should include an examination of how quickly potential clients are engaged by program 

staff and how long the intake procedure 

lasts. Once they have made up their minds 

to seek treatment, some potential clients 

may become apprehensive or afraid if their 

first steps toward recovery are not met with 

support by the program staff. It is important 

for staff members to greet walk-in clients 

and those who telephone promptly and to 

respond knowledgeably to their questions. 

Individuals who leave messages inquiring 

about treatment should be called back as 

soon as possible. 

The initial contact should be limited to an 

hour, with additional time for questions and 

an introduction to the treatment process. 

Detailed assessment usually can be delayed 

until a subsequent session. If intake cannot be completed during the initial contact, 

preliminary information should be collected 

and another appointment should be scheduled at the earliest mutually convenient 

time—preferably within 24 hours.

Convey respect

An important aspect of treatment engagement is making certain that all program staff 

members greet new clients in a respectful, 

friendly, and supportive manner that reflects 

sensitivity to their situations. If a caller 

has to be put on hold, this should be communicated in a pleasant voice. Abruptness 

or rudeness on the part of staff, no matter 

how busy the program or what emergency 

occurs, can result in no-shows or early dropout. (See chapter 3 of TIP 46, Substance 

Abuse: Administrative Issues in Outpatient 

Treatment [CSAT 2006f], for a discussion of 

training staff in customer service skills.)

Intake Interviews

Intake interviews may require a variety of 

approaches to ensure that potential clients 

feel connected to the treatment program. 
62 Chapter 5

These interviews should be used to collect 

screening information and lay the groundwork for treatment. Intake interviews should 

be conducted by counselors or staff members 

trained in intake procedures.

Use informal approaches for 

initial interviews

Potential clients who spend their first hours 

in an IOT program answering a series of 

structured questions in a formal interview 

are unlikely to reveal their personal problems or to become engaged in the process 

(Miller and Rollnick 2002). Research and 

anecdotal evidence suggest that other, less 

formal approaches are important for building rapport between the counselor and client 

and documenting important information. 

One such approach is the sandwich technique, in which a standard screening and 

assessment are “sandwiched” between two 

less formal discussions that focus on finding 

out the individual’s views, gaining cooperation, and defusing potential resentments or 

hostilities.

During the first 15 to 30 minutes of the 

interview, a counselor

Solicits the client’s perceptions of problems that brought him or her to 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

At this point, the counselor switches from 

a casual and conversational tone to a more 

directive tone as formal screening and 

assessment are conducted.

The counselor can offer an explanation such 

as, “We started talking rather informally 

about what brought you to treatment. Now, 

we need to shift gears and complete some 

forms to gather more detailed information. 

When we are finished, we can go back to dis-

•

•

•

•

•

cussing questions you still may have about 

treatment and this program.”

When summarizing findings and beginning 

to plan treatment, the counselor needs to 

use strategies that are appropriate to the 

client’s change stage. For the final portion 

of the intake, the counselor can focus on the 

individual’s expectations for treatment.

A less structured interview method uses a 

genogram for gathering information about 

the individual and his or her familial relationships (CSAT 2004c). A more detailed 

explanation of the family genogram, along 

with a sample, is included in chapter 6 of 

this TIP.

Adjust interviewing styles

Much attention has been given to the critical 

role that motivational interviewing plays in 

treatment engagement and retention (CSAT 

1999c). Appropriately solicitous approaches 

increase the likelihood that intake interviews 

elicit accurate information from potential clients. Such approaches also foster a 

productive working alliance between the 

counselor and the potential client that can 

enhance the client’s impetus to change and 

engage in treatment. Exhibit 5-1 presents 

effective interviewing styles based on TIP 

35, Enhancing Motivation for Change in 

Substance Abuse Treatment (CSAT 1999c), 

and input from the consensus panel.

Collect Screening 

Information

During the initial contact, sufficient information needs to be collected from the client 

to determine whether to continue the admission process or make an immediate referral 

to a more appropriate facility. No one seeking treatment should be turned away from 

the program without a referral to a specific 

person at another service facility.
Treatment Entry and Engagement 63

Record Basic Information

The following information often is documented on an intake form:

Name, age, and gender to establish identity and determine whether other special 

arrangements or interventions are needed 

(e.g., if the person is a minor). Some programs require a valid identification such 

as a driver’s license, birth certificate, or 

passport.

The referral source, if any, and supporting 

documentation of the need for treatment. 

It is important to note whether treatment 

is sought voluntarily or mandated formally 

by an organization that expects periodic 

reports and whether the potential client 

has consented formally to this arrange-

•

•

ment. (For information on the importance 

of obtaining signed consent agreements 

before any reports are made, see The 

Confidentiality of Alcohol and Drug Abuse 

Patient Records Regulation and the HIPAA 

Privacy Rule [CSAT 2004b].)

The individual’s perspective on why treatment is needed and any crises that may 

require immediate attention.

Pertinent medical conditions. 

Any suicidal or other violent thoughts.

The person’s usual residence to determine 

whether the individual lives in a designated catchment area, if required, as well as 

the stability of living arrangements, proximity to the program, and how this might 

affect attendance or transportation.

•

•

•

•

Exhibit 5-1

Effective Interviewing Techniques

Begin with a brief overview of the topics to be covered, the expected duration of the 

interview, and confidentiality requirements.

Ask the least threatening questions first.

Listen attentively and reflectively. Restate what the individual said to determine the 

level of understanding. Provide enough time for the individual to express himself or 

herself.

Support self-efficacy by communicating that the individual can change, make autonomous decisions, and act in his or her best interests.

Affirm the strengths, and compliment the positive values of the client.

Explain everything that is happening or planned in treatment, and allow time for 

questions.

Ask open-ended questions that cannot be answered with a one-word response to encourage the individual to talk, describe feelings, and express opinions.

Convey empathy through voice tone, facial expression, and body language as well as 

with direct expressions of caring.

Observe the client for nonverbal expressions of feelings that may either be inconsistent 

with or confirm what the individual is saying.

Avoid argument, remain nonjudgmental, and adjust to any resistance.

Probe gently to clear up discrepancies and inconsistencies.

Be completely candid and honest.

Help the client move beyond anger, resentment, frustration, or defensiveness; even 

if the individual does not return, this single contact can be a constructive, positive 

influence.

•

•

•

•

•

•

•

•

•

•

•

•

•
64 Chapter 5

The substance use disorder and its severity, including types and amounts of substances consumed, presenting signs and 

symptoms, and potential for withdrawal. 

Appendix 5-A (page 84) has a sample form 

that can be used to document the current 

substance use pattern and can be completed during a subsequent interview. More 

detailed information can be collected later.

Elapsed time since the most recent substance abuse treatment episode; what type 

of treatment or level of care was used and 

why it ended, especially if there are restrictions on readmission.

Other information that may be germane to 

treatment, scheduling, and special arrangements such as

Employment hours and work location

Next of kin or person to contact, with 

advance consent, to locate the client

Number and ages of dependent children 

living with the client

Date of the individual’s most recent 

physical examination and name of 

the primary care physician who can, 

with legal permission, release medical 

information

Primary language spoken, understanding 

of English, and literacy level

Use Short Screening 

Instruments To Document a 

Substance Use Disorder

Several short screening instruments are 

available and may be used to document the 

presence of a substance use disorder that 

later may be confirmed with a diagnostic 

interview. 

Not all screening instruments perform 

equally well for specific populations. A 

study comparing the effectiveness of eight 

frequently used screening instruments 

for ascertaining substance use disorders 

used the Structured Clinical Interview for 

Diagnosis of DSM-IV, Version 2, Substance 

Abuse Disorders module (Peters et al. 2000), 

•

•

•

–

–

–

–

–

a well-accepted, comprehensive diagnostic 

criterion for measuring substance-related 

disorders. The study found that only three 

instruments had high rates of accuracy, 

positive predictive value, and sensitivity, 

in addition to the capacity to distinguish 

between substance abuse and dependence 

disorders. These three instruments are 

The Center for Substance Abuse 

Treatment’s Simple Screening Instrument 

(reproduced in TIP 11, Simple Screening 

Instruments for Outreach for Alcohol and 

Other Drug Abuse and Infectious Diseases 

[CSAT 1994f])

A combination of the Alcohol Dependence 

Scale and the Addiction Severity Index 

(ASI)-Drug Use Subscale (see appendix 5-B 

for more information)

Texas Christian University Drug Screen 

(see appendix 5-B for more information)

Other widely used simple screening instruments are the CAGE Questionnaire, the 

Short Michigan Alcoholism Screening 

Test, the Offender Profile Index, and the 

Substance Abuse Screening Instrument. Each 

instrument is in the public domain, and there 

is no cost for reproduction and use. TIP 11, 

Simple Screening Instruments for Outreach 

for Alcohol and Other Drug Abuse and 

Infectious Diseases (CSAT 1994f), provides 

information on these and other screening 

instruments. Additional resources for screening tools include Assessing Alcohol Problems: 

A Guide for Clinicians and Researchers (Allen 

and Columbus 1995), Assessing Drug Abuse 

Among Adolescents and Adults: Standardized 

Instruments (National Institute on Drug 

Abuse 1994), and Diagnostic Source Book 

on Drug Abuse Research and Treatment

(Rounsaville et al. 1993).

Assessing Barriers to 

Treatment

During an initial contact, the counselor 

should be alert to any barriers the individual 

may face when entering treatment. 

•

•

•
Treatment Entry and Engagement 65

Intoxication or Withdrawal

Although some individuals stop consuming 

all abused substances a few hours or days 

before coming to the facility, others arrive 

at the IOT program shortly after ingesting a 

“last” dose of a substance. Intake staff must 

be able to recognize and know how to handle 

persons who are severely intoxicated, are 

manifesting signs of withdrawal from physical dependence on alcohol or drugs, or are 

at risk of developing such symptoms. Staff 

members need training and a protocol for 

determining when the intake process needs 

to be suspended until (1) such symptoms can 

be alleviated or allowed to remit spontaneously and (2) the individual can cooperate 

productively or return safely to the community. A severely intoxicated individual may 

be unable to provide accurate responses to 

intake questions, and the person’s symptoms 

may mask a serious medical condition. 

Staff members should note the potential 

client’s behavioral and physical signs of 

intoxication and evaluate them against the 

individual’s report of recent substance use. 

If discrepancies exist between the reported 

consumption patterns and signs of incoherence, drowsiness, or stupor, staff members 

should consider that a physical symptom 

could be the result of head injury, infections, 

diabetes, overdose, or some other cause. At 

a minimum, the program should be able 

to conduct a brief physical examination, 

assess vital signs, and document evidence 

of acute intoxication or potentially serious 

withdrawal symptoms. Persons whose level 

of consciousness is decreasing require urgent 

medical evaluation in a medical setting.

Each IOT program needs guidelines that 

indicate whether sick or intoxicated persons 

can be observed and assisted at the facility, 

should be transferred immediately to a more 

intensive level of care (e.g., detoxification 

facility, hospital emergency room), or are 

ready to return home. IOT program medical 

staff members must make the decision about 

who can be admitted safely. If medically 

trained staff members are unavailable on 

site to assess clients and to make these decisions, the IOT program should have access 

to immediate medical consultation or emergency treatment. Direct affiliations must be 

in place with other levels of care in the local 

alcohol and drug treatment system and with 

mental health facilities. If clients are too sick 

or intoxicated to transport themselves, the 

IOT program must arrange safe transportation home or to another treatment facility.

Acute or Chronic Medical 

Conditions 

During intake, all individuals need to be 

screened for potential medical emergencies. 

Those with unexplained acute symptoms 

(e.g., pain, altered consciousness, disorientation, delirium) need to be referred for 

medical evaluation. All applicants need to be 

asked about diagnosed medical conditions, 

onset of serious symptoms, previous head 

injury, recent hospitalizations for major 

medical problems, and medications they are 

taking. 

Psychiatric Stability

Individuals with mental disorders are at high 

risk for self-destructive and violent behaviors. Because use of alcohol and drugs can 

be associated with psychiatric symptoms and 

disorders, interrelationships between the 

substance use and the psychiatric symptoms 

should be considered in the screening process (Brems et al. 2002; Carey and Correia 

1998; Scott et al. 1998). The IOT clinician 

needs to be alert to any evidence of bizarre 

or acutely paranoid thinking, threats to 

harm oneself or 

others, disorganized thoughts, 

or delusions and 

auditory hallucinations. Individuals 

with such symptoms should be 

asked about any 

history of violent 

During intake, all 

individuals need to be 

screened for potential 

medical emergencies.
66 Chapter 5

or suicidal behavior, previous psychiatric 

hospitalization, current treatment of mental 

disorders, prescribed psychotropic medications, and whether these medications are 

being taken at recommended doses and 

times.

A simple ABC model that can help intake 

personnel detect overt signs of psychiatric 

disorders is shown in exhibit 5-2.

Physical Disabilities or 

Cognitive Limitations

The consensus panel recommends that 

IOT programs conduct early screening for 

physical, sensory, and cognitive disabilities 

because these conditions may affect clients’ ability to participate in treatment. 

Modifications in the treatment regimen or 

environment can help these clients function 

well in treatment.

A brief examination of cognitive functioning 

is recommended for individuals who appear, 

for unexplained reasons, to be disoriented 

with respect to time, place, or person or to 

have memory problems or language disturbances. Many clinicians use the Mini-Mental 

State Examination (MMSE) (Folstein et al. 

1975) for this purpose. The MMSE can be 

ordered at www.minimental.com. Cognitive 

impairment can limit the utility and accuracy of such frequently used assessment 

instruments as the ASI. Additional screening instruments for use with individuals 

with physical and cognitive disabilities are 

identified in TIP 29, Substance Use Disorder 

Exhibit 5-2

ABC Model for Psychiatric Screening

Adapted from CSAT 1994b, p. 16.

Appearance, Alertness, Affect, and Anxiety

Appearance: How are general hygiene and dress?

Alertness: What is the level of consciousness? Confusion?

Affect: Are there signs of elation, anger, or depression in gestures, facial expression, 

and speech?

Anxiety: Is the person nervous, phobic, or panicky?

Behavior

Movements: Is the person hyperactive, hypoactive/subdued, abrupt, agitated, or calm?

Organization: Is the person coherent and goal oriented?

Purpose: Is behavior bizarre, dangerous, impulsive, belligerent, or uncooperative?

Speech: What are the rate, coherence, organization, content, and sound level?

Cognition

Orientation: To person, place, time, and condition

Calculation: Memory and capability to perform simple tasks

Reasoning: Insight, judgment, and problemsolving abilities

Coherence: Delusions, hallucinations, and incoherent thoughts

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–
Treatment Entry and Engagement 67

Treatment for People With Physical and 

Cognitive Disabilities (CSAT 1998e), and TIP 

31, Screening and Assessing Adolescents for 

Substance Use Disorders (CSAT 1999d).

Crises and 

Emergencies

Counselors need to be alert to any crises that 

threaten clients’ safety or the safety of those 

around them.

Potential for Violence or 

Suicide 

A brief psychiatric evaluation should be 

completed to determine the potential risk of 

violence or suicide or the presence of psychosis. A full psychiatric evaluation should 

proceed only after withdrawal and lingering withdrawal effects have passed. TIP 43, 

Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs 

(CSAT 2005b), discusses risk factors for violence and suicide and recommends measures 

treatment programs can take.

Immediate Threats to the 

Client’s Safety

IOT program staff members need to be alert 

to any immediate threats of violence to staff 

or clients. The close association between 

domestic violence and substance abuse 

has become clearer and better documented 

in recent years (CSAT 1997b). It is now 

recognized that individuals’ unexplained, 

evasively acknowledged, or untreated injuries—especially to the face, head, neck, 

abdomen, or breasts—may indicate battering. 

Chronic headaches, depression, recurrent 

vaginal infections, abdominal or joint pain, 

sexual dysfunction, or sleep and eating 

disturbances also may indicate domestic 

violence (Naumann et al. 1999). Reports of 

child abuse by a spouse or significant other 

should raise concerns about related abuse of 

the concerned parent.

Suspicions of immediate danger should be 

investigated at the initial contact by asking questions such as, Do you feel safe at 

home? Do you feel safe in your current relationship? Is someone threatening you now 

or making you feel unsafe? The program 

should have arrangements with appropriate shelters, domestic violence counselors, 

and experts in forensic evidence who can 

be consulted about appropriate protection 

and safety plans (CSAT 1997b). TIP 25, 

Substance Abuse Treatment and Domestic 

Violence (CSAT 1997b), provides additional 

information.

Components of the 

IOT Admission Process

Admitting a potential client to substance 

abuse treatment entails 

Establishing the individual’s eligibility, 

which involves validating the suitability of 

the program’s services for the individual 

and assessing the individual’s readiness to 

change

Initiating treatment, which may involve 

detoxification, providing an orientation to 

the program, and addressing immediate 

barriers to treatment

Conducting a comprehensive biopsychosocial assessment 

Conducting a multidimensional 

assessment

Summarizing assessment findings

Developing an initial individualized treatment plan

Although treatment entry can be a straightforward procedure, treatment staff members 

should be understanding and willing to 

adapt the intake procedure for clients who 

have complicated problems and living situations. Treatment evolves with the results 

of ongoing assessments that both monitor 

the client’s progress and identify new or 

reemerging problems.

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68 Chapter 5

Eligibility

After screening individuals for substancerelated disorders and problems that could 

affect treatment, IOT staff verifies whether 

the IOT program offers a suitable treatment 

intensity and environment to meet clients’ 

needs. IOT programs should be prepared to 

justify the need for the specific services and 

support at admission and as clients progress 

through treatment.

Apply patient placement 

criteria

Criteria for matching clients to appropriate 

settings and services for specific problems 

are available. Attempts to specify placement criteria are designed to individualize 

substance abuse treatment and ensure its 

effectiveness.

The American Society of Addiction Medicine 

(ASAM) developed Patient Placement 

Criteria for the Treatment of Psychoactive 

Substance Use Disorders (PPC) (Hoffman et 

al. 1991). The criteria in this document are 

used widely by providers and a few payers, 

including Medicaid in some States. Research 

shows that the criteria described in ASAM 

PPC are reliable and have predictive validity 

(Gastfriend 1999). 

The most current version, the ASAM PPC2R (Second Edition, Revised) (Mee-Lee et 

al. 2001), separates IOT into two different 

degrees of treatment participation. Level 

II.1: Intensive outpatient treatment requires 

a minimum of 9 contact hours a week, 

whereas Level II.5: Partial hospitalization 

(daycare) involves at least 20 hours weekly 

of structured programming. Exhibit 5-3 provides an overview of the functional deficits 

and problem severity that indicate a client 

should be placed in Level II.1. The criteria 

for partial hospitalization are listed in ASAM 

PPC-2R. ASAM PPC-2R can be ordered from 

the ASAM Publications Distribution Center 

(Box 101, Annapolis Junction, MD 20701-

0101; (800) 844-8948; www.asam.org).

Admission to either of the Level II IOT 

options requires the following: 

A diagnosis of a substance-related disorder 

based on the Diagnostic and Statistical 

Manual of Mental Disorders, Fourth 

Edition (DSM-IV) (American Psychiatric 

Association 1994), or similar criteria (see 

appendix 5-C)

Identification of at least one criterion in 

ASAM PPC-2R dimensions 4, 5, or 6

Meeting the requirements of dimensions 2 

and 3 if biomedical, emotional, behavioral, 

or cognitive conditions or problems exist

The diagnosis of a substance use-related 

disorder is based on findings of the comprehensive assessment, a physical examination, 

and laboratory tests. A diagnosis also may be 

derived from administering specific instruments, such as those described in appendix 

5-B (page 85).

Assess readiness for change

Persons with substance use disorders who 

are not motivated to change may not benefit 

from or participate in intensive treatment 

interventions unless their motivation 

improves. These precontemplators (i.e., those 

who have not yet considered change) and 

contemplators (i.e., those thinking about a 

change in the near future) may require special preparatory counseling that is directed 

at raising their awareness about the negative 

consequences of substance use and generating a commitment to change (Connors et 

al. 2001a; CSAT 1999c). Dimension 4 of 

ASAM PPC-2R assesses individuals’ readiness to change. Programs should consider 

ascertaining individuals’ readiness to change 

before conducting full-scale assessments and 

developing comprehensive treatment plans. 

Several brief instruments are available to 

help staff members rapidly determine a 

client’s readiness to change or motivational 

stage (see exhibit 5-4).

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Treatment Entry and Engagement 69

Exhibit 5-3

The Six Dimensions of the ASAM PPC-2R for Level II.1 IOT

Source: Mee-Lee et al. 2001.

Dimension 1: Acute intoxication or withdrawal potential. Clients who are not experiencing or at risk of acute withdrawal (e.g., experiencing only sleep disturbances) can be 

managed in Level II.1 IOT, provided that their mild intoxication or withdrawal does not 

interfere with treatment. To be managed successfully in Level II.1 IOT, clients should be 

able to tolerate mild withdrawal, make a commitment to follow treatment recommendations, and make use of external supports (e.g., family).

Dimension 2: Biomedical conditions or complications. Clients with serious or chronic 

medical conditions can be managed in IOT as long as the clients are stable and the problems do not distract from the substance abuse treatment. 

Dimension 3: Emotional, behavioral, or cognitive conditions or complications.

Dimension 3 problems are not a prerequisite for admission to IOT. But if any of these 

problems are present, clients need to be treated in an enhanced IOT program that has 

staff members who are trained in the assessment and treatment of both substance use 

and mental disorders. IOT is appropriate for clients with co-occurring disorders who 

abuse family members or significant others, may be a danger to themselves or others, or 

are at serious risk of victimization by others. IOT also is indicated if mental disorders 

of mild-to-moderate severity have the potential to distract clients from recovery without 

ongoing monitoring.

Dimension 4: Readiness to change. The structured milieu of IOT is appropriate for 

clients who agree to participate in but are ambivalent about or engaged tenuously in 

treatment. These clients may be unable to make or sustain behavioral changes without 

repeated motivational reinforcement and support several times a week.

Dimension 5: Relapse, continued use, or continued problem potential. Despite prior 

involvement in less intensive care, the client’s substance-related problems are intensifying 

and level of functioning deteriorating. Appendix C of ASAM PPC-2R (Mee-Lee et al. 2001) 

discusses this dimension in detail and suggests instruments and questions for assessing 

four constructs involved in relapse and continuing use potential: (1) chronicity of problem use or periods of abstinence, (2) positive and negative pharmacological response to 

substances, (3) reactivity to external stimuli, including triggers and chronic stress, and 

(4) cognitive–behavioral measures of self-efficacy, coping, impulsivity, and assumption of 

responsibility or assignment of blame.

Dimension 6: Recovery environment. IOT supervision is needed for clients whose 

recovery environment is not supportive and who have limited contacts with non-substanceabusing peers and family members. These clients have some potential for making new 

friends and seeking appropriate help and can cope with a passively negative home environment if offered some relief several times a week.
70 Chapter 5

Beginning Treatment

Once the individual is determined eligible 

for IOT, detoxification is the first priority. 

When the individual is ready to be admitted 

to the IOT program, a staff member explains 

the treatment program so that the potential 

client can make an informed decision about 

enrollment.

Provide for detoxification

Detoxification, if necessary, should be 

accomplished before a client is admitted into 

the full IOT program. Clients experiencing 

symptoms of mild withdrawal from alcohol, 

sedative-hypnotics, opioids, or stimulants 

can undergo ambulatory detoxification in 

a Level II.5: Partial hospitalization or day 

treatment program (see exhibit 5-5). To 

undertake ambulatory detoxification of these 

clients, IOT programs should offer 20 hours 

of clinical programming per week and have 

direct access to medical services. 

Program staff must determine whether 

detoxification can be accomplished safely on 

an ambulatory basis in an IOT program that 

offers fewer than 10 hours of client contact 

per week and has limited access to medical services. In general, referral to a more 

Exhibit 5-4

Brief Screening Instruments That Assess Motivational Stage

Readiness Ruler is a simple approach that asks respondents to gauge their readiness 

and willingness to commit to change on a scale of 1 to 10.*

University of Rhode Island Change Assessment Scale is a self-administered questionnaire with 32 items that requires about 5 to 10 minutes to complete. Respondents rate 

statements about their substance use from “Strongly Disagree” to “Strongly Agree.” 

Summed items give scores that correspond to the four stages of change (DiClemente 

and Hughes 1990; Willoughby and Edens 1996).*

The Stages of Change Readiness and Treatment Eagerness Scale is a 40-question, written test that requires about 5 minutes to complete and has 5 separately scored scales 

of 8 items apiece that are summed to derive the scale score (Miller and Tonigan 1996; 

Miller et al. 1990).*

Readiness to Change Questionnaire—Treatment Version has 30 alcohol-related questions that can be self-rated on a 5-point Likert scale. A shorter 12-item version addresses only the precontemplation, contemplation, and action stages for hazardous drinkers 

(Heather et al. 1993, 1999).*

Circumstances, Motivation, Readiness, and Suitability Scales-Revised (CMRS) is a factorderived, 18-item instrument that a respondent at a third-grade reading level can selfadminister in 5 to 10 minutes (De Leon and Jainchill 1986; De Leon et al. 1994). The 

revised, copyrighted CMRS is applicable to both residential and outpatient modalities.

More information about the psychometric properties, target populations, scoring, utility, 

ordering, and other references for these instruments can be found at www.niaaa.nih.gov 

by typing “Alcoholism Treatment Assessment Instruments” and clicking on Search.

* Described in detail and reproduced for unrestricted use in appendix B of TIP 35, Enhancing Motivation for 

Change in Substance Abuse Treatment (CSAT 1999c).

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Treatment Entry and Engagement 71

intensive level of 24-hour care should be considered for clients who have been heavy and 

consistent alcohol drinkers or consumers of 

benzodiazepines or sedative-hypnotics or any 

combination of these substances for a period 

of weeks to months and who

Have a slow response (more than 2 hours) 

or allergic reactions to the medications 

used for detoxification

Have unstable vital signs, confusion, or 

delirium

Have serious and unstabilized medical 

disorders (e.g., heart, lung, liver disease; 

seizure disorders; HIV infection)

Are older adults or adolescents

Have a history of serious psychiatric disorders and complications

Have a history of seizures, delirium, or psychosis during previous withdrawals

Have a history of drug overdoses

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Abuse alcohol, sedatives, barbiturates, and 

anxiolytics in combination 

Have an unstable, unsupportive, or unsafe 

home environment without supportive 

friends or relatives to monitor medication use

Withdrawal from alcohol and sedativehypnotics can be life threatening. ASAM 

and other professional groups recommend 

using the Addiction Research Foundation’s 

Clinical Institute Withdrawal AssessmentAlcohol, Revised (CIWA-Ar), to assess and 

monitor the severity of alcohol withdrawal. 

The CIWA-Ar uses a scale of 10 quantifiable signs and symptoms; has documented 

reliability, reproducibility, and validity 

(Sullivan et al. 1989); can be administered 

in 5 minutes by staff members who have 

undergone a 3-hour training; and helps in 

making the decision whether to hospitalize 

the client or treat the client as an outpatient 

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Exhibit 5-5

Mild Withdrawal Symptoms for Four Drug Classes That

 Can Be Managed in Level II.5 Ambulatory Detoxification

Alcohol Mild withdrawal without need for treatment with sedativehypnotics; no hyperdynamic state; CIWA-Ar score of 8; no significant history of morning drinking.

Sedative-hypnotics Mild withdrawal with history of almost daily sedative-hypnotic use; 

no hyperdynamic state; no need for treatment with sedativehypnotics; no complicating exacerbation of affective disturbance; 

no dependence on other substances.

Opioids Mild withdrawal in context of almost daily opioid use but no need 

for substitute agonist therapy; withdrawal symptoms respond well 

to symptomatic treatment; comfortable by the end of the day’s 

monitoring.

Stimulants Mild withdrawal involving lethargy, agitation, or depression; the 

client has sufficient impulse control, coping skills, or support to 

engage in treatment and to prevent immediate continued use.

Source: Mee-Lee et al. 2001.
72 Chapter 5

(Fuller and Gordis 1994). The CIWA-Ar is 

not copyrighted and is available from the 

ASAM’s Web site 

(www.asam.org) by 

typing “Addiction 

Medicine 

Essentials” 

and clicking on 

Search. Appendix 

4-B of this TIP provides additional 

resources for the 

clinician regarding 

ambulatory detoxification. TIP 45, 

Detoxification and 

Substance Abuse 

Treatment (CSAT 2006e), provides additional information on detoxification.

Conduct informal orientation

A preliminary, informal orientation consists of a description of program rules and 

requirements, client’s rights and responsibilities, and confidentiality protections. The 

staff member answers specific questions 

about the anticipated duration of treatment, 

the frequency and length of sessions, and 

the program’s scheduled hours. Many individuals at admission are too distracted by 

the process, nervous about the commitment, 

or focused on their feelings to comprehend 

important details. All important points 

should be communicated again in a more 

formal orientation session or, at a minimum, 

described in brochures or handouts.

Conduct formal orientation

A formal orientation offers an opportunity 

for staff members, including the program 

director, to introduce themselves and 

welcome new clients, reinforce clients’ motivations to remain in treatment, and induct 

clients into appropriate roles. New clients 

need to hear—and believe—that they are 

respected as individuals and will be involved 

in planning their treatment. Although the 

primary treatment objective is to assist 

clients in achieving and maintaining abstinence, clients also need to know that the 

program will help them accomplish other 

positive and realistic goals (e.g., getting off 

probation, regaining child custody, enrolling 

in a vocational school). An orientation also 

should help clients allay any fears they may 

have about treatment. Ample time needs 

to be left in orientation sessions to answer 

questions. Topics for program orientation 

include

The general program philosophy, policies, and services offered. Clients should 

be informed of the program’s treatment 

philosophy, approach (e.g., individual and 

group counseling, psychoeducation, treatment phases), and policies (e.g., family 

involvement, drug testing, discharge criteria). Clients also need to understand how 

the program handles domestic violence, 

intoxication and driving, and the reporting 

of child abuse and neglect and infectious 

diseases. 

The program’s responsibilities to clients.

Confidentiality safeguards, procedures for 

issuing warnings to clients, process available to clients for appealing termination or 

other decisions, client access to staff members, 24-hour crisis assistance, referrals to 

outside agencies and services, availability 

of childcare services, and assistance with 

transportation should be discussed with 

clients. New clients are required to receive 

a written summary of Federal alcohol and 

drug confidentiality regulations. Programs 

subject to Health Insurance Portability 

and Accountability Act rules must provide 

additional information about client rights 

and how to exercise them (CSAT 2004b). 

Clients’ responsibilities to the program.

Clients need to understand their role in 

treatment plans and contracts and appreciate the importance of regular attendance, 

compliance with program and group rules, 

submission of drug-testing specimens, 

timely fee payments, participation in support groups or other community activities, 

and completion of homework assignments.

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Program staff 

should work with 

clients to plan a 

treatment schedule 

around available 

transportation. 
Treatment Entry and Engagement 73

Address immediate barriers 

to treatment entry

Barriers to treatment entry that clients reveal 

during the intake interviews require the 

attention of IOT program staff. In addition 

to the medical and mental health conditions 

discussed above, these barriers may include 

the lack of childcare assistance, transportation, shelter, or food. 

For some individuals, lack of affordable 

childcare assistance and reliable transportation are immediate barriers to treatment 

engagement. If the IOT program does not 

provide onsite childcare services, it should 

maintain a list of community-based childcare groups to which it can refer clients. 

Some programs offer vouchers for clients 

who are unable to afford this care, and some 

provide vouchers for public transportation. 

Program staff should work with clients to 

plan a treatment schedule around available 

transportation. 

A client who is struggling to meet shelter and 

food needs is unlikely to engage in IOT. The 

IOT counselor, through the program’s collaborations with community services, needs 

to connect the client to appropriate resources. After obtaining the client’s consent, 

the counselor can arrange with community 

food banks for emergency food allocations, 

contact emergency shelters or recovery 

housing groups, and contact the local 

social service agency to start the process of 

obtaining temporary financial relief. A case 

manager is helpful in these circumstances. 

Comprehensive 

Biopsychosocial Assessment 

To develop a tailored therapeutic regimen, 

the counselor gathers detailed information 

on substance use patterns and other problems. This broad investigation of multiple 

dimensions of functioning should continue 

throughout treatment. However, the most 

detailed assessment occurs during the comprehensive biopsychosocial assessment. 

Understand purposes of 

assessment

The comprehensive biopsychosocial assessment is the foundation for treatment 

planning, establishes a baseline for measuring a client’s progress during treatment, 

ascertains the relative severity of a client’s 

current problems, and helps set priorities 

for treatment interventions. The comprehensive assessment also identifies the client’s 

strengths that can foster recovery. Repeated 

assessments are important for monitoring 

the client’s progress and adjusting care if 

needed.

Develop assessment methods 

and protocols

IOT clinicians gather evidence about each 

client’s problems through

Clinical observations

Structured and informal interviews

Standardized tests and instruments

Physical examinations

Laboratory drug tests

Medical records from previous treatment 

episodes (with the client’s permission)

Records and reports from referring sources 

(with the client’s permission)

Interviews with spouse, family members, 

friends, and co-workers (with the client’s 

permission)

Most aspects of an individual’s functioning 

can be explored adequately by a few wellchosen questions and observations. Brief 

screening questionnaires help direct more 

detailed assessments. Because this comprehensive biopsychosocial assessment serves 

a variety of purposes for both the client and 

the program, IOT programs need to consider the assessment tools, content, and staff 

training required to administer the instruments competently, as well as the cost of 

purchasing them. To guide the selection of 

appropriate assessments each IOT program 

is encouraged to consider

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74 Chapter 5

The problems most commonly found in 

the population being served (e.g., language 

barriers) and the exigencies of assessing 

the population.

The financial resources that can be devoted to intake and detailed assessments.

The availability of qualified staff members 

to conduct interviews, administer and 

score standardized instruments, or perform physical examinations.

The information needed to identify acute 

problems, enroll a new client, document 

admission, complete required State or 

insurance forms, and provide baseline findings for program performance 

evaluation.

The scientific accuracy, utility, and psychometric properties of selected instruments 

and the availability of normative data or 

cutoff scores for the population being 

served.

The availability of translated materials 

and the ease of use of these materials.

The willingness of referring sources and 

treatment providers to forward requested 

records on a timely basis. The report that 

accompanies a referral (e.g., by a private 

physician, an employee assistance program, children’s protective services, the 

criminal justice system) may contain critical information about how the applicant’s 

substance use disorder was discovered and 

what consequences may ensue if progress 

in treatment is not demonstrated. 

Multidimensional Assessment 

Client records, which are a crucial part of 

multidimensional assessment, may include 

notes from the intake interview, toxicology 

results, reports from the referring agency or 

previous treatment providers, findings from 

other clinicians, self-administered screening tests, and specially ordered diagnostic 

consultations. To round out the assessment, 

some IOT programs design intake screening 

and comprehensive assessment forms, and 

others use standardized, multidimensional 

assessment instruments as the basic admis-

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sion document. The ASI is a commonly used, 

multidimensional assessment instrument 

that can serve as a basic assessment document. Together, these clinical impressions 

and assessment instruments provide the 

foundation for initial treatment plans. 

Using the Addiction Severity 

Index

The ASI generates a profile of a respondent’s 

problem severity in six functional domains: 

medical status, employment and support 

status, alcohol and drug use, legal status, 

family and social relationships, and psychiatric status. The 161-item ASI is useful 

for measuring changes or improvements in 

functional and treatment outcomes. Chapter 

6 of TIP 46, Substance Abuse: Administrative 

Issues in Outpatient Treatment (CSAT 2006f), 

presents a discussion of how the ASI can be 

used for program performance evaluation. 

At the completion of each section in the ASI, 

the respondent is asked to rate from “Not at 

All” to “Extremely” the extent to which he 

or she is troubled by the problem and feels 

a need for counseling or treatment in that 

area. The interviewer rates the severity of 

each problem area on a 10-point scale and 

indicates his or her confidence about whether questions were understood and answered 

truthfully. The instrument has demonstrated 

high reliability and concurrent predictive 

validity (Leonhard et al. 2000; McLellan et 

al. 1992a; Schottenfeld and Pantalon 1999).

Appendix 5-D (page 88) lists areas for further 

exploration within the six domains of the 

ASI and discusses ways to explore other topics that are not included in the six domains 

of the ASI.

Summary of Assessment 

Findings

The process of compiling the assessment 

findings into a report and presenting the 

report to the client leads to the development 

of an individualized treatment plan. 
Treatment Entry and Engagement 75

Compile the summary report

The summary report includes an overview 

of the clinical findings with references to 

admission documents, archival reports, 

findings from screening and assessment 

instruments, laboratory test results, and the 

physical examination. Many IOT programs 

format this summary according to the assessment dimensions of ASAM PPC-2R, the six 

domains of the ASI, or other special problem 

areas (e.g., housing for the homeless, parenting skills for single parents). Regardless 

of the format, the report should facilitate a 

quick review of related problems and aid clinicians and clients in setting priorities.

Present assessment findings 

to the client

The assessment summary is best presented 

in a straightforward manner in language 

that the client understands, with a clear 

interpretation of the significance of the 

findings. It is a good idea to introduce 

information in a motivational style, asking 

for responses and considering the client’s 

verbal or nonverbal reactions without being 

judgmental or confrontational. For example, 

the counselor might say, “It seems that this 

information is distressing you” or “Is this 

what you expected to hear?” The counselor 

should avoid labeling the behavior in a negative way or interjecting opinions. 

The counselor notes which findings seem 

most disturbing to the client. The counselor tries to elicit the client’s reactions to 

the effects of substance abuse on his or her 

health, relationships, and legal and employment statuses. These reactions direct the 

clinician to the problems the client is most 

interested in solving. They also point out 

discrepancies between the client’s values or 

goals and the adverse effects of substance 

abuse. These concerns can be highlighted in 

the treatment process to enhance motivation 

for change.

The Treatment Plan

Formulating a treatment plan is necessary to 

ensure clients’ engagement and initial progress.

Prepare the treatment plan

Once the assessment findings have been 

summarized and discussed, the client—and 

significant others, if appropriate—collaborates with the clinician in developing 

a comprehensive treatment plan. This plan 

identifies the client’s primary problem, individualized goals, and clinical interventions 

designed to achieve these goals (Connors 

et al. 2001a). The order and manner in 

which problems are addressed is tailored to 

each client’s needs. It is not appropriate for 

substance abuse treatment programs to construct one-size-fits-all treatment plans for all 

clients, prescribing interventions to achieve 

goals that reflect the program’s philosophy, 

not necessarily the client’s needs. Although 

the treatment plan may focus on abstinence 

in the early stages of treatment, it addresses 

all noted problems, even though some problems may not be solved until long after the 

client leaves the IOT program. 

An Emphasis on the Client’s Prioritizing Problems

One research study of IOT programs found that longer retention and better treatment outcomes were associated with an early focus on the problems that clients considered most 

important to them (e.g., family relationships, housing, medical conditions). Although these 

results could be interpreted as confirming the observation that clients who do well tend to 

remain in treatment, they show the importance of addressing problems that clients identify 

(Weinstein et al. 1997).
76 Chapter 5

Some variation of three general goals usually is incorporated in individualized plans 

for substance abuse treatment (American 

Psychiatric Association 1995; Schuckit 

1994):

Achieving a substance-free lifestyle

Improving life functioning

Preventing relapse or reducing the frequency and severity of relapses

Most treatment plans also incorporate the 

following elements:

A few clearly stated, unambiguous goals 

that do not compete with one another.

These should be realistically attainable by 

the client.

Specific actions for addressing each 

goal. The clinician should ensure that the 

client understands the actions to be taken 

and how they will help the client achieve 

the goals.

Objective, easily measurable criteria 

for monitoring whether actions are 

completed and goals are accomplished.

Examples include (1) attending a specified 

number of Alcoholics Anonymous (AA) 

meetings each week and (2) maintaining 

abstinence for 3 months as monitored by 

three times per week BreathalyzerTM tests, 

self-reports, and daily ingestion of disulfiram (Antabuse®).

The sequence in which goals are 

addressed and activities undertaken.

Acute problems need to be addressed first. 

Until the client is stabilized and testing is 

completed, it may not be possible to finalize the sequence of treatment services.

A specified timeline or target date for 

goals. The plan identifies goals that are 

likely to be met during IOT, those that will 

be worked on during continuing care, and 

those that need input from other agencies 

or community groups.

The resources, responsible persons, or 

activities required. The means for achieving each goal are listed in detail.

Specific dates for reviewing the treatment plan and modifying it to reflect 

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problems addressed or emerging issues 

to be assessed.

A signature line for the client to indicate 

participation in development of the treatment plan and agreement with its specifications. The client receives a copy as a 

reminder of both his or her responsibilities 

and role as a partner who works with the 

clinician to achieve treatment goals.

Plan for continuing 

community care 

Comprehensive planning and ongoing review 

of the treatment plan during IOT lay the 

groundwork for ongoing recovery support following a client’s discharge. Beginning early 

in treatment, the client is encouraged to help 

design the continuing care plan to develop 

a sense of ownership and involvement 

in implementing it. The consensus panel 

believes that allowing the client to choose 

continuing care goals and types of engagement can increase satisfaction, compliance, 

and positive outcomes, because the client is 

given some authority over the treatment plan. 

The earlier this process is initiated, the more 

time is available to address concerns, ambivalence, or other issues. Chapter 3 provides a 

more detailed discussion of continuing care.

Sample Treatment Plans

The following two case histories illustrate 

different ways problem summaries and 

treatment plans can be developed and documented. The first case summarizes problems 

that often are discovered by using the ASI 

as the basic assessment instrument, with 

supplemental followup questions by the 

interviewer. The treatment plan indicates 

goals, objectives, actions to be taken, target 

dates for accomplishment, and responsible 

persons involved. The problems in the second case are summarized according to the 

six dimensions of the ASAM PPC; the treatment plan specifies objectives, interventions, 

responsible persons, and dates for completion or service delivery.

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Treatment Entry and Engagement 77

Sample Case 1

Clinical summary 

Alice is a 23-year-old, Caucasian, single 

mother of two daughters who are fathered by 

the same man, Lewis. Lewis introduced Alice 

to alcohol and marijuana while she was in 

high school. At age 15, Alice discovered she 

was pregnant and dropped out of school to 

live with Lewis. She has alternated between 

staying with him and staying with her mother ever since. Her drinking increased steadily 

over the years. Shortly after the birth of her 

second daughter 4 years ago, Alice and Lewis 

were introduced to crack cocaine. Alice’s 

use of crack rapidly escalated. She also 

continued to drink to “come down.” She lost 

several fast-food jobs because of unexplained 

absences. Because of her children she was 

eligible for Temporary Assistance for Needy 

Families and has depended on this assistance. 

To support her drug habit, Alice turned to 

prostitution, theft, and trading sex for crack. 

Before admission, she smoked crack almost 

daily and drank excessively. She also has 

injected a cocaine/heroin mix twice, at 

Lewis’s urging.

Born in a rural community, Alice moved to 

a large city with her mother and five older 

siblings when she was 10, leaving behind an 

unemployed and abusive father, who was 

dependent on alcohol and who died of liver 

cirrhosis 5 years ago. Alice’s relationship 

with her mother always has been strained, 

partly because her mother struggled long 

hours as a cleaning woman to support her 

children and partly because she had numerous boyfriends whom Alice resented. It seems 

to the counselor that Alice has spent most of 

her life searching for approval and love from 

anyone who pays attention to her.

Lewis has been incarcerated for a drug 

charge for the past year; he will be in prison 

for at least the next 5 years and will be 

unable to provide support for his children 

or for Alice. Alice had moved back with her 

mother when Lewis began his incarceration, 

but her mother threw Alice out of her house 

after Alice stole money from her mother’s 

purse. Alice has been living with anyone who 

will take her in for the last 9 months. 

The immediate events that precipitated 

Alice’s seeking treatment are a pending criminal charge for shoplifting (she was placed 

on probation for a previous shoplifting 

charge) and the recent removal of her children from her custody and their placement 

in foster care. An anonymous caller to the 

child welfare agency complained that Alice 

left her children unattended for long periods 

and that the older daughter was truant from 

school most days. 

Alice has a history 

of criminal justice 

system involvement, mostly for 

prostitution. Her 

current probation 

officer has told her 

if she does not seek 

treatment, she will 

be violating her 

probation. Alice 

has entered treatment twice before 

but dropped out 

both times after 

only a few sessions. 

She is now shocked 

at the loss of her children and terrified 

that she could do some long jail time. She 

believes she is ready to change her life and 

appears motivated for treatment. Although 

her mother is angry at Alice and appalled 

at the placement of her grandchildren into 

foster care, she has agreed to let Alice move 

back as long as she gets into and stays in 

treatment. Her mother stresses, however, 

that this cannot be a long-term living situation for Alice. The probation officer referred 

Alice to a local IOT program, where she was 

evaluated and admitted.

Although she has engaged in many risky sexual behaviors and has injected drugs twice, 

Alice did not report any medical problems 

...allowing the client 

to choose continuing 

care goals and types 

of engagement can 

increase satisfaction, 

compliance, and 

positive outcomes...
78 Chapter 5

but has not seen a physician since her younger daughter was born. At that time, she had 

no prenatal care, was abstinent briefly, and 

did not reveal her substance abuse during 

the 1-day hospital stay. Alice has never been 

tested for HIV or other sexually transmitted diseases (STDs) and does not remember 

the last time she went to a dentist. She has 

never had psychiatric evaluation or treatment, although one of her sisters committed 

suicide and several brothers also use substances. Alice reported that she has difficulty 

sleeping, feels “devastated” about the loss of 

her children, and cries frequently.

Alice has never been employed regularly and 

has no skills, but she was a good student, is 

articulate, and appears to be bright.

Alice stated that she wants to change her life, 

primarily to regain custody of her children. 

She says she is “done with Lewis” because 

she does not think he will ever change. She 

realizes that she needs to cease illegal activities; give up drugs; stop getting drunk; find 

safe, permanent housing; and obtain training and a job. She is optimistic that these 

goals are achievable, but she has an unrealistic view of the difficulties she faces and the 

time it will take to reach her goals. She does 

not appear to have any close friends who do 

not use drugs. Alice does not attend church 

and has no recreational interests.

Master problem list 

Children, ages 8 and 4, removed from custody and placed in foster care

Crack cocaine and alcohol dependence

Ongoing illegal activities and a pending 

criminal charge

No permanent residence

No apparent job skills or work history

Lack of positive support system

Strained relationship with mother and 

family members

No recent physical or dental examination; 

at high risk for HIV, STDs, and hepatitis

History of dropping out of substance abuse 

treatment

•

•

•

•

•

•

•

•

•

Possible depression, but never evaluated 

(family history of substance use disorders 

and suicide)

The IOT program assigns case managers and 

counselors to clients who have numerous 

problems that require extensive coordination with various community agencies. After 

conferring with Alice about her priorities 

and preferences, treatment staff developed 

the following treatment plan. This client has 

multiple pressing needs, and her treatment 

plan includes more goals than are required 

for clients with fewer challenges.

Short-term goals 

1. Address cocaine and alcohol 

dependence

Objective: Help client understand the 

importance of abstaining from all psychoactive drugs

Action: Enroll client in appropriate psychoeducation and early recovery groups 

in the IOT program; encourage her to 

attend mutual-help groups in the community (AA and Cocaine Anonymous 

[CA]); regularly monitor urine and 

breath drug tests

Target date: Immediately

Responsible persons: Client, counselor

2. Engage client’s mother in treatment

Objective: Increase emotional support 

for client’s recovery 

Action: Explore mother’s interest in 

attending family education group and 

participating in family therapy 

Target date: Contact mother immediately, 

with client’s consent; if mother is willing, 

begin family education immediately

Responsible persons: Mother, client, primary counselor, family counselor

3. Establish communication with child 

welfare services and client’s children

Objective: Begin process of family reunification; facilitate reasonable visitation 

schedule

•
Treatment Entry and Engagement 79

Action: Obtain client consent to contact 

child welfare representative to ascertain 

conditions for return of child custody 

and negotiate an action plan (This plan 

may include regular reports about the 

client’s treatment progress, having the 

client attend parenting classes, and having the client participate in regular, 

observed visits with her children.)

Target date: Within 2 weeks 

Responsible persons: Client, case manager, child welfare representative

4. Establish communication with 

criminal justice system

Objective: Avoid client’s probation 

violation; seek leniency for client’s 

shoplifting charge

Action: Obtain client consent to 

contact probation officer; get officer’s 

perspective on client and what 

conditions may be negotiated (e.g., 

regular reports to probation officer 

about treatment attendance and 

compliance, community service for 

shoplifting conviction)

Target date: Within 2 weeks

Responsible persons: Case manager, 

client, probation officer

5. Obtain medical and dental evaluation

Objective: Assess client’s health; prevent 

client’s potential transmission of infectious diseases

Action: Refer client for medical and 

dental evaluations, including testing for 

HIV infection and other drug-related 

diseases; enroll client in health education group with counseling about HIV 

testing; encourage the client to stop highrisk behaviors, consent to testing, and 

follow through on needed medical care

Target date: Within 2 weeks

Responsible persons: Client, case manager, health care coordinator, medical staff

6. Evaluate psychological functioning

Objective: Evaluate client’s mental 

health; assess her suicide risk; treat her

depression if necessary

Action: Observe signs of continuing 

depression after client is stabilized; 

refer her for psychological evaluation, 

if indicated

Target date: Within 30 days; ongoing

Responsible persons: Client, primary 

counselor, clinical supervisor, consulting psychologist or psychiatrist, medical 

director

Intermediate goals

1. Sustain abstinence from cocaine 

and alcohol

Objective: Reinforce treatment progress; 

assist client in meeting other goals by 

sustaining abstinence

Action: Help client identify cues for 

drug use; teach client relapse prevention 

techniques; monitor drug test results; 

encourage continuing participation in 

AA or CA groups in the community

Target date: Ongoing

Responsible persons: Client, case manager, medical staff, group counselor

2. Obtain transitional housing

Objective: Move client into safe, stable 

housing that supports continuing recovery

Action: Obtain client consent to contact 

local transitional housing program to 

arrange for placement and daily transportation to IOT program 

Target date: Initiate within 60 days; 

ongoing

Responsible persons: Client, case manager, case aide, transitional housing 

admission staff

3. Undergo vocational testing; begin 

working toward a general equivalency 

diploma (GED) 

Objective: Enhance client’s employability and self-esteem 

Action: Refer client to an educational 

specialist for testing; have client attend 

GED classes
80 Chapter 5

Target date: Initiate activities within 90 

days; ongoing

Responsible persons: Client, educational 

specialist, GED or adult education 

coordinator

4. Obtain employment

Objective: Help client become economically self-sufficient 

Action: Refer client to a vocational counselor to test client and determine an 

appropriate career goal; ensure attendance in life skills group and job club; 

encourage participation in volunteer activities that enhance employment-related 

skills and enhance the client’s résumé

Target date: Initiate activities within 90 

days; obtain at least part-time employment within 6 months

Responsible persons: Client, vocational 

counselor, job club and life skills group 

leaders, case manager 

5. Cultivate a positive support group; 

participate in healthy leisure activities

Objective: Encourage client to develop 

friendships with those who support a 

new abstinent way of life; encourage 

client to participate in appropriate 

recreational activities that she and her 

children enjoy

Action: Ensure that client continues to 

attend AA or CA meetings; enroll client 

in recreational group and parent training classes to meet other mothers; help 

client explore other community activities

Target date: Ongoing

Responsible persons: Client, case manager

Long-term goals

1. Sustain abstinence from cocaine and 

alcohol

Objective: Assist client in meeting life 

goals by remaining abstinent

Action: Encourage ongoing participation 

in AA or CA groups in the community

Target date: Ongoing

Responsible persons: Client

2. Obtain full-time employment

Objective: Help client become economically self-sufficient 

Action: Support client in job search 

activities; refer client for search assistance if necessary

Target date: 1 year

Responsible persons: Client, vocational 

counselor, job club and life skills group 

leaders, case manager

3. Obtain permanent housing

Objective: Move client into safe, stable, 

permanent housing 

Action: Assist client in finding housing 

in the community; assist client in negotiating lease agreement 

Target date: Within 1 year

Responsible persons: Client, case manager, case aide, transitional housing staff

4. Regain child custody

Objective: Reunite client with children

Action: Help client meet the requirements of the child welfare services for 

regaining custody of her children

Target date: 2 years 

Responsible persons: Client, caseworker, 

social worker from child welfare

Sample Case 2

Clinical summary 

Joe is a 24-year-old, unmarried, AfricanAmerican man who lives in a poor 

neighborhood of a large city and works as a 

dock loader for a large trucking company. 

He has been a heavy drinker and marijuana 

smoker since his teens but only recently 

started snorting cocaine. Joe lives with an 

aunt and uncle, paying a small monthly rent 

for a basement room, and he hangs out with 

his street buddies most of the time, “boozing 

and drugging” at dance clubs and pool halls. 

Joe never knew his father and was raised by 

his grandparents. His alcoholic mother left 

Joe and two younger brothers in his 
Treatment Entry and Engagement 81

grandparents’ care when she ran off with a 

man—only to die in an accident about a year 

later when Joe was 8 years old. His beloved, 

very religious grandfather died of complications from diabetes when Joe was in high 

school. Although his grandmother is alive 

still, Joe seldom sees her. None of the family 

members are close.

Now Joe is in serious trouble: a street brawl 

that he got into after a dance ended with 

the shooting death of one of his friends. Joe 

is one of those charged, though he swears 

he was not involved. He was, however, so 

drunk and high that he does not remember 

what happened. Because Joe has a history of fighting while drunk and a series of 

previous assault charges, the court has mandated treatment because of the alcohol and 

cocaine found in Joe’s urine after his latest 

arrest. He feels lucky to have been released 

and sent to an IOT program rather than to 

jail or a residential facility.

Joe is overweight but otherwise reports no physical complaints or serious medical problems. 

The one bright spot in Joe’s life is the 2-yearold son, Charles, he fathered with a “nice” 

girl (Brianna) he has known since high 

school. Brianna says that she loves Joe and 

would like them to be a family. However, she 

is very concerned about Joe’s alcohol and 

drug use and is thinking about ending the 

relationship. Although Brianna knows that 

Joe thinks Charles is special, she is reluctant to let the father and son go anywhere 

together—fearing that Joe is not responsible. 

Brianna is a stabilizing influence on Joe, 

with a strong spiritual side that reminds 

Joe of his grandfather. However, to impress 

Brianna and Charles, Joe has acquired a 

lot of bills that he sees no way to pay off. 

Creditors are hounding him. Moreover, Joe 

knows that his job is in jeopardy if he does 

not show up for work more regularly. He 

has been skipping work after attending wild 

parties. As a high school dropout, Joe does 

not have many opportunities to increase his 

income and has no aspirations for a better 

job. Also, it seems as though the more 

worried he is, the more money he spends on 

drugs and his son and girlfriend.

When asked, Joe says he wants to clean up his 

act and become a man like his grandfather. 

However, he does not see a way out, especially 

if he is convicted of manslaughter. The thought 

of spending time in prison terrifies him.

Integrated problems list 

Withdrawal potential. Although he drinks 

daily, it does not appear that Joe will have 

more than minimal withdrawal symptoms 

when he stops consuming alcohol. These can 

be managed, if needed, by the IOT program 

as can any rebound depression he may experience from quitting cocaine.

Biomedical condition or complications. Joe 

definitely needs to see a physician for a thorough physical examination. His weight needs 

to be evaluated, along with his eating habits.

Emotional/behavioral/cognitive status.

Joe’s legal and financial problems are causing a great deal of stress. His repeated 

fighting while under the influence may mask 

other psychological problems. It is not clear 

whether Joe ever fully has expressed his grief 

about losing his mother and grandfather. 

His isolation from family members and his 

job situation need to be explored.

Readiness to change. Joe does not seem to 

appreciate fully how much his drinking and 

drug use have complicated his life, but he 

regrets the fight in which his friend was killed. 

He genuinely is conflicted between his love for 

his son and admiration of his girlfriend’s values and his desire to remain one of the gang.

Relapse or continued use potential. All Joe’s 

buddies, except for his girlfriend, abuse substances seriously and encourage his continued 

drinking and drug use. He has not abstained 

spontaneously for any period and seems to be 

using more drugs, more frequently.

Recovery environment. Most family members show no support for Joe’s recovery. His 

mother was addicted to alcohol; there may be 
82 Chapter 5

a more extensive history of substance abuse 

in the family. It is unclear how far Brianna 

is willing to encourage Joe’s recovery; it also 

is unclear how attached Joe is to his son and 

how willing he is to be a supportive father.

Joe has applied for treatment at an IOT 

program that has an evening schedule for 

employed clients and a variety of medical, psychological, and case management capabilities. 

After reviewing his problem list, Joe and the 

intake counselor developed the following plan 

for his initial treatment. It will be reviewed 

and revised again after 4 to 6 weeks, when the 

need for continuing IOT may have diminished.

Initial Treatment Plan

Specific 

Objectives Interventions

Responsible 

Persons Timing

Achieve 

2 weeks 

of continuous 

abstinence

Monitor for potential withdrawal 

and needed medication on days 

1 through 3; enroll in substance 

abuse education and early recovery 

groups 3 times per week; screen for 

drug and alcohol use 2 times per 

week; attend individual counseling 

1 time per week

Client, medical 

staff, primary 

counselor, group 

leaders

9 hours 

per week 

in evening 

treatment 

program over 

first 4 to 6 

weeks

Determine 

health 

status and 

control 

weight 

and diet

Obtain full medical history, 

physical examination, lab work; 

participate in health education 

group 1 time per week

Client, medical 

staff

As soon as 

possible

Relieve 

stress 

from 

unpaid 

debts and 

collectors

Consolidate debts and develop 

repayment plan; enroll in money 

management skills group after 

completing health education; refer 

client to Debtors Anonymous

Client, case 

manager, group 

leader, consultation with credit 

agency

Begin as 

soon as 

client is 

stable—2 to 3 

weeks

Clarify 

legal status and 

explore 

options

Contact court about trial date, 

reporting requirements, potential 

for plea bargain, or alternative 

sentencing

Client, program’s 

legal consultant, client’s 

lawyer, primary 

counselor, court 

representative

As soon as 

client is 

stable

(continued)
Treatment Entry and Engagement 83

Initial Treatment Plan (continued)

Specific 

Objectives Interventions

Responsible 

Persons Timing

Stabilize 

employment

Give health excuse for missing 

work, if needed, for first 3 days 

of treatment; monitor pay stubs 

to see whether Joe is working 

regularly

Client, medical 

staff, primary 

counselor

Ongoing

Strengthen 

treatment 

commitment 

and motivation for 

recovery

Explore discrepancies between 

client’s religious values and commitment to son and girlfriend and 

his continuing substance abuse 

and lack of direction

Client, primary 

counselor, clinical supervisor

Begin 

individual 

counseling 

sessions as 

soon as client is stable 

Identify 

drug-free 

support 

network

Require attendance at a mutualhelp group or community 

alternative at least 5 times per 

week and participation in structured sports or leisure group 1 

time per week

Client, primary 

counselor

Begin mutualhelp group 

attendance 

immediately; begin 

recreational 

activities 

within 30 days

Obtain 

Brianna’s 

support for 

Joe’s recovery and 

explore their 

relationship

Encourage Brianna to attend family education 1 time per week and 

couples counseling 1 time per 

week

Client, girlfriend, 

primary counselor, family 

therapist

Begin family 

education 

immediately; begin 

couples 

counseling 

within 1 

month

Explore 

grief and 

isolation 

from family

Observe reactions to group discussions of family relationships; 

refer client for grief counseling if 

needed

Client, group 

leaders, primary 

counselor, clinical supervisor

Defer referral to next 

phase
84 Chapter 5 Appendix 5-A. Substance Use History Form Client’s Name: Date: Interviewer: Drug Type Street Name Ever Used Year of First Use Current Use* Date/Time Last Use Usual Amount of Daily Use Frequency/ Duration of Extended Use Route/Mode Observed Signs† Alcohol Cocaine Methamphetamine Stimulant Anxiolytic Heroin Methadone Other Opioid Sedative-Hypnotic Hallucinogen PCP Cannabis Inhalant Nicotine Other * Note if just released from controlled environment. † Circle observed signs, if any, of currently used drugs: Needle track marks Burns or stains on fingers Dilated or constricted pupils Agitation Flushed face Scratching Burns on inside of lips Incoherence Swollen hands or feet Tremors Nodding Sores/abscesses Smell of alcohol, marijuana, or methamphetamine (production) Unusual speech pattern (slurred, rapid, incoherent) Unsteady gait Sources: CSAT 1994a, 1994f.
Treatment Entry and Engagement 85

Addiction Severity Index—Several versions of the ASI (including Spanish and 

clinical training versions) are available at 

no cost from www.tresearch.org. This Web 

site includes a variety of ASI manuals and 

related materials, all free of charge. The 

ASI Helpline ([800] 238-2433) provides 

assistance with research applications and 

answers training questions. Training materials for the ASI, known as the Technology 

Transfer Package, developed by National 

Institute on Drug Abuse, are available 

from the National Technical Information 

Service ([800] 553-6847) for approximately 

$150. The package includes forms, training videotapes, a handbook for program 

administrators, a training facilitator’s 

manual, and a resource manual.

Alcohol Dependence Scale (ADS)—This 

instrument consists of 25 items designed to 

provide a quantitative measure of alcohol 

dependence. The test can be administered 

in 5 minutes and covers alcohol withdrawal symptoms, impaired control with respect 

to alcohol, awareness of compulsion to 

drink, increased tolerance to alcohol, 

and drink-seeking behavior. A computerized version of the ADS is available. This 

instrument is copyrighted; user’s guide 

and questionnaires must be purchased. 

(Order from Marketing Services, Addiction 

Research Foundation, 33 Russell Street, 

Toronto, Ontario, Canada M5S 2S1; [800] 

661-1111.)

Composite International Diagnostic 

Interview (CIDI)—Core Version 2.1, 

Alcohol and Drug Modules (World Health 

Organization 1997)—This instrument 

covers the diagnostic criteria for both 

DSM-IV and International Classification 

of Diseases, 10th Edition (ICD-10) (World 

Health Organization 1992), for substance 

abuse, harmful use, and dependence disorders as well as onset of some symptoms, 

withdrawal, and consequences of substance use and other psychiatric diagnoses. 

•

•

•

Clinician interview and computerized, 

self-administered versions are available 

and require about 70 minutes to complete. 

Twelve-month and lifetime versions are 

available in English, Spanish, French, and 

Dutch. (Visit www.who.int/msa/cidi/index.

html.)

Diagnostic Interview Schedule, Version

4—This instrument elicits information 

about the presence of syndromes meeting 

DSM-IV diagnostic criteria in the past year, 

the course of these disorders, functional 

impairment, treatment utilization, perceived need for treatment, links between 

psychiatric and physical causes, and dating of most recent symptoms and risk factors. The latest version requires 90 to 120 

minutes to administer and has explicit 

instructions for close-ended and precoded 

questions that are scored by a computer. 

(Order from Department of Psychiatry, 

Washington University School of Medicine, 

St. Louis, MO 63108; [314] 286-2267; 

mccrarysl@epi.wustl.edu.)

MINI International Neuropsychiatric 

Interview (M.I.N.I.)—This instrument is 

an abbreviated psychiatric interview tool 

that screens for major Axis I psychiatric 

disorders using DSM-IV and ICD-10 criteria 

(Sheehan et al. 1998). The M.I.N.I. has high 

validity and reliability, can be administered 

in approximately 15 minutes, and has been 

translated into 20 languages. A computerized version can be self-administered. A 

more detailed M.I.N.I. Plus also is available 

that addresses all 24 major Axis I diagnostic categories in the DSM-IV, 1 Axis II disorder, and suicidality and requires approximately 30 to 45 minutes to administer. 

(Download various versions of the M.I.N.I. 

in English and Spanish from www.medicaloutcomes.com.)

Psychiatric Research Interview for 

Substance and Mental Disorders 

(PRISM)—This instrument produces reliable DSM-IV diagnoses for substance-

•

•

•

Appendix 5-B. Instruments for Determining 

Substance-Related and Psychiatric Diagnoses
86 Chapter 5

related and primary psychiatric disorders 

(Hasin et al. 1996). PRISM includes procedures for differentiating primary disorders, substance-induced disorders, and 

effects of intoxication and withdrawal. 

PRISM takes between 1 and 3 hours to 

administer, depending on the respondent’s 

history, and can be useful for focusing 

treatment. PRISM is not copyrighted, but 

interviewer training is required and scoring is computerized. (Order from New 

York State Psychiatric Institute, Columbia 

Presbyterian Medical Center, Department 

of Research, Assessment and Training, 

[212] 923-8862; www.nyspi.cpmc

.columbia.edu.)

The Structured Clinical Interview 

for DSM-IV Axis I Disorders (SCID-I), 

Clinical Version—The SCIDI-I uses the 

comprehensive “gold standard” for psychiatric diagnoses of not only substancerelated disorders but other psychiatric disorders (First et al. 1997). A skilled mental 

health professional needs 1 hour or more 

to administer the complete and detailed 

version, but because the instrument is 

modular, only 10 minutes is required for a 

substance abuse or dependence diagnosis.

The Substance Dependence Severity 

Scale (SDSS)—The SDSS is a semistructured interview that provides current (last 

30 days) diagnoses of DSM-IV substance 

abuse or dependence (Miele et al. 2000). In 

addition, the SDSS assesses current severity 

•

•

level of dependence and has items that can 

yield diagnoses using the ICD-10 classification system. The instrument was designed 

specifically to measure changes in diagnostic 

severity over time. It measures quantity and 

frequency of recent drug use and is thereby 

sensitive to variation in client clinical status. The SDSS requires 30 to 45 minutes 

to administer. Training typically requires 2 

to 3 days but may take longer if staff members have little or no background in clinical 

diagnosis and assessment. Computerized 

data entry and scoring programs are available. There are no licensing fees. (Order 

from New York State Psychiatric Institute, 

Columbia Presbyterian Medical Center, 

Department of Research, Assessment and 

Training, [212] 960-5508; www.nyspi.cpmc.

columbia.edu.)

Texas Christian University Drug Screen 

(TCUDS)—This instrument consists of 25 

questions and can be administered and 

scored in less than 5 minutes. TCUDS 

often is used with incarcerated persons 

but is appropriate for the general population. TCUDS quickly identifies individuals 

who report heavy drug use or dependence 

(based on the CIDI—see above). TCUDS 

is available free of charge. (Order from 

Institute of Behavioral Research, Texas 

Christian University, TCU Box 298740, 

Fort Worth, TX 76129; [817] 257-7226; 

visit www.ibr.tcu.edu.)

•
Treatment Entry and Engagement 87

DSM-IV Diagnostic Criteria for 

Substance Dependence

The individual has a maladaptive pattern 

of substance use with clinically significant 

impairment or distress manifested by three 

or more of the following criteria, occurring at 

any time in the same 12-month period:

Tolerance is defined by either of the 

following:

A need for markedly increased 

amounts of the substance to achieve 

intoxication or the desired effect

Markedly diminished effect with 

continued use of the same amount of 

the substance.

Withdrawal is manifested by either of the 

following:

The characteristic withdrawal 

syndrome for the substance

Use of the same (or a closely related) 

substance to relieve or avoid 

withdrawal symptoms.

The substance is often taken in larger 

amounts or over a longer period than 

was intended.

There is a persistent desire or there are 

unsuccessful efforts to cut down or control substance use.

A great deal of time is spent in activities 

necessary to obtain, use, or recover from 

the effects of the substance.

Important social, occupational, or recreational activities are given up or reduced 

because of substance use.

Use of the substance is continued despite 

knowledge that a persistent or recurrent 

physical or psychological problem is likely to have been caused or exacerbated by 

the substance.

1.

•

•

2.

•

•

3.

4.

5.

6.

7.

Specify:

With physiological dependence if evidence 

of either tolerance or withdrawal is present 

or

Without physiological dependence if no evidence of either tolerance or withdrawal is 

present.

DSM-IV Diagnostic Criteria for 

Substance Abuse

A. The individual has a maladaptive pattern 

of substance use with clinically significant impairment or distress manifested 

by one or more of the following criteria, 

occurring within a 12-month period:

 1. Recurrent substance use resulting 

in a failure to fulfill major obligations at work, school, or home

 2. Recurrent substance use in situations in which it is physically 

hazardous (e.g., driving an automobile, operating a machine when 

impaired by substance use)

 3. Recurrent substance-related legal 

problems

 4. Continued substance use despite 

having persistent or recurrent 

social or interpersonal problems caused or exacerbated by 

the effects of the substance (e.g., 

arguments with spouse about the 

consequences of intoxication)

B. Symptoms have never met the criteria 

for substance dependence for this class 

of substance (i.e., a diagnosis of substance dependence preempts a diagnosis 

of substance abuse).

•

•

Appendix 5-C. DSM-IV Criteria for Substance 

Dependence and Substance Abuse*

_______________________

* Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Copyright 2000. 

American Psychiatric Association (2000).
88 Chapter 5

Six Assessment Domains

Medical status

Information collected in this area determines the level of physician or medical 

involvement, laboratory tests, and health 

education needed. The program may want to 

explore

Client’s current complaints or symptoms of 

physical illness and infectious diseases

Client’s availability of health insurance 

and a personal physician

Client’s medical history including injuries, 

operations, hospitalizations, chronic diseases, vaccinations, and allergies

Client’s current medical treatment and 

prescribed medications

Client’s diet, exercise and activity level, 

and perception of health status

Client’s attitude toward traditional 

medical treatment and alternative or folk 

medicine

Screening client for infectious diseases 

(CSAT 1994e, 1994f, 2000c) and administering the Risk Assessment Battery, a 

self-administered HIV-risk assessment 

instrument

Employment or support 

status

Clients’ economic status is an indicator of 

their recovery potential and need for additional training or vocational counseling. 

Inquiries focus on

Sources of income, number of dependents, 

perception of socioeconomic status, and 

financial solvency or indebtedness

Eligibility for or receipt of benefits such as 

Medicaid or Medicare or employer health 

benefits

Work history, marketable skills, access to 

transportation, job qualifications, and satisfaction with job and pay

•

•

•

•

•

•

•

•

•

•

History of job terminations, previous referrals to an employment assistance program, 

and outcomes

Education, including highest grade completed and educational accomplishments or 

difficulties

Attitude toward money and ability to manage money

Patterns of alcohol and 

drug use

Patterns of substance use provide information about the severity and duration of the 

client’s current substance use and previous 

treatment episodes. Questions can review 

Reasons for seeking treatment

Quantity, frequency, route of administration, and cost of substances currently used; 

how long the use pattern has persisted; 

and primary and secondary drugs that are 

causing problems

History of periods of abstinence, including 

efforts to control or cut back use

Desired effects of current use, context of 

substance use, and usual physical and 

emotional consequences

Experience with substances other than the 

ones currently being abused

Triggers and circumstances for relapse

Prior treatment, including duration and 

dates, types of treatment, voluntary or 

coerced entry, response to treatment, 

reason for discharge, and length of time 

before and reasons for relapse

Criminal history and legal 

status

A client’s current legal status and history of 

criminal involvement may have implications 

for treatment. Topics to explore in this area 

include

•

•

•

•

•

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Appendix 5-D. Supplements to the Six 

Assessment Domains in the ASI and Other Topics
Treatment Entry and Engagement 89

History of juvenile offenses or adult arrests 

or convictions, including types of crimes

Time spent incarcerated and nature of the 

crimes

Episodes of substance abuse treatment 

while in the criminal justice system

Status and relevant dates of pending drug 

court appearances, pretrial release hearings, meetings with probation or parole 

officers, or trials

Determination of a criminal justice system 

mandate for treatment

Unresolved legal issues

Family and social 

relationships

The client’s relationships and living arrangements have a powerful influence on the 

recovery process. Social networks involving 

or encouraging alcohol or drug use have 

a negative effect on treatment outcome 

(Longabaugh et al. 1998). A social network 

supportive of drinking is associated with less 

involvement in AA (Connors et al. 2001b). 

Topics to explore are

Marital or primary relationship status, 

duration, and satisfaction; the involvement 

of significant others with substances; and 

their attitudes toward recovery

Current living arrangements, household 

composition, satisfaction level with household members, residential stability and 

reasons for any changes in the last year, 

and contribution to the household

Children (including stepchildren) and their 

ages, living and custody arrangements, and 

any charges or reports of neglect or abuse 

and related outcomes

Friendships, including the numbers, perceived closeness, and activities undertaken 

together

Living relatives and perceived closeness or 

alienation and relatives’ current and previous involvement with substances

Conflicts with relatives or friends in 

the last 30 days and the nature of these 

encounters

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Domestic violence. In many States, providers have a duty to inform law enforcement 

of evidence of abuse. Providers need to be 

familiar with applicable laws in their State. 

Programs also should be prepared to recommend alternative housing for clients who are 

living with domestic violence.

TIP 25, Substance Abuse Treatment and 

Domestic Violence (CSAT 1997b), discusses the complicated interconnections 

between substance abuse and battering or 

victimization, stressing the importance of 

identifying people in destructive, exploitative relationships and helping them openly 

address issues that are otherwise likely 

to sabotage recovery. TIP 25 contains the 

Danger Assessment (Campbell 1995) and 

the Psychological Maltreatment of Women 

Inventory (available at www-personal.umich.

edu/~rtolman/pmwimas.htm) (Tolman 

1989), which are not yet validated as clinical 

tools but which contain questions that can 

be used in interviews or as suggestions for 

promoting discussion. 

Childhood history. Childhood history can 

have a dramatic, often unrecognized, influence on current functioning. Questions in 

this area focus on

Perceived closeness of family members 

while growing up and currently

Primary caregivers during childhood and 

memories of their expressed interest, affection, and disciplinary practices

Quality and number of close childhood 

friendships and recollections of childhood 

problems or traumatic events

Significant childhood illnesses, accidents, 

or diagnoses and treatment

Childhood experience of emotional, physical, or sexual abuse, including frequency 

and duration of episodes, age at victimization, and the perpetrator’s identity; family 

knowledge of or reactions to these events; 

whether and how social services or children’s protective services were involved; 

and subsequent counseling or treatment 

and responses

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90 Chapter 5

TIP 36, Substance Abuse Treatment for 

Persons With Child Abuse and Neglect Issues

(CSAT 2000b), includes information about 

assessing adults for childhood abuse and 

neglect. It includes symptoms and effects, 

direct questioning techniques, and screening 

and assessment instruments. Appropriately 

trained and supervised staff members should 

screen and assess clients with respect to traumatic events.

The parent–child relationship. TIP 36, 

Substance Abuse Treatment for Persons 

With Child Abuse and Neglect Issues (CSAT 

2000b), contains information for assessing the parent–child relationship. These 

tools include the Parental Acceptance and 

Rejection Questionnaire and the Parent–

Child Relationship Inventory. Requirements 

for reporting child abuse or neglect and 

strategies for working with children’s protective services and child welfare systems are 

reviewed.

Current child abuse or neglect. Parents with 

substance use disorders are at increased 

risk for abusing or neglecting their children. 

In many States, providers have a duty to 

inform law enforcement of evidence of child 

abuse. Providers need to be familiar with 

applicable State laws. Although caution is 

advised about potential misinterpretation 

of socioeconomic and cultural differences 

in parenting styles, observable signs of 

potential child neglect or abuse by a client 

include, but are not limited to the following:

Verbal abuse or belittling of children or 

wrongly blaming them for the client’s mistakes or frustrations

Taking inadequate safety precautions (e.g., 

leaving young children alone at home or 

with underage babysitters, letting them 

roam by themselves in unsafe places)

Child’s indiscriminate attachment to persons other than the parent or the child’s 

flinching or cowering unnecessarily when 

the parent is present

Expressing unrealistic, age-inappropriate 

behavioral expectations

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Describing children in sexual terms

Reports of inappropriate punishment of 

children by oneself or a partner

Children’s consistently unkempt appearance, obvious underweight condition or 

hunger, or unexplained bruises or other 

injuries

Psychiatric status

Many people with substance-related diagnoses have co-occurring psychiatric disorders. 

The existence of a psychiatric disorder and 

the need for a referral to a mental health 

provider may be indicated if (Schottenfeld 

and Pantalon 1999)

The onset of psychiatric symptoms preceded initial substance use.

Symptoms persisted during previous periods of abstinence.

Symptoms continue 2 to 4 weeks after all 

substance use ceases.

A family history of the suspected mental 

disorder exists.

Symptoms of the suspected mental disorder are atypical for the substance being 

used or the dosage being consumed.

Questions about the mental health status of 

clients should determine

Current or unaddressed symptoms of psychiatric disorders (last 6 months)

Previous diagnoses of a psychiatric disorder or central nervous system impairment

Current or prior psychiatric treatment and 

currently prescribed medications for psychiatric disorders, dosage, and orders for 

administration

Other Topics

Sexuality

A person’s feeling about sexuality may affect 

substance abuse treatment. Although sexuality is a sensitive topic, questions can explore

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Treatment Entry and Engagement 91

The client’s sexual orientation and personal/familial/social reactions if he or she 

identifies as other than heterosexual

Whether the client is sexually active and, if 

so, the number of partners in the last 6 to 

12 months

Satisfaction with sexual functioning

Any association of sexual activity with 

substance use/violence/control, feelings of 

victimization, and any current charges of 

sexual abuse or rape

Self-concept

The clinician can observe or ask about

Level of positive self-regard, self-efficacy, 

and determination or persistence

Coping skills, facility for communication, 

and problemsolving abilities

Personal pride in accomplishments and 

realistic sense of strengths

Recreation and leisure 

activities

Non-substance-related recreation and leisure activities are important components 

of sustained recovery. They can remove the 

client from social pressures to use alcohol 

and drugs and provide a healthy outlet for 

new energies. If the client does not have 

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any active recreational interests—and has 

spent most leisure time in substance-related 

pursuits—maintaining abstinence may be difficult without assistance in finding appealing 

alternatives. The counselor can ask the client 

about

Recreational activities and whether these 

involved alcohol and drug use

Potential leisure time pursuits, including 

why these are appealing and how realistic 

they are to pursue

Spirituality and personal 

values

Spirituality and personal values can sustain 

clients and supplement treatment efforts. 

Acceptance of a higher power is a fundamental element of mutual-help groups such 

as AA and Narcotics Anonymous. Other personal values and affiliations can contribute 

to stability and sobriety. The counselor can 

explore

Religious affiliation and its current and 

prior importance

Racial/ethnic/cultural identity and its relative importance, including immigrant status and acculturation issues, if applicable

Community activities, political interests, 

and current involvement

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93

Substance use disorders exist within several social contexts, one of 

which is the family. Family members, whether they are from the family of origin or family of choice, are important forces in a client’s life. 

Each client has a family, a family history, and a family story that 

play important roles in recovery. Many clients come from substanceusing families and have been raised with alcohol abuse or drug use 

as part of their lives. Addressing this legacy is part of their recovery. 

In addition, a client’s family members often have significant substance use and other psychiatric problems of their own. Intensive 

outpatient treatment (IOT) programs that take a comprehensive 

approach to evaluating the family are likely to identify other individuals who would benefit from being admitted to a substance abuse 

or mental health treatment program. Some family members may be 

in treatment already. For these reasons, many IOT programs incorporate a family systems approach. Family education, family therapy, 

and other services are necessary in an IOT program’s process so that 

the contributions and influence of family members support recovery.

A complete discussion of family therapy for substance use disorders 

in IOT programs is not within the scope of this TIP. This chapter 

introduces features of family involvement in IOT programs and 

briefly discusses family therapy as an enhanced service that IOT programs may offer or, more frequently, to which they may refer clients 

and their families. The Center for Substance Abuse Treatment has 

developed TIP 39, Substance Abuse Treatment and Family Therapy 

(CSAT 2004c), that addresses how a substance use disorder affects 

the family, how family therapy works to change the interactions 

among family members, and the integration of family therapy into 

substance abuse treatment. 

Families of people who abuse substances live in a world shaped by 

substance use. This world may include inconsistent behaviors and 

few or very rigid rules. Family members may have difficulty expressing their emotions, achieving intimacy, and solving problems. They 

frequently may experience but may not express anger, shame, guilt, 

6 Family-Based Services

In This 

Chapter...

Planning 

for Family 

Involvement

Engaging the 

Family in 

Treatment

Family Services 

Family Clinical 

Issues in IOT
94 Chapter 6

sadness, and hopelessness. To function, 

families often subscribe to the following: 

don’t trust, don’t feel, and don’t talk. The 

result can be an unhealthy environment in 

which individuals may be isolated, engage in 

destructive alliances, be overly involved with 

other family members, or develop 

significant medical 

and stress-related 

problems. 

Increasingly, treatment professionals 

view substance use 

disorders from a 

family systems perspective (Crnkovic 

and DelCampo 

1998). Research findings document a relationship between family involvement in 

treatment and positive outcomes and attest 

to the need for family-based services (Rowe 

and Liddle 2003). Family involvement in 

treatment seems to work equally well for 

adults and adolescents (Stanton and Shadish 

1997). When the family is ready and able to 

shift from old, negative behaviors to new, 

healthier ones, family members become collaborators in the treatment process (Edwards 

and Steinglass 1995). Most IOT programs do 

not offer couples- or family-based therapies 

(Fals-Stewart and Birchler 2001). However, 

potential benefits of family therapy are such 

that IOT programs should have wellestablished links with organizations that 

provide these services.

No matter how alienated family members 

may be, they are critical to the strength and 

duration of the client’s recovery. Family 

members are the individuals who were part 

of the client’s life before treatment and will 

be part of his or her life after treatment. 

Family-based services that are part of IOT 

help ensure that family functioning adjusts 

to and positively influences the recovery of 

the client.

Planning for Family 

Involvement

IOT planning for family-based services 

involves defining the client’s family in broad 

and flexible terms, setting essential goals, 

and determining the desired outcomes.

Defining the Family

In recent years, the concept and definition 

of family have broadened significantly to 

include people who are important to the client. These people can include a spouse, a 

boyfriend or girlfriend, a same-sex partner, 

parents, siblings, children, extended family 

members, friends, co-workers, employers, 

members of the clergy, and others. The 

term “family of origin” commonly is used to 

describe individuals related by blood, such 

as parents, grandparents, and siblings. The 

term “family of choice” is used to describe a 

family created by marriage, partnership, or 

friendships and other associations.

When determining the client’s concept of 

family, the key is to identify who will be supportive of recovery and who might seek to 

undermine it. The treatment provider can 

begin this process by creating a genogram (see 

appendix 6-A, page 107) to assess the family 

of origin or choice. Similarly, a social network 

map (see appendix 6-B, page 109) can help 

the counselor identify and understand the 

family of origin and family of choice. 

Creating a family genogram. This technique renders the client’s family relationships schematically and helps the counselor identify trends or patterns in the family 

history and understand the client’s current 

situation. As treatment progresses, the 

genogram is revised to reflect new knowledge and changes in the family (CSAT 

2004c).

Assessing the client’s social supports 

with a social network map. A social network map displays the links among individuals who have a common bond, shared 

social status, similar or shared functions, 

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...family members... 

are critical to 

the strength and 

duration of the 

client’s recovery.
Family-Based Services 95

or geographic or cultural connection. 

Highly flexible, social networks form and 

disband on an ad hoc basis depending on 

specific need and interest. A social network assessment is used in social service 

arenas, including substance abuse treatment. When the assessment is used in IOT, 

individuals are identified who can support 

the client or participate in the treatment 

process (Barker 1999). 

Goals and Outcomes of Family 

Services

One main goal of involving families in 

treatment is to increase family members’ 

understanding of the client’s substance use 

disorder as a chronic disease with related 

psychosocial components. Edwards (1990) 

states that family-based services can have the 

following effects:

Increase family support for the client’s 

recovery. Family sessions can increase a 

client’s motivation for recovery, especially 

as the family realizes that the client’s substance use disorder is intertwined with 

problems in the family. 

Identify and support change of family patterns that work against recovery. 

Relationship patterns among family members can work against recovery by supporting the client’s substance use, family conflicts, and inappropriate coalitions. 

Prepare family members for what to 

expect in early recovery. Family members 

unrealistically may expect all problems to 

dissipate quickly, increasing the likelihood 

of disappointment and decreasing the likelihood of helpful support for the client’s 

recovery. 

Educate the family about relapse warning signs. Family members who understand warning signs can help prevent the 

client’s relapses.

Help family members understand the 

causes and effects of substance use disorders from a family perspective. Most 

family members do not understand how 

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substance use disorders develop or that 

patterns of behavior and interaction have 

developed in response to the substancerelated behavior of the family member who 

is in treatment. It is valuable for individuals in the family to gain insight into how 

they may be maintaining the family’s dysfunction. Counselors should help family 

members address feelings of anger, shame, 

and guilt and resolve issues relating to 

trust and intimacy.

Take advantage of family strengths. 

Family members who demonstrate positive 

attitudes and supportive behaviors encourage the client’s recovery. It is important to 

identify and build on strengths to support 

positive change.

Encourage family members to obtain 

long-term support. As the client begins 

to recover, family members need to take 

responsibility for their own emotional, 

physical, and spiritual recovery. 

A comprehensive IOT program views the 

client as part of a family system. When the 

family is involved in treatment, the following 

treatment outcomes are possible:

The client is encouraged to enter 

treatment.

The client is motivated to remain in 

treatment.

Relapses are minimized.

A supportive and healthy environment for 

recovery is provided.

Other family members who may need treatment or other services are identified and 

treated.

Changes in the family’s longstanding dysfunctional patterns of communication, 

behavior, and emotional expression may 

protect other family members from abusing substances.

Engaging the Family 

in Treatment

Difficulties with engaging the family in treatment often are cited as reasons for not using 

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96 Chapter 6

a family systems approach and, in many 

cases, substantial obstacles exist. Family 

members may be resistant, or the client 

may be ambivalent or object to the family’s 

involvement in treatment. But given the 

potential benefits associated with taking a 

family approach to service delivery, engaging 

the family in treatment is worthwhile.

Strategies To Engage the 

Family

The following approaches have proved helpful in encouraging families to engage in the 

treatment of a family member: 

Include family members in the intake 

session. The counselor can involve family 

members in the treatment process from 

the beginning. If a family member makes 

the initial call to the program, the counselor can ask that person to come with the 

client. If the client calls, the client can be 

asked to bring a family member. If the client is reluctant at this point, the counselor 

can gently encourage the client to include 

family members but should not make it a 

condition of the person’s entry into treatment. In another approach, the counselor 

can ask, “Who close to you is concerned 

about your substance use and might be 

willing to serve as a support to you during 

•

your recovery?” The client then might be 

asked to invite these supportive people to 

come to the initial intake interview. During 

the intake interview, family members can 

be asked to complete a brief written family 

assessment. A more comprehensive family systems approach can involve multiple 

private and family interviews. These interviews and other early meetings with the 

family develop support from a family that 

is empowered to address systemic issues. 

Similarly, the initial meeting helps family 

members learn about substance use disorders, their influence on a family, and the 

services the program can offer to the family (see exhibit 6-1).

Use client-initiated engagement efforts. 

The counselor and client collaborate on a 

plan to engage family members in treatment. The client can be given the opportunity to invite chosen family members to 

participate in the program. If this effort is 

unsuccessful, then, with the client’s written 

permission, the counselor telephones, visits, or sends a personal note to the identified family members. Federal confidentiality rules require that client permission be 

documented (CSAT 2004b). 

Offer a written invitation. The IOT provider can give the client written invitations, 

with the clinic’s contact information, to 

deliver to family members. Giving the client 

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Exhibit 6-1

Suggestions for Engaging Family Members at Intake 

Emphasize the need to gather information from family members.

State the program’s policy about family members’ participation in treatment.

Indicate the program’s desire to hear family members’ concerns about the client’s 

substance abuse.

Acknowledge family members’ influence over the client and their desire to help.

Make clear that family members’ participation will help the client on the road to recovery.

Emphasize how the program can help family members maintain a relationship with the 

client and manage their own feelings (anger, frustration, depression, and hopelessness).

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Family-Based Services 97

the invitations allows the provider to determine whether the client is willing to 

involve family members in treatment and 

which family members the client wants to 

involve in the process. The invitation briefly describes the treatment program and 

identifies activities family members will be 

asked to participate in. For example, a 

family member may be asked to attend 

family education sessions, complete an 

assessment questionnaire, remove all substances from the home (if applicable), participate in family counseling sessions, or 

attend a celebration of the completion of a 

treatment phase. 

Offer incentives. Incentives may help 

address recruitment problems. Family 

members can be provided with coupons (e.g., for pizza, movies) for attending sessions or completing assignments. 

Refreshments also help family members 

feel welcome. In addition, providers can 

facilitate transportation (e.g., arrange 

carpools) and childcare services and 

remove other obstacles to family members’ 

participation. 

Plan picnics or dinners for families.

Multifamily picnics and dinners are a 

part of some IOT programs and can be 

scheduled for holidays or weekends. These 

events can be held on the program’s 

grounds or in nearby parks or community 

centers and provide a supportive and nonthreatening environment where individuals 

can have fun and learn about substance 

use disorders, recovery, and the IOT program. The client and family members are 

asked to bring a dish, but all are welcome. 

Immediately after the meal, a counselor 

conducts an hour-long educational session covering topics such as recovery support groups, family-oriented services, and 

characteristics of substance use disorders. 

Participants are told of the educational 

nature of the sessions when invited.

Use community reinforcement training 

(CRT) interventions. CRT interventions 

have improved the retention of family 

members in treatment and induced people 

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who abuse substances to enter treatment 

(Meyers et al. 1998, 2002). Among other 

strategies, the CRT approach teaches family members that substance abuse is not a 

moral failing but a disease and that they 

are not the cause of and cannot be the 

cure of their loved one’s substance use 

disorder. They also learn to identify and 

pursue their own interests, communicate 

in nonjudgmental ways, encourage drinking of nonalcoholic beverages during social 

occasions, manage dangerous situations, 

and discuss treatment entry with the family member who abuses substances when 

the consequences of abuse are severe 

(Kirby et al. 1999b). 

Use the resources of the program. To 

create a family-friendly environment, IOT 

staff at all program levels need to work 

together toward the goal of engaging families. For example, flexible program hours 

and large offices or meeting rooms may be 

needed to accommodate family schedules 

and large families. Safe toys should be 

made available for children so that they 

are less likely to disrupt a session. Front 

office staff should be trained to encourage 

and reinforce the efforts of family members who call or come in with the client 

for the initial visit. Programs can organize 

their client record systems and procedures 

so that staff members have easier access to 

family-related information for each client.

Provide a safe, welcoming environment.

Family members may be anxious or reluctant to participate in the treatment process. A welcoming environment encourages 

them to participate despite their concerns. 

A safe, clean, and cheerful meeting space 

is important. Good lighting, a well-marked 

and well-maintained exterior, culturally 

appropriate décor, comfortable furniture, 

and amusements for children convey the 

message that family members are welcome, 

valued by the treatment team, and essential 

to the recovery of the client. Ice-breaking 

activities, simple games, and role-play activities can make the group meeting inviting 

and encourage family involvement.

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98 Chapter 6

Overcoming Barriers to 

Engaging Family Members in 

Treatment

Not all family members participate in the 

treatment process. Sometimes individuals are reluctant to become involved with 

treatment, even though they care about the 

client. Women are more likely to be involved 

in their male partners’ treatment; men are 

less likely to participate in their female partners’ treatment (Laudet et al. 1999). Also, 

the client may not want family members to 

be involved because of threats of domestic 

violence or past abuse by a family member, 

guilt about the substance abuse, fear that 

family secrets may be revealed, concern 

about adding to the family burden, or other 

reasons. All family members who do participate must feel free to raise pertinent issues, 

even if another family member objects. 

Because of the risk of domestic abuse that 

comes with raising difficult issues, providers 

must assess carefully the potential for violence within the family (CSAT 2004c). 

Despite these barriers, the IOT provider is 

encouraged to take every possible action to 

engage families of clients in the treatment 

process. Better client retention, fewer relapses, 

improved family functioning, and family 

healing are all possible outcomes (O’Farrell 

and Fals-Stewart 2001). 

Supportive supervision of the counselors providing these family services 

Gives staff members confidence that they 

are providing appropriate levels of service 

while addressing clinical issues that inevitably arise

Ensures that counselors and staff members 

understand their limitations in working 

with family members 

Guards against counselors and staff members attempting to provide therapy for 

which they have not been trained 

When working with families, programs 

can make use of existing partnerships with 

agencies and groups that provide enhanced 

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family services, individual counseling for 

other family members, health care, and 

financial and legal services to support 

clients’ families.

Family Services 

Family members

May need guidance on how to address 

many issues that can arise during early 

recovery

May have questions or misconceptions 

about substance use disorders

May need to find healthy ways to handle 

their justifiable feelings of anger, frustration, shame, helplessness, guilt, and sadness that stem from attempts to fix the 

client’s substance use disorder 

May need the counselor’s intervention 

to understand and avoid behaviors that 

contribute to the client’s continued use of 

alcohol and drugs 

The types of services described in this section 

can support the efforts of family members as 

the client moves through the course of treatment. Although every family is different, and 

the pace of recovery varies from family to 

family, a sample treatment calendar is provided in exhibit 6-2. IOT services can assist 

family members in accomplishing the tasks 

described in the calendar.

Family Education Groups

Family education groups provide information 

about the nature of a substance use disorder; 

its effects on the client, the family, and others; 

the nature of relapse and recovery; and family 

dynamics. These groups often motivate families to become more involved in treatment.

The family education group typically meets 

weekly for 2 to 3 hours, often in the evening 

or on weekends, and includes between 10 and 

40 individuals. The group is facilitated by a 

counselor and usually covers these topics: 

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Family-Based Services 99

Medical aspects of addiction and 

dependence

Relapse and relapse prevention

Addiction as a family disease

Subconscious refusal to admit that the client has a substance use disorder (i.e., denial)

Enabling behaviors

Communication

Reasons for testing and monitoring of 

the client 

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Leisure time planning

Parenting skills

Community support groups and resources

Group members listen to lectures, discuss 

topics, and engage in exercises that help 

them become knowledgeable about substance 

use disorders and their effects on the family. 

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Exhibit 6-2

A Treatment Calendar for Family Members

Source: Matrix Center 1989.

Beginning stage: 1–5 weeks

Commit to treatment.

Understand that a substance use disorder is a chronic illness. 

Support abstinence.

Begin to identify and discontinue behaviors that support substance use.

Learn about the family support groups: 

Al-Anon (www.al-anon.alateen.org)

Nar-Anon (www.naranon.com)

Families Anonymous (www.familiesanonymous.org) 

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–

–

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Middle stage: 6–20 weeks

Assess the relationship with the client.

Develop a realistic perspective on addiction-related behaviors so the family member 

remains involved with the client but establishes some protective personal distance.

Work to eliminate behaviors that encourage the client’s substance use (i.e., enabling 

behaviors).

Move past behaviors that are primarily a response to the client’s substance use (i.e., 

codependence).

Seek new ways to enrich the family member’s life.

Begin practicing new communication methods.

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Advanced stage: 21+ weeks

Work to develop a healthy, balanced lifestyle that supports the client and addresses 

personal needs.

Exercise patience with recovery.

Evaluate and accept changes, adaptations, and limitations.

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100 Chapter 6

Multifamily Groups

Multifamily groups can be thought of as 

microcosms of the larger community. They 

offer more opportunities for learning, adaptation, and growth than do groups of one 

client and family members. These groups 

provide family members with a sense of normalcy and a support network. Individuals 

learn that other families face similar difficulties. This discovery may reduce the stigma 

and shame commonly found among families 

struggling with substance use disorders. 

Families often exhibit mutually supportive, 

spontaneous involvement with one another 

and reinforce one another’s problemsolving 

approaches. Cross-learning—in which, for 

example, a man learns to understand his 

wife better by listening to other husbands 

and wives—is one of the most powerful 

effects of multifamily therapy. Incorporating 

multifamily groups into IOT has been shown 

to increase the length of treatment for 

female clients, increase completion rates for 

men, and improve family functioning and 

children’s behavior (Boylin and Doucette 

1997; Meezan and O’Keefe 1998). Treatment 

providers report that having more than one 

generation present in the group can help 

institute a family’s commitment to abstinence and recovery (Conner et al. 1998).

Multifamily groups typically engage several clients and their family members in 

group exercises 

that teach them 

how to develop 

healthy communication techniques, 

avoid enabling 

behaviors, reduce 

codependence, and 

get help. Until a 

multifamily group 

coalesces, it may 

be helpful for members’ participation to be 

structured (e.g., talking only about themselves, not about the person in IOT). 

IOT providers should foster an atmosphere 

of acceptance and emotional safety so that 

learning occurs in a relaxed setting. Group 

sessions generally are scheduled weekly and 

last for 2 to 4 hours with group size ranging from 12 to 30 members (6 to 8 families) 

(Crnkovic and DelCampo 1998). Clients’ 

recovery may be aided by the inclusion of 

supportive individuals from outside the family (e.g., sponsors, friends, religious leaders, 

co-workers). The consensus panel recommends that multifamily groups be co-led 

by two therapists trained in this process. 

Membership may change frequently, and 

clients and their families join the group as 

others graduate from the treatment program.

Family Therapy Groups

In 1997, Stanton and Shadish conducted a 

meta-analysis that compared the effectiveness of family education, family therapy, and 

other forms of family intervention for people 

with substance use disorders. Their results 

suggested family therapy is more effective 

than family education groups and other 

family services. However, family therapy can 

be delivered only by specially trained therapists. Forty-two States require that people 

practicing as family therapists be licensed. 

In most States, a family therapist must have 

a master’s degree to practice independently 

(CSAT 2004c). Family therapy addresses the 

dynamics in the family that may encourage substance abuse and offers support for 

changing these dynamics. It emphasizes 

that the family as a dynamic system, not 

merely the inclusion of family members in 

treatment, is the hallmark of family therapy 

(CSAT 2004c). These sessions may include 

individual family, couples, and child-focused 

therapy. (Family therapy for adolescents 

is discussed in chapter 9.) Because not 

all IOT programs provide these types of 

therapy groups, providers should consider 

establishing referral agreements with other 

community service organizations that provide family therapy. 

Cross-learning...is

one of the most 

powerful effects of 

multifamily therapy.
Family-Based Services 101

Individual family therapy 

This type of therapy helps family members 

look at their interactions and identify the 

factors in the family that contribute to a 

substance use disorder. Family members are 

encouraged to restructure negative patterns 

of behavior and communication into interactions that are more conducive to recovery 

for everyone. Through family therapy, adults 

and children express to the client how behavior has affected them and how new coping 

skills now are affecting their lives. The client 

has the opportunity to use new skills learned 

in treatment and to receive constructive 

feedback from family members in a safe 

environment. During these sessions, families 

may address issues such as irresponsible 

behavior, indebtedness, substance use in the 

home by other family members, availability 

of alcohol on special occasions, and how to 

reveal treatment and recovery to others. The 

content of these sessions varies significantly, 

based on the needs and motivations of the 

family members. Family therapy may be 

scheduled monthly or more frequently. 

Couples therapy

Couples counseling is useful in improving 

certain aspects of functioning in families 

with substance use disorders (O’Farrell and 

Fals-Stewart 2002). This therapy focuses on 

improving a couple’s relationship and reducing problems related to substance abuse.

The spouse or significant other is taught to 

reinforce abstinence, decrease behaviors 

that cue substance use, and avoid protecting the client from the adverse consequences 

of substance use. Both partners are taught 

to increase positive exchanges, improve 

communication, and work together to solve 

problems. The number of sessions can be 

six or more and can include sessions for one 

couple or groups of couples (Fals-Stewart et 

al. 1996). 

Child-focused therapy

Play and structured recreational activities 

for children and parents can reduce conflict 

in families with substance use disorders. In 

groups with their children, parents are taught 

parenting and problemsolving skills and 

are given information about normal childhood development. Parents recovering from 

substance use disorders have a chance to 

experience pleasurable recreational activities 

with their children (e.g., volleyball, soccer) 

and learn to interact with them in a structured, therapeutic setting. Older children can 

be educated about substance use and how it 

can affect them and their families.

Family Retreats

Some IOT providers have found that family retreats can be effective in helping 

families harmed by substance use disorders, 

although research is unavailable on this 

topic. Participants can take important steps 

toward healing damaged relationships. Some 

participants have described family retreats 

as the most important aspect of their experience in treatment.

Most family retreats cover 2 days, usually 

over a weekend; participants spend nights 

at home. Retreats provide clients and their 

family members with the opportunity to 

work intensively with one another to address 

powerful emotions such as shame and 

guilt and to restore lost intimacy and trust. 

Participants take part in education sessions, 

exercises, and group activities. Day 1 activities can include family education on

Communication skills

Experiencing and working with feelings

Developing trusting relationships within 

the family

Creating healthy expectations

Reestablishing roles

Participants receive an assignment the 

evening of day 1 to work on at home. 

Assignments may focus on developing 

relapse contracts, reading from journals, or 

sharing positive family memories. Day 2 can 

focus on a therapeutic event during which

•

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102 Chapter 6

Participants discuss the assignments they 

completed the night before.

Family members are encouraged to tell 

one another important things, which may 

never have been said or discussed before.

Family sculpting exercises are conducted; 

this activity dramatically illustrates relationships and communication patterns 

that need to change. In family sculpting, 

each family member takes a turn positioning the other family members in relation 

to one another, posing them as he or she 

sees fit, and explaining the choices (CSAT 

1999a).

Programs that conduct retreats find that 

executing a “contract for participation” 

with the client helps ensure that the retreats 

are well attended. Therapists may need to 

assist the client in recruiting family members to attend. Retreats should be staffed by 

therapists who are experienced in managing 

highly emotional events.

Support Groups for Families

Mutual-help groups provide the continuing 

emotional, educational, and interpersonal 

support that family members often need as 

clients complete their treatment. Attending 

support group meetings helps family members adjust to changes being made by the 

recovering member and begin new lives of 

their own. Family support groups may be 

sponsored on an ongoing basis by the IOT 

program or consist of community-based 

fellowships such as Al-Anon, Nar-Anon, 

Alateen, Adult Children of Alcoholics 

(www.adultchildren.org), Adult Children 

Anonymous (www.12stepforums.net/acoa.

html), and Families Anonymous.

When a family support group is sponsored 

by the IOT program, it usually meets weekly. 

Family members can discuss problems and 

concerns that arise because of the client’s 

recovery and reconnection with the family. Such groups offer continuity for family 

members during the difficult treatment and 

recovery periods. Surrounded by familiar 

program staff members and other family 

•

•

•

participants, family members build on the 

momentum of their previous experiences in 

treatment. Examples of the issues discussed 

include parenting, decisionmaking, conflicts, 

sexual functioning, intimacy, anger management, mood swings, reestablishing trust, 

adjusting roles, learning what is “normal,” 

renegotiating relapse prevention contracts, 

and substance use by other family members.

Community-based 12-Step support groups 

such as Al-Anon, Nar-Anon, and Alateen are 

independent from the IOT program. Because 

family members may be reluctant to initiate 

contact with such groups, IOT providers can 

assist family members by providing information about meetings, such as what happens 

at these meetings, the rituals observed, who 

attends, how meetings are conducted, the 

purpose of the meetings, and where to find 

them. Members of mutual-help groups can 

be invited to give talks to the family members in the IOT program. Providers also 

should emphasize that the meetings are 

anonymous. By encouraging family members to attend at least three meetings before 

deciding whether to continue, the IOT provider increases the probability that family 

members have a positive experience and 

continue to attend. IOT staff can encourage 

members of multiple families from the program to attend meetings together so that they 

can reinforce and reassure one another.

Family Clinical Issues 

in IOT

Diverse questions, concerns, and behaviors are presented by family members 

during IOT sessions. The complexity of 

human relationships and interactions is 

revealed in treatment and can challenge 

both participants and counselors to use the 

opportunities and experiences therapeutically. Long suppressed anger, family secrets, 

shame, and confusion may surface. Family 

members may harbor feelings and thoughts 

that can affect the client and the family 

adversely and that require resolution within 

a therapeutic environment. 
Family-Based Services 103

Unrealistic Expectations 

About Treatment Outcomes

Family members often have unrealistic 

expectations about treatment and the 

client’s recovery. Family members may not 

understand the nature of a substance use 

disorder or are unable to accept that it is a 

chronic, relapsing disease and recovery is a 

lifelong process. Some family members, for 

instance, can be so fatigued and emotionally 

depleted from the stress of living with the 

person who abuses substances that they have 

unrealistic hopes for treatment. Strategies 

and solutions to address unrealistic expectations and common fallacies about treatment 

and recovery include the following:

Informing the family early in treatment 

about common but unrealistic expectations. By gently raising this issue early in 

treatment during individual family sessions, 

the IOT counselor can draw attention to and 

begin to dispel any fallacies. The counselor 

can probe for related family beliefs, answer 

family members’ specific questions, and 

provide real-life examples before unrealistic 

expectations lead to an undermining of family and client functioning. This process also 

can identify specific educational needs.

•

Using a variety of formats to provide 

clear, understandable information about 

substance use disorders. A family education group is a basic component of IOT 

programming that is effective in debunking many fallacies about substance use 

disorders. For instance, the group can be 

used to dispel the idea that once a client 

is in treatment, he or she will stop having the urge to use; that once use stops, 

everything will be “perfect”; or that doctors 

and counselors will teach how to get well. 

A counselor can obtain or develop written 

materials (fact sheets, brochures, posters) 

at appropriate reading levels and in relevant languages. These materials need to 

be available at the program facility and 

distributed to family members at intake 

and during treatment. A brief, informative 

video can be played during family sessions, 

in counselors’ offices, or in the waiting 

room.

Reaching many family members. It is 

important to educate as many family members as possible and to ensure that the 

most influential family members become 

knowledgeable about substance use disorders and then redirect other family members if necessary.

•

•

Changing Realities: Working With Clients Who Are Estranged 

From Their Families

In one IOT program, some clients revealed that they did not participate in family groups, 

family nights, and other family-oriented activities because they had no family. The clients 

had been ostracized by or estranged from family members for an extended period.

The counselors suggested that clients and staff rename the “family” events so that clients 

could feel more comfortable bringing other individuals such as co-workers or friends who 

made up their family of choice. Instead of Family Night, the program sponsored Support 

Network Night.

The results

Participation in the events increased. More clients and their supporters attended 

treatment activities.

Clients were encouraged to build an abstinent support network that included friends, coworkers, neighbors, or others as well as members of their family of origin.

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104 Chapter 6

Family Responses to Relapse

Clients can relapse, and family members 

may be unwilling or unable to be compassionate or nonjudgmental about episodes of 

relapse. Typically, relapse is an unpopular 

topic with family members. If relapse occurs, 

counselors need to be prepared for a range of 

emotional responses from families, including 

anger, panic, blame, depression, spitefulness, 

and relief. Some families may abandon or 

withdraw from the client; others may attempt 

to engage the client in substance-using activities; still other families may be caught in 

patterns of depression and resignation or 

panic and fear.

The following therapeutic options may help 

counselors in assisting families that may 

experience a family member’s relapse:

Prepare the family members as well as 

the client for the possibility of relapse. 

Family members are likely to be the first to 

know when a client relapses. IOT programs 

focus on strengthening the client’s relapse 

prevention skills, but families also need 

•

assistance. IOT staff members can help 

families

Understand that relapse can happen and 

that each family reacts in unique ways.

Accept that their reactions to the relapse 

crisis do not necessarily indicate that the 

family is in deep trouble.

Prepare a plan that identifies steps the 

family will take if relapse occurs.

Identify ways that family members can 

support one another.

Seek help if the plan fails.

Assist family members in engaging support services and resources. Communitybased support groups such as Al-Anon, 

Nar-Anon, Alateen, and Alatot (for children of parents who abuse alcohol) are 

available in most areas and are indispensable sources of help for many families. 

Family members should be encouraged to 

attend meetings regardless of the client’s 

recovery status. In these groups, family 

members focus on their own needs, accept 

what they cannot change, and engage in 

healthy, satisfying activities. To facilitate 

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–

–

–

•

Living the Treatment Process

Anthony’s wife and son were relieved and optimistic when he entered treatment. Soon 

they would be able to enjoy the husband and father they had missed during many 

years of substance abuse. As the weeks passed, however, Anthony’s family grew more 

angry and disappointed. He rarely spent time with them and was always at recovery 

meetings. He showed little interest in their lives and was not physically or emotionally 

available to them. “I thought treatment would make our lives better, but it’s just not 

true,” said his wife.

Counselor’s response

Validate the feelings of family members.

Explain that Anthony’s recovery requires his full attention. For a time, he will be 

unable to devote much attention to the needs or expectations of others. Only as his 

recovery progresses and risk of relapse recedes can he become less self-focused.

Discuss the warning signs of relapse.

Emphasize the family members’ need to focus on enhancing their own lives, independent of the addicted loved one, including involvement in support groups such as 

Al-Anon.

•

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Family-Based Services 105

attendance, some IOT programs offer these 

groups space at their facility. Others sponsor their own family support groups, led by 

alumni of the programs, that are open to 

all who wish to attend for as long as they 

desire.

Seek interventions for individual family members when their responses to 

relapse are unhealthy. The IOT counselor 

needs to be alert to the possibility that 

relapse by a client may require additional 

family interventions and referrals to other 

service professionals. For example, another 

family member also may be in recovery 

and may need additional assistance from 

a support group. Another family member 

may become depressed as a result of the 

client’s relapse, or an adolescent may act 

out. The client and other family members 

may benefit from psychological or psychiatric interventions. 

Sabotage by Family Members

A family can sabotage the client’s progress 

when one or more family members behave in 

ways that undermine the client’s abstinence 

or treatment. For example, family members 

may continue to use or leave alcohol or 

drugs where the client is likely to see them. 

They may state to the client or others that 

the client is likely to fail or may refuse to let 

the client use the family car to go to a support meeting or treatment session. Examples 

of successful clinical approaches to discourage sabotage and encourage positive 

participation are as follows:

Schedule individual family sessions to discuss the specific behaviors that are sabotaging recovery efforts. 

Discuss alternative behaviors that support 

recovery, and offer support for making the 

behavioral changes.

Determine whether individual therapy 

is needed, and support family members 

with a referral to a family therapist as 

appropriate.

•

•

•

•

Work with family members to create a contract that specifies how their behavior is to 

change.

Monitor progress.

Family Life Without Substance 

Abuse

As recovery begins, some family problems 

resolve with abstinence. Issues of trust and 

worries about how the family will be different are likely to emerge. Here are a few 

common questions and some suggested 

answers on how IOT counselors can help 

families:

How do we reestablish trust?

Teach family members that a lack of 

trust is a normal and natural reaction 

in early recovery but, at the same time, 

the recovering person may sense this 

lack of trust and may become angry or 

sad.

Indicate that the newly abstinent 

member may suffer from a “time 

warp” in which a week seems more like 

a month. Such different perceptions 

of time can add to conflict around 

the trust issue because the client may 

expect the family’s trust after what 

is, in reality, only a short period of 

abstinence.

Discuss the idea that mistrust 

transforms into trust only as the 

client maintains abstinence and 

demonstrates positive changes in 

behavior. Ask the client to accept that 

family members may not trust him or 

her for a period. 

Suggest that family members agree 

to extend their trust incrementally to 

the client. For example, an adolescent 

client may be given permission to 

use the family car for an outing if 

the adolescent’s school attendance is 

satisfactory for a specific period.

•

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1.

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106 Chapter 6

How do we have fun again?

Suggest creating new family rituals 

to replace old ones that involved 

substance use.

Suggest establishing and celebrating 

“family” abstinence anniversaries.

Encourage participation in events 

sponsored by Al-Anon, Nar-Anon, and 

other family support groups.

Urge participation in multifamily 

groups sponsored by the treatment 

program.

Ask each member to identify a favorite 

“family fun” activity for the entire 

family to enjoy.

Ask members to consider separate 

couples and parent–child activities 

to create new relationships between 

family members.

Ask members to keep a family journal 

that includes ideas, feedback, and 

comments from family members on 

various activities, rituals, and other 

family events.

What do we say to friends, neighbors, 

and associates about treatment and 

recovery?

Assist family members in discussing 

and coming to decisions about what 

information they want to share with 

others and when. Write down this 

information, give it to all family 

members in the form of an agreement, 

2.

•

•

•

•

•

•

•

3.

•

and have each member sign the 

agreement.

Review the privacy and confidentiality 

provisions that govern treatment 

programs with family members to 

remind them that providers will not 

discuss these topics with others and 

that family members are in control 

of what others know. Use family 

support group sessions to discuss this 

issue so that members learn from the 

experiences and examples of other 

families.

Have family members “rehearse” 

situations they are likely to encounter 

to practice appropriate responses.

First the bottle, now the meetings. Will 

it ever get better?

Acknowledge that the spouse or 

significant other is disappointed and 

frustrated.

Point out that recovery is the first 

and most important goal during this 

difficult period and that people in 

recovery often immerse themselves 

in recovery activities with the same 

intensity with which they used 

substances.

Assist the spouse or significant other 

in focusing instead on his or her own 

recovery and in attending Al-Anon, 

Nar-Anon, or other support groups.

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Family-Based Services 107

The genogram is useful for engaging the 

client and significant family members in 

a discussion of important family relationships. Squares and circles identify parents, 

siblings, and other household members, and 

an enclosed square or circle identifies the client. Marital status is represented by unique 

symbols, such as diagonal lines for separation 

and divorce. Different types of connecting 

lines reflect the nature of relationships among 

household members. For instance, one solid 

line represents a distant relationship between 

Appendix 6-A. Format and Symbols for 

Family Genogram*

Format for Family Genogram

Symbols Useful for Genograms

Symbols Relationships

= male

= alcohol or drug abuse

 (indicate drug of abuse)

= mental or physical illness

Members of client's household (dotted lines):

m 1981 Marriage (give year)

Marital separation (give year)

Divorce (give year)

1992 Living together relationship 

or liaison (give year)

Induced abortion

= female

= client

= alcohol or drug abuse and

 mental or physical problems

X X = deceased

1982 1984

d 1980 m 2003

s 1990

d 1992

d 1996

Family Interaction Patterns (nature of relationships)

Distant

Very close

Estranged/cut off

Conflictual

Fused and conflictual

(a bond of ongoing conflict

 that is mutually satisfying

 and/or rewarding)

x

Children: List in birth order with birth year

Adopted or foster children = dotted line

Note any changes in custody

1983 1985 1987 1988 1989

_______________________

*Source: New Jersey Division of Addiction Services, New Jersey Department of Health and Senior Services.

Alcohol

Cocaine

Heroin

m (year) ❲

❲

1st generation:

2nd generation:

3rd generation:

4th generation:
108 Chapter 6

two individuals; three solid lines represent 

a very close relationship. Other key data, 

such as arrest information, are written on the 

genogram as appropriate.

This sample genogram depicts a family that 

initially was seen as a close, loving family 

unit. The son, John, had come under the 

influence of some “bad friends” and had 

become involved in abusing and selling substances. While expressing their willingness to 

help, the family denied the seriousness of the 

situation and minimized any problems in 

the nuclear or extended family.

When the discussion was extended to one 

of John’s maternal uncles, Mrs. G. admitted 

that her brother had been arrested a number 

of times for heroin possession. Questions 

about the maternal grandmother’s reaction to John’s “problem” caused the united 

family front to begin to dissolve. It became 

apparent that Mrs. G.’s mother took an 

“insensitive position” regarding John’s substance use disorder and there was a serious 

estrangement between her and her daughter. 

In discussing the details of the uncle’s criminal activity (which was a family secret that 

even John and his brothers did not know), it 

emerged that Mrs. G. had for years agonized 

over her mother’s pain. Now, desperately 

afraid of reliving her parents’ experiences, 

Mrs. G. had stopped talking to her mother. 

John’s brothers felt free to open up and 

expressed their resentment of their brother 

for putting the family in this position.

Mr. G., who had been most adamant in 

denying any family problems, now talked 

about the sense of betrayal and failure he 

felt because of John’s actions. It was only 

through the leverage of the family’s experience that the family’s present conflict 

became evident.

Client John G. and His Family

Grandparents:

Aunts/Uncles:

Client and

Siblings:

Children

(Nephews/Niece):

Parents:

work together Lives nearby,

works with

mother

1982

1980

1983 1985

m 1978

Cocaine

John

Arrested for

selling drugs

Lives 2 hours away

Bailed out his son

repeatedly

"Let my son rot

in jail"

Heroin

Jailed for drugs Mrs. G many times

The G. Family

(household members)

Mr. G.

X
Family-Based Services 109

Designing a social network map is a practical strategy to survey various aspects of 

social support available to clients and their 

families. Mapping a client’s social network 

is a two-stage process. First, the client uses 

a segmented circle to categorize people in 

the network (e.g., friends, neighbors). Then, 

a grid is used to record a client’s specific 

responses about the supportive or nonsupportive nature of relationships in the 

network (Tracy and Whittaker 1990). This 

approach allows both clinicians and clients 

to evaluate (1) existing informal resources, 

(2) potential informal resources not currently 

used by the client, (3) barriers to involving 

resources in the client’s social network, and 

(4) whether to incorporate particular informal resources in the formal treatment plan. 

Mapping also can identify substance-using 

behaviors of individuals in the client’s social 

network. The map takes an average of 20 

minutes to complete and provides a concise 

but comprehensive picture of a family’s 

social network. Practitioners report that the 

social network map identifies and assesses 

stressors, strains, and resources within 

a client’s social environment (Tracy and 

Whittaker 1990). This interactive, visual tool 

allows clients to become actively engaged 

and gain new insight into how to find support within their social networks. 

Instructions

Step one. Explain to the client that you 

would like to take a look at who is in the 

client’s social network by putting together 

a network map. The client can use a first 

name or initials for each important person in his or her life; either the clinician or 

the client can enter the names in the appropriate segment of the circle shown at right. 

Sample script. Think back over this past 

month, say since [date]. What people have 

been important to you? They may have been 

people you saw, talked with, or wrote letters 

to. This includes people who made you feel 

good, people who made you feel bad, and 

others who just played a part in your life. 

They may be people who had an influence on 

the way you made decisions during this time.

There is no right or wrong number of people 

to identify. Right now, just list as many people as you can think of. Do you want me to 

write, or do you want to do the writing? First, 

think of people in your household—whom 

does that include? Now, going around the 

circle, what other family members would you 

include in your network? How about people 

from work or school? (Proceed around each 

segment of the circle.) Finally, list professional people or people from formal agencies 

whom you have contact with.

Look over your network. Are these the people 

you would consider part of your social network this past month? (Add or delete names 

as needed.) 

Appendix 6-B. Family Social Network Map*

Household

Other

Family

Work, School

Formal

Services

Neighbors

Friends

Clubs,

Faith-Based

Organizations

_______________________

* Source: Tracy and Whittaker 1990, pp. 463–466. Reprinted with permission from Families in Society

(www.familiesinsociety.org), published by the Alliance for Children and Families.
110 Chapter 6

Step two. Number the sections of the circle 

1 through 7, as shown in the Area of Life 

section of the grid (exhibit 6-3). If there are 

more than 15 names on the circle, the client selects the top 15 people to enter on the 

social network grid. Transfer the 15 names 

and the numbers that correspond to the sections of the map to the social network grid. 

Names of people in the network also should 

be put on individual slips of paper for the 

client to use in preparing the network grid. 

Step three. After the names from the social 

network map have been added to the leftmost column of the social network grid, ask 

the client to consider the nine categories in 

the column headings. The client uses the 15 

slips of paper with the names from the social 

network map to respond, sorting the slips 

into groups corresponding to the numerical 

options that accompany each category in the 

grid. For example, when considering how 

critical of the client each individual in his or 

her life is, the client sorts the slips into piles 

representing those who (1) hardly ever, (2) 

sometimes, or (3) almost always criticize. The 

name of each person and the appropriate 

number for his or her level of support are 

then entered onto the network grid in each 

life area. The finished grid gives an overall picture of support in the client’s social 

network.

Sample script. Now, I’d like to learn more 

about the people in your network. I’ve put 

their names on this network grid with a number for the area of life. Now I’m going to ask 

a few questions about the ways in which they 

help you. 

The first three questions have to do with the 

types of support people give you. Who would 

be available to help you out in concrete 

ways? For example, who would give you a 

ride if you needed one or pitch in to help you 

with a big chore or look after your belongings 

for a while if you were away? Divide your 

cards into three piles: those people you can 

hardly ever rely on for concrete help, those 

you can rely on sometimes, and those you’d 

almost always rely on for this type of help.

Now, who would be available to give you 

emotional support? For example, who would 

comfort you if you were upset or listen to 

you talk about your feelings? Again, divide 

your cards into three piles. (Proceed through 

remainder of the questions.)

Clinical Application

Mapping a client’s social network provides 

a visual and numerical depiction of the client’s significant relationships. The following 

aspects of social functioning are highlighted:

Network size

Availability of support

Criticism client faces

Closeness

Reciprocity

Direction of help

Stability

Frequency of contact

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•

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•

•

•

•

•
Family-Based Services 111 Exhibit 6-3. Social Network Grid Used in Conjunction With Network Map ID __________ Respondent _____________ Area of Life Concrete Support Emotional Support Infor- mation/ Advice Critical of Client Direction of Help Closeness How Often Seen How Long Known 1. Household 2. Other family 3. Work/School 4. Organizations 5. Other friends 6. Neighbors 7. Formal services 1. Hardly ever 2. Sometimes 3. Almost always 1. Hardly ever 2. Sometimes 3. Almost always 1. Hardly ever 2. Sometimes 3. Almost always 1. Hardly ever 2. Sometimes 3. Almost always 1. Goes both ways 2. You to them 3. They to you 1. Never very close 2. Sort of close 3. Very close 0. Does not see 1. Few times/yr. 2. Monthly 3. Weekly 4. Daily/twice or more per week 1. < 1 yr. 2. 1-5 yrs. 3. > 5 yrs. Name #010203040506070809101112131415
112 Chapter 6

Publications and Videos

A helpful reference is Family Therapy: An 

Overview (Goldenberg and Goldenberg 

1985). This book presents a comparison of 

six theoretical models of family therapy, 

including the psychodynamic, experiential/

humanistic, structural, communication, and 

behavioral models. Meyers and colleagues 

(2003) offer an overview of community reinforcement and family therapy (CRAFT) that 

emphasizes the approach’s empirical support. Using concerned family members and 

friends, CRAFT works to bring those who 

deny they have a substance use disorder into 

treatment.

American Outreach Association (AOA)

(www.americanoutreach.org). AOA is a private, nonprofit organization that produces 

pamphlets to help families cope with alcohol 

and substance abuse. The pamphlets can 

be downloaded from AOA’s Web site. Topics 

include strategies on confronting children 

who use substances, effective ways for parents to communicate with their children, and 

ways to help someone with alcohol and drug 

abuse problems.

Films for the Humanities and Sciences 

(www.films.com). This organization offers 

150 educational films on substance abuse, 

covering topics such as treatment issues and 

the effects of addiction on family members 

and including a series on young adults and 

substance abuse. 

Gerald T. Rogers Productions (www.

gtrvideo.com). This company produces films 

and videos on substance abuse for many 

audiences, from first graders to families with 

members who abuse substances.

Hazelden Foundation (www.

hazeldenbookplace.org). Hazelden Bookplace 

is an online resource center and marketplace 

for products and services from Hazelden 

Publishing & Educational Services and 

provides resources to help individuals, families, and communities prevent and recover 

from substance use and related disorders.

Johnson Institute (johnsoninstitute.org). 

This organization offers books, booklets, 

and videos that are distributed through the 

Hazelden Bookplace Web site. Some familyrelated videotapes available are Parenting 

Issues for Recovering Families, The Kid and 

Me: Parenting for Prevention, The Enabler, 

Intervention, and Intervention: How to Help 

Someone Who Doesn’t Want Help.

National Families in Action (NFIA) (www.

nationalfamilies.org). NFIA is a national 

drug education, prevention, and policy 

center with the mission of helping families 

prevent substance abuse among children 

by promoting science-based policies. NFIA 

offers books, pamphlets, and afterschool programs to keep young people substance free. 

NFIA has collaborated with other organizations on several projects, including Allied 

Systems Strengthening Families Project and 

the Drug-Free America Foundation.

NIMCO, Inc. (www.nimcoinc.com). This 

organization offers videos on alcohol, 

tobacco, and drug education and prevention 

topics. Videos cover such issues as drinking 

and driving, steroid use, substance abuse in 

the workplace, and the effects of substance 

abuse on the mind and body. 

Pyramid Media (www.pyramidmedia.com).

This company offers films and videos about 

substance abuse that are appropriate for 

training, educational groups, and individual 

and family viewing.

Substance Abuse and Mental Health 

Services Administration’s National 

Clearinghouse for Alcohol and Drug 

Information (NCADI) (www.ncadi.samhsa.

gov). NCADI is a national resource center 

Appendix 6-C. Resources for 

Family-Based Services
Family-Based Services 113

funded by the Federal Government that 

offers a large inventory of publications and 

videos for treatment professionals, clients, 

families, and the general public, including 

Alcoholism Tends To Run in Families. This 

fact sheet presents important information 

about the influence of parental alcoholism on children and families. It considers 

evidence that links alcoholism to dysfunctional marital relationships, child abuse, 

depression, physical problems, and impaired 

school performances, among other undesirable effects.

Moyers on Addiction: Close to Home (www.

pbs.org/wnet/closetohome). This is the 

online companion to the PBS show. It 

features real-life stories of struggles with 

addiction, information on treatment and 

prevention, and downloadable resources 

such as family guides, viewer’s guides, teacher’s guides, and health professional’s guides 

to the PBS series.

Family Support Groups

Adult Children of Alcoholics (ACOA) (www.

adultchildren.org). ACOA is a 12-Step, 12-

Tradition program that offers support for 

grown children of parents with alcohol or 

drug addiction. 

Al-Anon family groups (www.al-anon.org). 

Al-Anon is a fellowship of relatives and 

friends of people who have alcohol problems 

who share their experiences, strengths, and 

hopes. Members believe that alcoholism is 

a family illness and that changed attitudes 

can aid recovery. The program is based on 

the 12 Steps and 12 Traditions of Alcoholics 

Anonymous. 

Families Anonymous (FA) (www.

familiesanonymous.org). FA is a 12-Step, 

mutual-help, recovery support group for relatives and friends of those who have alcohol, 

drug, or behavioral problems. FA pamphlets, 

booklets, newsletters, and daily inspirational 

thought book are written by the members.

Nar-Anon family groups (www.naranon.

com). Similar to Al-Anon, Nar-Anon is a fellowship of relatives and friends of people 

who abuse substances and offers a constructive program for members to achieve peace 

of mind and to gain hope for the future. 

Contact information is available in local telephone directories.

National Asian Pacific American Families 

Against Substance Abuse (www.napafasa.

org). This nonprofit organization is dedicated 

to addressing the alcohol, tobacco, and drug 

issues of Asian and Pacific Islander (API) 

populations in the continental United States, 

Hawaii, and the six Pacific Island jurisdictions, as well as elsewhere. Its nationwide 

network consists of approximately 200 API 

and human service organizations, and its Web 

site lists resources, services for public and professional audiences, and current activities. 

115

7 Clinical Issues, 

Challenges, and 

Strategies in Intensive 

Outpatient Treatment

Once clients are engaged actively in treatment, retention becomes 

a priority. Many obstacles may arise during treatment. Lapses 

may occur. Frequently, clients are unable or unwilling to adhere 

to program requirements. Repeated admissions and dropouts can 

occur. Clients may have conflicting mandates from various service 

systems. Concerns about client and staff relationships, including 

setting appropriate boundaries, can compromise care. Intensive 

outpatient treatment (IOT) programs need to have clear decisionmaking processes and retention strategies to address these and other 

circumstances. 

This chapter discusses common issues that IOT programs face 

and offers practical approaches to retaining clients in treatment. 

Experience has taught IOT clinicians that every problem can have 

many solutions and that the input and ideas of colleagues lead to 

creative approaches and solutions. The chapter presents specific 

scenarios and options from clinical practice and experience for clinicians to consider, modify, or implement.

Client Retention

Reducing client attrition during treatment must be a priority for 

IOT providers. Compared with clients who drop out, those who 

are retained in outpatient treatment tend to be White, male, and 

employed (McCaul et al. 2001). Client attributes associated with 

higher dropout rates are labeled “red flags” by White and colleagues (1998); these red flags include marginalized status (e.g., 

racial minorities, people who are economically disadvantaged), lack 

of a professional skill, recent hospitalization, and family history of 

substance abuse. Being aware of these red flags can help clinicians 

intervene early to assist clients at increased risk of dropping out. 

Veach and colleagues (2000) found that clients who abuse alcohol 

were more likely to be retained and those who abuse cocaine were 

less likely to be retained in outpatient treatment. Other studies have 

In This 

Chapter...

 Client Retention

Relapse and 

Continued 

Substance Use

Substance Use by 

Family Members

Group Work Issues

Safety and Security

Client Privacy

Clients Who Work

Boundary Issues
116 Chapter 7

found that the substance a client abuses is 

not a good predictor of retention (McCaul et 

al. 2001).

The following strategies improve retention of 

clients in treatment:

Form a working relationship with the client. The counselor should foster a respectful and understanding relationship with 

the client. This therapeutic relationship 

reduces resistance and successfully engages 

the client in working toward mutually 

defined treatment goals.

Learn the client’s treatment history. If 

the client has dropped out of treatment 

previously, the counselor should find out 

why. If the client has engaged and been 

retained successfully in treatment before, 

the counselor should ask what made treatment appealing.

Use motivational interviewing. The counselor should help clients work through 

ambivalence by supporting their efforts to 

change and helping them identify discrepancies between their goals and values and 

their substance use. Involving clients in 

activities, such as support groups, also is 

effective.

Provide flexible schedules. IOT providers need to consider the client populations 

they serve and schedule groups accordingly. For example, morning groups can be 

for clients who work swing and night shifts 

and for women with school-age children 

and evening groups for those working regu-

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lar business hours. It can be difficult for 

clients to fit many hours of treatment into 

their week. 

Use the group to engage and reengage 

the client. The counselor should encourage members to talk about their ambivalence, how they are overcoming it, and 

their experiences of dropping out of treatment, as well as the negative consequences 

of dropping out. The counselor can supply 

all group members with an updated telephone list and encourage them to talk to at 

least two other members daily. The counselor can ask members to call those who 

are absent to let them know that they were 

missed and are important to the group. 

It is important to check with clients to be 

sure that they are receptive to these phone 

calls; some may view them as intrusive and 

disrespectful.

Increase the frequency of contact during 

the early treatment period. Clients often 

feel vulnerable or ambivalent during the 

first few weeks of treatment. Counselors 

need to contact each client frequently during this period to enhance retention. These 

contacts can be brief and made by telephone, e-mail, or letter. At the same time, 

counselors should encourage clients to contact other group members to reinforce the 

value of reaching out for support.

Use network interventions. Counselors 

need to work with individuals in the community who are invested in the client’s 

recovery to encourage the client to stay 

in treatment. These individuals can be 

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Multiple Retention Challenges

Clinical issue. A man, age 35, single, and an immigrant from El Salvador, has failed to return to 

treatment or contact his counselor in the last 3 days.

Approach

The counselor writes a note to the client in Spanish, encouraging him to return to treatment.

The counselor arranges for the client to get a ride to the next group session and for public 

transportation vouchers for subsequent sessions.

The counselor schedules an individual counseling session for the client to discuss several retention problems, which include lack of transportation, language barriers, and shame over lapses 

to his previous drinking pattern.

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•
Clinical Issues, Challenges, and Strategies in IOT 117

probation officers, ministers, employee 

assistance program counselors, friends, 

and co-workers. If the program identifies 

supportive individuals early in treatment 

and obtains a written consent for release of 

information from the client, the counselor 

can ask these individuals to encourage the 

client to attend sessions or increase his or 

her commitment to recovery. 

Deliver additional services throughout the treatment period. Fishman and 

colleagues (1999) found that attrition 

was lower during the intensive “servicesloaded” phase of IOT and, conversely, that 

attrition increased during the less rigorous 

program phases. 

Never give up. The counselor should 

make continual efforts to follow up with 

clients who have dropped out. Successful 

techniques include telephone calls, letters, 

and home visits to encourage the client to 

return to the program. This level of dedication can affect the client’s attitude and 

willingness to complete treatment.

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Relapse and Continued 

Substance Use

Lapses often happen in the difficult early 

months in treatment. These brief returns to 

substance use can be used as a therapeutic 

tool; the goal is to keep them from becoming full relapses with a return to substance 

use. IOT clients living in the community are 

exposed to pressures to relapse, often while 

struggling with cravings and their own resistance to change. Clients need to use relapse 

prevention strategies when they are exposed 

to alcohol and drugs, experience cravings, 

are encouraged by others to return to substance use, or are exposed to personal relapse 

triggers (Irvin et al. 1999). (See appendix 7-A, 

page 135, for descriptions of several instruments for assessing clients’ relapse potential.)

General relapse prevention strategies are to

Educate clients and their family members about addiction and recovery. •

The Difference Between a Lapse and Relapse

Jack’s experience: A lapse.

Jack comes to group distressed because he drank on the weekend. He has been abstinent for 2 

months and is concerned that he has jeopardized his employment and the return of his driver’s 

license. He discusses the episode with his counselor, and they identify treatment options. The 

therapeutic goal is to reinforce Jack’s desire to stay abstinent, and the episode becomes an opportunity to strengthen his relapse prevention skills.

This is a lapse, that is, a brief return to substance use following a sustained period of abstinence 

(a month or more). The client still is committed to his recovery and has not experienced loss of 

control. The event is used to help the client identify relapse triggers and increase his understanding and ability to withstand pressures to use substances.

Phil’s experience: A relapse.

Phil is in treatment for methamphetamine use. He has disappeared from treatment again.

When he returns, he is hyperactive, has a positive drug test, and refuses to talk about the test 

results or his return to drug use. He then fails again to return to the program. He is seen on the 

street obviously intoxicated. The compulsion to use is strong.

This is a relapse, that is, a prolonged episode of substance use during which the client is not 

open to therapeutic intervention or learning. Often a relapse can lead to dropout and indicates a 

continuing struggle by the client with his or her disease.
118 Chapter 7

Clients and family members need information about the disease of addiction 

and its stages, cues to relapse, early signs 

of relapse, how addiction affects relationships, and how to find resources for 

support (e.g., Al-Anon). Counselors need 

to enlist the support of family members 

and significant others to keep them from 

sabotaging treatment. Family members 

need advice on how to support the client 

in recovery and how to cease enabling 

behaviors. 

Conduct an early assessment of specific 

relapse triggers. Together with the counselor, clients can conduct a functional 

analysis of their substance use, working 

to identify and understand with whom, 

where, when, and why they use substances. 

Functional analysis is a tool that identifies 

not only clients’ high-risk circumstances 

for substance use but also the ways in 

which triggers are linked to the effects that 

substance use produces. TIP 33, Treatment 

for Stimulant Use Disorders (CSAT 1999e), 

and TIP 35, Enhancing Motivation for 

Change in Substance Abuse Treatment

(CSAT 1999c), explain how to perform a 

functional analysis.

•

Develop a relapse prevention plan immediately. A relapse prevention plan should 

include coping strategies developed by the 

counselor and client, such as going to support group meetings, avoiding places where 

the client used substances in the past, 

identifying good things about a substancefree life, and telephoning the client’s 

sponsor regularly. TIP 33 (CSAT 1999e) 

contains information and worksheets 

to develop a relapse prevention plan. 

Technical Assistance Publication (TAP) 

8, Relapse Prevention and the SubstanceAbusing Criminal Offender (Gorski et al. 

1993), and TAP 19, Counselor’s Manual 

for Relapse Prevention With Chemically 

Dependent Criminal Offenders (Gorski and 

Kelley 1996), are helpful in developing a 

relapse prevention plan.

Provide intensive monitoring and support. These activities include random drug 

testing (including urine samples that are 

collected under observation of program 

staff to prevent tampering), family counseling or education sessions about supporting 

the client during and after treatment, and 

the client’s self-monitoring of exposure and 

response to substance use triggers. 

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A Relapse Prevention Quiz

This quiz can be a tool to support and strengthen a client’s readiness to avoid relapse. Having 

senior members in a group answer the questions reinforces their knowledge while they educate 

newer members in relapse prevention skills. 

What might you say to co-workers if they ask you to have a drink or get high with them?

Craving a drink or drug is quite natural for people who are dependent on alcohol or drugs. 

What three things can you do to get past the craving?

What are three common reasons for feeling that you don’t belong in a support group such as 

Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)?

What two things can you do if someone at an AA or NA meeting annoys you?

Why must recovery from your disease be your highest priority?

What three qualities should you look for in a sponsor?

Emotional discomfort takes a variety of forms. What are the three biggest problems for you? 

Anger, depression, self-pity, loneliness, boredom, worry, frustration, shame, guilt, or another 

emotion?

What three things can you do to handle each emotional discomfort you identified?

What are the key elements of an assertive response when offered alcohol or drugs?

Why is it important to avoid starting romantic relationships during early recovery?

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Clinical Issues, Challenges, and Strategies in IOT 119

Evaluate and review all slips and lapses.

Despite their negative consequences, lapses 

can be used therapeutically. The counselor 

and client can learn more about what constitutes high-risk situations for the client. 

The client needs to consider the slip or 

lapse a discrete, unique event that does not 

need to be repeated or continued. The client should remember that abstinence can 

be regained and that the client can renew 

his or her commitment to abstinence. 

Clients should be reminded to contact the 

counselor, other group members, their 

sponsor, or other mutual-help group members when they sense that they are verging 

on relapse. 

Use the behavioral contract with clients.

A behavioral contract spells out treatment 

expectations and goals, the rewards when 

goals are met, and the consequences if the 

contract is broken. The counselor should 

involve clients in writing the contract, 

encouraging them to use their own words. 

The behavioral contract helps bind clients 

to their commitment to abstinence and 

change. TIP 35 (CSAT 1999c) provides 

more information on behavioral contracts.

Introduce the stages of change. Marlatt 

and Gordon (1985) and Prochaska and col-

•

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•

leagues (1994) recommend using relapse 

prevention interventions that are matched 

to the client’s stage of change. Joe and 

colleagues (1998) and Connors and colleagues (2001a) argue that for clients 

who are ambivalent about abstinence, for 

example, initial interventions might focus 

on strengthening their resolve by analyzing the pros and cons of use, rolling with 

resistance, and never directly confronting 

clients. Subsequent interventions support 

abstinence by altering stimulus control 

and developing skills for negotiating highrisk situations. After a client experiences 

a period of abstinence, emphasis shifts to 

lifestyle modifications that promote longterm abstinence. 

Substance Use by 

Family Members

A client may have one or more family members who also actively abuse substances. In 

fact, research shows that individuals with 

substance use disorders are more likely than 

others to have family histories of substance 

use disorders (Johnson and Leff 1999). The 

client may be in regular contact with 

Multiple Dropouts and Readmissions

Some clients relapse or drop out of treatment and return repeatedly to treatment before they 

achieve a stable recovery. Providers may be reluctant to keep offering scarce treatment resources 

to the same individuals or to readmit individuals who drop out continually. Programs can 

respond to multiple dropouts and readmissions strategically by

Conducting a comprehensive evaluation of each client to determine whether IOT is the appropriate level of care. Some clients, for example, may benefit from a brief inpatient placement to 

ready them for IOT (see chapter 5).

Reviewing the client’s cycle of dropouts and admissions. Several cycles may be appropriate for a 

client with severe, complex needs and issues. Arbitrary rules regarding the number of permitted 

admissions and dropouts may be too rigid to support recovery of a severely impaired individual.

Establishing an admissions committee to review and recommend action regarding clients who 

seek readmission following repeated dropouts. The committee can include staff and alumni 

representatives.

Developing a profile of clients likely to drop out and designing a plan for them.

Arranging a psychiatric evaluation for the client, which may indicate that psychiatric treatment 

and medication are required.

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120 Chapter 7

members of the extended family, a close 

friend, spouse, or a boyfriend or girlfriend 

who uses substances. Active substance use by 

someone living in the same place as the client 

or who is part of the client’s social support 

network clearly threatens a client’s recovery. 

The IOT counselor can consider using these 

options:

Stay alert for others using substances. 

Construct and update regularly a genogram or social network assessment (see 

chapter 6) to identify possible substance 

use among family members, significant 

others, and friends who are likely to influence the client’s recovery. Gather information from the family and client about the 

nature, extent, and frequency of any substance use.

Request that the family and client develop an agreement about substance use in 

the home. It is important to enlist family 

members in the treatment process to help 

the client and any other family members 

who are using substances (see chapter 6). 

A substance use agreement, signed by family members, identifies substances that 

will not be kept or consumed in the home 

and the consequences for violating the 

agreement. Part of the agreement can be 

to report all substance use to IOT program 

staff for discussion during group and individual sessions.

Assist the client in identifying alternative 

housing if needed. Recovery homes, halfway houses, and shelters, among others, 

may be necessary temporary alternatives 

for a client who needs alcohol- or drug-free 

housing during and after treatment. If the 

client’s recovery is undermined continually 

in current housing, the counselor should 

consider such a housing referral.

Provide information about treatment 

to a family member who needs it. Offer 

information about treatment options 

or referrals to a family member with a 

substance use disorder in a manner that 

ensures the privacy of the individual and 

does not divert attention from the client’s 

treatment and recovery. 

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Group Work Issues

Group work is a core service of IOT and 

offers many opportunities for educating, 

supporting, and nurturing clients. Clients’ 

feelings toward their peers are important 

factors in shaping the way clients view the 

treatment experience. Clients are more likely 

to continue with treatment when they feel 

accepted, supported, and “normal” and 

receive empathy and kindness from others in 

the treatment group.

Many issues can affect group work and 

impede the progress of clients. For example, 

clients may be disruptive or withdrawn, 

have poor English or comprehension skills, 

and attend sessions sporadically. TIP 41, 

Substance Abuse Treatment: Group Therapy,

provides additional information on working with clients in therapeutic groups (CSAT 

2005f).

Developing Group Cohesion

Group cohesion can be a central element in 

a client’s recovery process. Frequent changes 

in group membership make it difficult to 

build group cohesion. Washton (1997) suggests that frequent shifting of clients among 

groups can result in higher dropout rates. 

This observation argues for limiting changes 

in group composition that sometimes occur 

in a “phased” or “stage-oriented” IOT 

program. Adding new clients to groups generates challenges for the counselor who must 

become oriented to new clients. The following approaches help create effective IOT 

groups and group cohesion:

Create group rituals. When new clients 

join a group or others depart, group rituals 

promote a sense of acceptance, safety, and 

support. Current members should orient 

new members to group rules and speak 

about their group experience. A ritual 

can mark a client’s graduation from the 

program and celebrate his or her success. 

Departure rituals may include a client’s 

demonstration of recovery knowledge and 

•
Clinical Issues, Challenges, and Strategies in IOT 121

skills, a group discussion of the departing 

client’s strengths and how group members 

can be supportive, a review of the client’s 

relapse prevention plan and options if the 

plan should fail, and presentation of the 

program’s emblem (see below).

Institute a program emblem. Staff and 

clients can design a program emblem to 

build and sustain group cohesion. The 

emblem is a visual symbol that represents 

the essence of the treatment program. For 

example, a coin, badge, or cup might be 

inscribed with a recovery motto such as 

“Serenity and Strength Day by Day” or 

“Hope, Freedom, and Recovery.” A logo 

might feature the rising sun, a stately oak, 

or clasped hands. These emblems can 

incorporate and reflect various cultural 

and ethnic values and designs. Some 

programs leave space in the emblem to 

inscribe each client’s name and his or her 

program completion date. Programs that 

have emblems have found that clients keep 

them and use them as reminders of their 

commitment to recovery and their success 

in remaining abstinent. The emblem and 

motto should convey a message of support 

while maintaining the confidentiality of 

the client (e.g., by not including the name 

of the treatment program).

Explore the group’s feelings about clients who drop out. When a member 

relapses and drops out of the group, the 

group provides a safe environment for 

•

•

other members to discuss their feelings or 

fears about failure and relapse and their 

own relapse prevention strategies. Because 

a client’s perception of his or her ability 

to complete the program influences the 

outcome, counselors need to support group 

members with positive statements about 

their potential to do well in treatment.

Encourage identification with the program in addition to the group. It can 

be helpful if clients develop a sense of 

belonging to the group and the treatment 

program. For instance, IOT staff can share 

information about the overall goals of the 

program, use guest counselors or supervisors to co-facilitate groups, and encourage former clients to return to share their 

experiences. Contacts with alumni outside 

treatment can be valuable, too.

Maintain effective group size and staffing. The ideal adult IOT group consists of 

8 to 12 clients, although up to 15 clients 

may be on the group roster (CSAT 2005f). 

Programs may need to adjust group sizes 

according to staff resources, the availability of co-therapists, the experience of the 

counselors, and the composition of the client population (e.g., adult or adolescent, 

women or men, people with co-occurring 

mental disorders). 

At least one therapist should have the 

required academic credentials for group therapy; a co-therapist can be an intern or trainee 

•

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Example of a Sendoff for a Treatment Program Graduate

As a client leaves treatment, he or she is invited to take a marble from a bowl of marbles. The 

group leader then tells the graduate: “Now that you have begun this new stage in your recovery, 

keep this marble with you always—perhaps in your pocket or purse. Keep it where you will see it 

often to remind you of how hard your addiction was on you and your family. More important, 

it will remind you of how firm and resolved you must be in your commitment to stay clean and 

work on a healthy recovery program. 

“Each time you reach into your pocket or purse and touch that marble, you will be reminded of 

the hard times that are behind you and those that may lie ahead. If, after all this, you decide that 

you do not care about the hard times and suffering that your addiction has caused and may cause 

again, and you decide that you want to sink back down into the mess of your addiction, then take 

the marble and toss it as far as you can, because you will have already lost the rest of your marbles!”
122 Chapter 7

who assists with managing client behaviors 

and observing the dynamics of the group. 

Preparing Clients for Group

IOT programs should orient new clients 

about how group therapy is conducted and 

how they are to use the group counseling 

sessions (see chapter 4). One way to do this 

is with a pregroup interview that allows the 

counselor to assess clients’ readiness for 

treatment, learn more about clients’ circumstances, and help shape clients’ expectations 

by answering questions and supplying 

information (CSAT 2005f). This information 

should include group norms and expectations and be reviewed with clients so that 

it is clear from the outset. Programs also 

should consider posting group norms on the 

wall of the meeting room and having clients 

read them aloud at the beginning of each 

group session.

Working With Uncommitted, 

Ambivalent Clients

Some clients in group treatment may not be 

committed to their recovery from substance 

use disorders. Clients who have been mandated to treatment by the justice system may 

feel that they do not have a problem but are 

only following a judge’s orders. Some clients 

may be late habitually or talk about their 

continuing interest in a substance-abusing 

lifestyle. The counselor cannot permit the 

client to attend group while under the 

influence of drugs or alcohol because this 

behavior can compromise the progress of 

other members of the group. However, the 

counselor can address behaviors displayed 

by uncommitted clients by 

Discussing the behaviors with the client 

individually to identify the issues and discuss options

Moving the client to a precontemplator or 

other group or terminating the client from 

the program

Introducing more structure into the group 

to enhance its therapeutic value for all 

members (e.g., by combining theme-oriented 

information with client discussion and 

concentrating less on process and more on 

organized content) 

Working With Clients Who 

Have Severe Mental Disorders 

Individuals diagnosed with severe mental 

disorders often require a high level of management by trained medical and substance 

abuse treatment professionals. These clients 

may have difficulty bonding with a group 

and may be disruptive or unable to focus for 

long periods. To enhance the effectiveness of 

group for individuals diagnosed with severe 

mental disorders, IOT providers are encouraged to consider these approaches: 

•

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Treating Individuals Who Have Severe Mental Disorders

Sam increasingly was unable to control his outbursts when in group. Although he usually was 

able to return to a calm state, the incidents persisted. His counselor was aware that Sam experienced hallucinations and, with input from Sam’s psychiatrist, determined that Sam was receiving 

little benefit from being in a group. His treatment plan was revised to increase his individual 

counseling sessions in place of group participation.

Marjorie was diagnosed with bipolar disorder and functioned well while taking prescribed medications. Her counselor noticed behavior changes in group (such as flirting with male members, 

hyperactivity) over several days. After Marjorie was referred to her psychiatrist, it was determined 

that she had stopped taking her medications. After she resumed taking her medications, her 

symptoms disappeared.
Clinical Issues, Challenges, and Strategies in IOT 123

Treatment should be coordinated with the 

client’s psychiatric care provider to determine how best to respond to crises that 

may arise during group.

Group treatment should be guided by clients’ readiness for and ability to engage in 

group work (Substance Abuse and Mental 

Health Services Administration 2002).

Group treatment staff members should be 

educated and trained about mental disorders so that they are familiar with the 

signs and symptoms of psychoses and crisis 

intervention techniques.

For more information about treating this population, see chapter 9 of this volume or TIP 

42, Substance Abuse Treatment for Persons 

With Co-Occurring Disorders (CSAT 2005e).

Working With Disruptive 

Clients

Clients in group express a wide range of feelings, thoughts, and behaviors. Some members 

may disrupt the work of the group by challenging or interrupting others, demonstrating 

their impatience and restlessness, or other-

•

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wise offending other group members. Some 

strategies to address these disruptions are to

Ensure that all clients know the group 

rules; provide them in writing, if possible.

Consistently point out group rules about 

disruptive behaviors and the consequences 

for engaging in them.

Reassess the client’s level of readiness to 

change, and assign the client to another 

group if appropriate.

Hold individual counseling sessions to 

discuss specific disruptive behaviors, how 

they are disruptive, and why they are not 

allowed; then explore and identify factors 

that may underlie the behaviors.

Refer the client to a mental health professional if needed.

Working With Quiet, 

Withdrawn Clients 

Clients may be reluctant to participate in 

group therapy for many reasons. They may 

be fearful or ashamed of revealing to strangers the extent of their substance use and 

related behaviors. Cultural values may inhibit the sharing of personal problems with 

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The Angry Client in Group

Problem behaviors

Yelling

Foul language

Interrupting

Being mean or insulting to others

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Key concepts for counselors

Be in control.

Avoid a power struggle.

Address the behavior, not the content.

Don’t raise your voice.

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What to do

Listen reflectively to validate the client’s feelings and to deescalate the situation. If the client 

remains angry, use these approaches: 

State that you are there to protect and safeguard the members of the group.

Identify specific behaviors that are inappropriate.

State that these behaviors are not allowed.

Identify the consequences if the behaviors continue (e.g., being removed from the group, not 

being permitted to participate in discussion for the remainder of the group session).

Follow through with the stated consequences if the behaviors are repeated.

Transfer the client to a different group or clinical service.

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124 Chapter 7

those outside the family. Language and comprehension barriers may make it difficult to 

follow or participate in the conversation.

Clients may refuse to take part in group 

discussions beyond the level of perfunctory comments because they resent being in 

treatment, are depressed or have some other 

mental disorder, find the group boring, or 

are uncomfortable in a group. Some clients 

resist treatment because they believe that 

they do not have a disease or do not belong 

in treatment.

Some strategies to assist withdrawn clients 

are to

Ask clients individually why they are 

quiet; then explore options based on the 

feedback.

Assess and diagnose language and comprehension skills, and assign clients to a group 

that functions at an appropriate pace and 

level.

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Provide individual mentoring to ensure 

that treatment information is conveyed 

and understood.

Create a “buddy system,” pairing clients 

to encourage a sense of acceptance and 

belonging among the members of the 

group.

Contract with the client to increase participation in the group incrementally.

Refer the client for psychiatric evaluation, 

if needed.

Adjust the client’s treatment plan to 

include individual rather than group counseling if that seems to be in the client’s 

best interest.

Responding to Intermittent 

Attendance

It takes time for a group to become a cohesive unit, and clients who do not attend 

sessions regularly can impede the group 

process. The client who misses sessions may 

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Helping the Client “Speak”

A counselor noted that, time after time, a client sat quietly in group and spoke only a few words, 

usually when she was called on. Despite gentle, persistent encouragement from the members of 

the group and the counselor, the client was quiet and watchful.

After a week, the counselor suggested this reticent client write out whatever she might want to 

communicate. The client was instructed to take an open-ended approach to the writing, similar to 

writing in a journal.

The counselor also asked the client to complete the following statements:

My health concerns are

The most stress this week came from

This week I’d rate my stress level as ____, with 1 being low and 10 being high.

The best thing that happened this week was

I’m working on my treatment goals by

How I’m feeling about group is

My most likely relapse trigger is

I get support for the healthy changes I’m making from

I participated in the following substance-free activities this week

After several days, the client returned with a sheet containing her thoughts and comments about 

daily events, her concerns for her children, and the statements completed. The counselor used 

the information to begin developing a relationship with the client that helped her feel more comfortable in the program and ultimately with the group.

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Clinical Issues, Challenges, and Strategies in IOT 125

feel left out of discussions and may jeopardize the development of trust among group 

members that is at the heart of forthright 

communication. Counselors may find that 

such clients are strongly ambivalent about 

being in treatment, have practical barriers 

that prevent them from attending regularly, 

or feel uncomfortable in the group.

Some strategies to assist these clients are to

Assess their readiness to change, and 

assign them to a precontemplator or other 

group whose members are at a similar 

stage of readiness.

Identify and address any barriers such as 

lack of reliable transportation, conflicting 

work hours, lack of child care, protests by 

the spouse or significant others to treatment, and fear of violence from a domestic 

partner.

Assign these clients to a group whose members share a similar cultural orientation, 

age range, gender, substance used, or level 

of psychological functioning.

Provide refreshments on days when attendance is high to reward desired behavior.

Monitor attendance and seek guidance 

from the supervising clinician.

Safety and Security

Clients, family members, and staff members 

must feel comfortable and safe when coming to the IOT program. IOT programs that 

treat high-risk clients need to monitor these 

clients carefully, anticipate problems, and 

plan appropriate interventions. Common 

safety and security issues that IOT programs 

face are identified by examples in exhibit 7-1 

along with the counselor responses.

Presence of Drug Dealers or 

Gang Members at the Facility

Every IOT program should post prominent 

signs (in multiple languages where appropriate) inside and outside its facility that 

prohibit loitering, drug-related activity, or 

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•

•

•

unauthorized persons on the premises. One 

or more trained staff members promptly and 

firmly should ask individuals not in treatment or not participating as family members 

to leave. Police assistance should be requested if there is any resistance to the request or 

if unauthorized individuals return.

In some cases, a client may encourage the 

presence of drug dealers or gang members. 

Criminal justice-mandated clients and 

individuals who are ambivalent about treatment, for example, may be susceptible to the 

influence of individuals who use substances 

and are part of their social networks. If the 

counselor finds this to be true, the counselor should inform the client that program 

rules prohibit such activity and explain 

the consequences of the client’s continued 

involvement with drug dealers or gang 

members. A client may need the encouragement of the counselor and the support of 

program rules and policies to end harmful 

associations. 

Stalking, Domestic Violence, 

and Threats Against Clients

IOT programs must take appropriate steps to 

ensure the safety of clients and staff members 

during treatment. Safety may be threatened 

by stalkers, violent domestic partners, former 

spouses and significant others, drug-related 

associates, or gang members. Counselors 

should consider following these steps:

Privately and in a nonjudgmental way, ask 

the client about restraining orders, threats, 

or violent incidents that have occurred or 

that may occur. Knowing about possible 

problems helps staff members and the client take needed precautions. They can be 

alert for evidence of any immediate danger 

and attempt to prevent it. Treatment staff 

have a duty to warn if the danger is clear 

and imminent, provided that confidentiality regulations are met (CSAT 2004b).

Intervene early to deescalate any situation 

that potentially could become violent.

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126 Chapter 7

Place violence-related information, such as 

occurrences of stalking, in the client’s case 

record. Help the client create a detailed, 

personal safety plan, and include it in the 

case record. (See TIP 25, Substance Abuse 

Treatment and Domestic Violence [CSAT 

1997b], for a sample plan.)

Require the client to sign a no-contact 

agreement that prohibits contact with a 

batterer during the course of treatment, 

with clearly delineated consequences for 

violations.

•

•

Assist the client in obtaining a civil protection order that prohibits harassment, contact, communication, or physical proximity 

by a batterer, stalker, or other threatening 

individual.

Connect the client to community services 

that address domestic violence, such as 

advocates, counselors, emergency housing, 

and financial assistance.

•

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Exhibit 7-1

Examples of Immediate Safety Concerns and Counselor Responses

Threat of violence against another. While in group, a male client expressed strong feelings of anger toward another man involved with the client’s ex-wife. The client stated that 

he had a gun and wanted to kill the other man.

Counselor response. The counselor removed the client from the group and engaged 

him in a discussion about his feelings and remarks. The counselor expressed concern 

about the client’s well-being and assessed whether he understood the seriousness of his 

statements. The client’s anger began to subside, and the counselor had him sign a “no 

violence” contract.

For several days thereafter, the counselor telephoned or spoke in person with the client to 

assess his feelings and thoughts. The client stated he would “never do anything like that” 

and had regretted his outburst. 

Threat of suicide. A female client telephoned her counselor and said she was tired of 

struggling with her addictions and other problems and was thinking about killing herself.

Counselor response. The counselor assessed the immediacy of the threat by reviewing 

the case record to determine whether there had been any previous attempts at suicide 

and asking the client whether she had a specific plan and the means to carry out the 

plan. If the counselor were still concerned, he or she would have consulted immediately 

with the supervisor or program director to develop and document a plan to inform the 

police, relatives, and the client’s doctor and scheduled an immediate one-on-one session. Because these criteria were not met, the counselor, with the agreement of the client, 

scheduled an individual therapy session. During the session the counselor and client 

negotiated a “no suicide” contract that included a commitment by the client to see a psychiatrist for evaluation as soon as possible.

The counselor recorded the incident in the case record and discussed it further with the 

supervisor.
Clinical Issues, Challenges, and Strategies in IOT 127

Treating Violent Clients

Occasionally, a client may display violent 

behaviors while in treatment, such as brandishing a weapon or threatening others. IOT 

staff can take these steps:

Have all newly admitted clients sign a 

client code of conduct that states that 

threats of violence or acts of violence result 

in immediate termination of treatment 

and possible criminal prosecution. Give 

examples.

Notify a law enforcement agency if a threat 

to safety exists or an assault or other crime 

occurs on the program premises; report the 

incident and client’s name, address, and 

treatment status, as permitted by Federal 

regulations.

If the client is mandated into treatment 

from the justice system, follow the steps 

prescribed in the program’s agreement 

with the justice agency. Certain rule violations, for instance, may require that the 

•

•

•

IOT provider notify the justice agency. 

Response to other violations may fall within the discretion of the treatment program. 

(See TIP 44, Substance Abuse Treatment 

for Adults in the Criminal Justice System

[CSAT 2005d].)

Notify supervisors about threats.

Clients Arriving Under the 

Influence of Drugs or Alcohol

Clients in IOT programs are expected to 

attend sessions drug and alcohol free. 

Arriving under the influence interferes with 

clients’ participation, their ability to recall 

material covered, and the ability of other 

group members to benefit from therapy. It 

also indicates that a client’s substance use 

disorder is active and that an alternative 

treatment plan is indicated, at least for that 

day. Strategies to respond to such occurrences 

are as follows:

•

Under the Influence in Group

George arrives at group intoxicated. His speech is slurred, he staggers somewhat, and he laughs 

loudly and inappropriately.

Counselor response.

Inserts an educational video, and instructs the group to continue on its own for the next 15 

minutes. Alternatively, asks another staff member to sit in temporarily with the group.

Escorts George from the group.

Obtains a urine sample and conducts a BreathalyzerTM test to determine the substances 

consumed.

Asks George in a one-on-one session how he will return home. Because George drove to the 

facility, the counselor tells him that he cannot drive home and that the counselor will contact 

police if George tries to drive. The counselor reviews with George the names of family members 

who can provide a ride home. The counselor follows applicable Federal, State, and local laws 

regarding contacts with authorities (CSAT 2004b). 

Allows George to use the phone to call his wife to pick him up. Note: Some programs pay for a 

cab.

Expresses concern about the substance use and encourages George to return to the next session 

where the episode will be discussed therapeutically.

Key point. The counselor did not engage George in a discussion about his substance use, such as 

why it occurred and the circumstances. Instead, the counselor immediately focused on confirming George’s substance use, ensuring his safety, encouraging him to return to treatment when 

sober, and preserving group time for the benefit of the other clients.

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128 Chapter 7

Develop clear program rules regarding 

use of drugs during treatment. If a client 

arrives under the influence, a therapeutic response is called for. The counselor 

takes the client aside, reviews the rules, 

and helps the client arrange alternative 

transportation if the client drove to the 

program. The client is instructed to return 

when abstinent and is informed that the 

substance use will be discussed in the 

next session. The counselor also can write 

a note to or call the client to emphasize 

that the client is expected to return to the 

group—actions that are intended to normalize the event and reduce any feelings of 

failure and shame. 

Assess the client’s health status. When a 

client arrives under the influence of drugs 

or alcohol, the counselor should assess 

the client’s need for acute care or detoxification. If it is indicated, the counselor 

should refer the client to detoxification. 

In a life-threatening overdose situation, 

no signed release is required to arrange 

for emergency medical care. If indicated, 

emergency personnel can be called. If 

acute care is refused, the counselor should 

contact a family member or significant 

other to escort the client home. (Unless 

the situation is life threatening, the significant other can be contacted only if the 

client has signed a release specifying such 

contact is permitted.) The counselor also 

should provide the family member with 

emergency care numbers. 

Client Privacy

Treatment programs often receive inquiries 

about clients or unsolicited information 

about clients. Some clients in treatment may 

be HIV positive but indicate they have not 

reported their status to their partners or a 

well-known leader or celebrity may enter the 

program. Each situation presents client privacy and ethical issues for IOT providers.

•

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Inquiries About Clients

Federal confidentiality regulations do not 

permit providers to reveal, even indirectly, 

that someone is a client unless a signed 

release has been obtained from the client and is on file. IOT staff members must 

consult a list of client-approved individuals 

before they (CSAT 2004b)

Acknowledge that a client is a participant 

in the program.

Share any information.

Transfer a telephone call to the client.

Take a message for a client.

Unsolicited Information 

About Clients

Clients’ spouses, domestic partners, or 

other acquaintances may leave messages 

with information about clients’ continued 

substance abuse or other activities and history while they are in treatment. Sometimes 

these individuals share their identities but 

do not want them revealed to clients because 

they fear for their safety. The counselor can 

respond to unsolicited information by (1) 

raising the general topic with the client during individual counseling and revising the 

treatment plan accordingly and (2) increasing the frequency of drug testing if substance 

use has been reported.

Knowledge of HIV Status 

Withheld From Partner 

Substance abuse, particularly the injection 

of drugs, increases risk of HIV infection 

(Pickens et al. 1993). During treatment the 

IOT counselor may learn that a client has 

not informed a partner of his or her HIVpositive status, exposing the partner to 

potential infection. The following approaches help reduce this risk while maintaining 

client confidentiality: 

Ensure that the client is informed fully 

about the connections among drug use, 

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Clinical Issues, Challenges, and Strategies in IOT 129

unprotected sex, and the transmission of 

HIV/AIDS.

Acknowledge and discuss with the client 

any fears, feelings of embarrassment, and 

guilt about revealing his or her HIV status 

to a partner. 

Include information about HIV transmission in educational materials and presentations made to family members. 

Assist the client in finding ways to talk 

about the issue with the partner, offer 

assistance in informing the partner if the 

client consents, and refer the client to an 

HIV/AIDS counselor for assistance.

Encourage the client to participate in a 

support group for HIV-positive individuals, 

and provide a specific program referral.

Discuss possible referrals to communitybased providers if notifying the partner 

results in a need for services. 

(See TIP 37, Substance Abuse Treatment for 

Persons With HIV/AIDS [CSAT 2000c].)

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Entry of a Well-Known 

Individual Into Treatment

Recovery from substance use disorders is the 

focus of treatment for all clients, regardless 

of their position or visibility in the community. When a well-known person, such as a 

political leader, sports personality, artist, 

member of the clergy, or media representative, enters an IOT program, a variety of 

issues may surface. Examples include

Increased risk to maintaining privacy 

and confidentiality. Interest in the client 

may result in inquiries by media representatives, curious callers, or program visitors. 

Remind all staff, including administrative 

and support personnel, as well as clients, 

to adhere to the program’s confidentiality 

procedures that protect the privacy of every 

client.

Feelings of privilege. Well-known clients 

may enter treatment with a belief that they 

do not need to follow all the program’s 

procedures or meet each requirement. 

•

•

The Informant

Maria calls the IOT counselor to say that her husband Juan (an IOT client) is drinking almost 

every night and gets really drunk every weekend. She insists that the program “has to do something about it—treatment isn’t working.”

Counselor response. Because Juan has signed a release that permits the counselor to speak 

with Maria, the counselor asks for her permission to confront Juan with this information. Maria 

refuses permission because she is afraid Juan will be angry with her. The counselor schedules a 

session with the couple to discuss problems at home.

The counselor tells Maria that, without her permission, the information will not be conveyed 

directly; rather, it will be used in the most therapeutic manner possible. That is, the counselor 

will pay increased attention to Juan’s behavior and communications and will perform breath 

tests more frequently to obtain evidence of alcohol use.

Key points.

The counselor avoids being drawn into keeping the wife’s secrets; a couples session is scheduled 

to discuss openly the relationship and the husband’s drinking.

IOT staff members must have a written release to discuss Juan’s behavior with anyone.

Spouses and others who provide information about clients need to be protected from possible harm.

Information obtained “anonymously” can be therapeutically useful.

Clients may continue in the program, even though they may be surreptitiously using substances, 

if all other program criteria are met.

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130 Chapter 7

Counselors must assist these clients in 

assimilating as quickly as possible into 

the treatment milieu by (1) relating to the 

private and not the public individual, (2) 

communicating treatment procedures and 

requirements, and (3) securing a signed 

behavioral contract. Individuals who are 

well known in the community may be 

concerned about protecting their privacy. 

The IOT counselor can assist these clients 

by (1) acknowledging their concerns while 

assuring them that others in similar circumstances have completed treatment and 

are recovering successfully, (2) evaluating 

the feasibility of their being treated out 

of town, (3) reviewing and discussing the 

program’s confidentiality regulations and 

policies, and (4) encouraging clients to 

attend support group meetings, which have 

a strong tradition of protecting the identity 

of participants.

Effect on the treatment milieu. The presence of high-profile clients or relatives and 

friends of such clients may mean that the 

treatment environment is tense or unsettled because of media attention; group 

cohesion based on trust may be slow to 

develop. The IOT counselor might consider 

these approaches: (1) discuss interpersonal 

issues that a client may have with other clients in individual counseling sessions, (2) 

use the group process to discuss confidentiality, trust, or other concerns, and (3) place 

any clients who express a concern about 

being in a group with a high-profile client 

in different groups.

Dual relationships. High-profile clients 

may offer to help the counselor or program financially, through a personal 

appearance, or through their influence. 

Acceptance of such an offer from a client 

introduces a “dual relationship,” which 

is unethical. Programs should not accept 

gifts or favors from clients beyond the 

published fee schedules. Only after a client 

has been out of treatment for an extended 

period (which many programs consider to 

be 1 year or longer) should the person be 

•

•

considered a successful alumnus and eligible to support the program in these ways.

Clients Who Work

Many clients have employment-related challenges, which can include schedule conflicts, 

associating with co-workers who use substances, and unrealistic employer requests.

Conflicting Work and 

Treatment Schedules

Individuals who enter IOT may face conflicts 

between work responsibilities and attending IOT group sessions. Some clients may 

rotate shifts or be asked to work overtime 

or work on weekends. Work schedules may 

interfere with treatment sessions. This situation most likely occurs when the employer is 

unaware that the employee is in treatment. 

The following approaches may be helpful, 

depending on the client’s situation:

Encourage clients to make treatment and 

recovery their first priority; help clients 

understand that by doing so they are better 

able to meet their work obligations.

Support clients in making treatment a high 

priority by being flexible with treatment 

schedules.

Encourage clients to inform their employers that they have a health condition and 

to ask the employers to cooperate with 

efforts to address the health condition.

Working and Socializing 

With Co-Workers Who Use 

Substances

Clients may have used substances with 

co-workers and may find it difficult to renegotiate their relationships with co-workers 

and to avoid circumstances that can lead to 

relapse. Options for addressing these issues 

include

Assisting the client in identifying specific 

work-related circumstances that may be 

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Clinical Issues, Challenges, and Strategies in IOT 131

uncomfortable or increase the risk of 

relapse

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

substances

Using role plays and other counselor–

client interactions so the client can practice responding to questions about treatment and invitations to use substances in 

ways that preclude uncomfortable discussions and limit risk-oriented situations

Encouraging the client to transfer to another work environment that is more supportive of recovery, if possible

Employer Requests

If the employer referred the client to treatment, the employer may expect information 

from the IOT provider about whether the 

client can assume his or her job responsibilities. Many large employers have policies 

that address this question, specifying when 

an employee can resume driving a bus or 

carrying a gun and mandating regular drug 

testing for a specified period. Key points concerning this issue include that

IOT providers do not have the expertise to 

determine whether a client can perform his 

or her job duties. Only the employer can 

determine this.

IOT providers can inform an employer 

(with the client’s consent) about the client’s 

progress in treatment and the drug test 

results.

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•

IOT providers can refer the employer to 

resources such as professional associations 

and the drug-free workplace information 

available on the Internet from the Center 

for Substance Abuse Prevention Workplace 

Resource Center (workplace.samhsa.gov).

IOT providers can negotiate with the 

employer for an additional period of continuing care for the employee; this period 

reinforces treatment gains and reduces the 

risk of relapse.

Millions of private-sector workers in the 

aviation, maritime, railroad, mass transit, pipeline, and motor carrier industries 

are governed by Federal legislation (the 

Omnibus Transportation Employee Testing 

Act of 1991) that makes workplace drug 

testing mandatory. If an employee of one of 

these industries fails a workplace drug test 

and is mandated to treatment, the treatment 

program is required to inform the employer 

in writing of assessment results and treatment recommendations (Macdonald and 

Kaplan 2003).

Helping Clients Achieve 

Balance

Once in treatment, clients sometimes try to 

make up for past harmful behavior during 

periods of substance abuse. Feeling guilty 

and remorseful, clients may take on additional work, extend their workdays, and try 

to become perfect employees. IOT providers 

should caution clients about the risk of 

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Conflicting Schedules

Emily decided to seek treatment for her substance use disorder. She was employed at a firm that 

depended on her to work on key projects. During treatment entry, the IOT counselor learned that 

Emily’s supervisor sometimes expected her to work beyond regular hours. On these occasions she 

would be unable to attend IOT group sessions consistently.

Counselor response. After exploring this issue, the counselor concluded that Emily was unable 

to resolve her schedule conflicts with her employer without jeopardizing her position. The counselor then arranged for Emily to attend a Saturday group session and to increase the number of 

individual counseling sessions to compensate for the reduced number of group sessions. Emily 

was able to complete treatment successfully.
132 Chapter 7

compromising their recovery efforts by taking on too much responsibility too quickly. 

The following responses may assist a client 

who tries to overcompensate:

Remind the client that recovery is the first 

priority.

Encourage the client to maintain balance and perspective with respect to the 

type and intensity of activities that are 

undertaken.

Assist the client in understanding that 

there will be time to address past mistakes 

once recovery is solidly underway.

Boundary Issues

Clients in treatment and IOT program staff 

members interact with one another on many 

levels—intellectual, emotional, and spiritual. 

The IOT experience is intense for all participants. Forming a therapeutic relationship 

with the client helps the counselor focus 

on the client’s recovery and influence the 

client’s behavior. At the same time, clients 

work together in group sessions over weeks 

and months on issues of profound significance to them. Furthermore, group members 

may attend community-based support 

groups together during and after IOT. In the 

process, they often develop trust and genu-

•

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•

ine concern and caring for one another. The 

intensity and environment of an IOT program can lead to behaviors and issues that 

challenge the boundaries between staff members and clients. The following are examples 

of these challenges and suggested responses. 

Clients Giving Gifts to Staff

Gift giving is relatively common and may 

have meanings and consequences that 

require careful consideration by counselors. 

For example, the customs and traditions of 

some cultures encourage gift giving to show 

respect for someone who offers a valuable 

service. Recent immigrants from these cultures may continue this practice and bring 

a small gift or food item to the IOT counselor or other program staff members. In 

some cases, failure to accept the gift may be 

viewed as a lack of courtesy and result in the 

client’s dropping out of treatment.

Other gifts given by clients to IOT staff members may be inappropriate and should be 

refused politely and tactfully. Most program 

rules prohibit staff members from accepting 

gifts if they

•Exceed a certain value (e.g., more than $20)

Co-Workers Who Use Substances

John and several co-workers went out together every Friday evening after work and drank heavily. 

They drank on Saturday and continued drinking during the Sunday football games they watched 

together. After making a decision to stop drinking and enter treatment, John wondered what he 

could say to his co-workers.

Counselor response. The counselor suggested that John follow these steps:

Maintain distance from friends and co-workers who use substances.

Avoid explaining or defending his decision to enter treatment.

Avoid giving detailed explanations for refusing invitations to activities where substances are used.

Practice using concrete statements to avoid situations in which substances are used, such as “I 

need to attend to personal problems in the family”; “Thanks, but no.” Practice these statements 

in group sessions; role play the responses in individual counseling sessions.

The counselor also worked with John to develop a new social network and find recreational activities that would support his recovery.

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Clinical Issues, Challenges, and Strategies in IOT 133

Are not the result of a religious or cultural 

tradition

Are offered in anticipation of some 

response or benefit (e.g., special treatment 

or favor)

Are obviously personal in nature

Are likely to cause discomfort, questions, 

or confusion for others about the relationship between counselor and client

Other programs permit only such gifts as 

flowers, candy, cookies, or plants that can be 

shared by all staff members and clients rather than given to an individual staff member.

IOT providers should develop program 

rules that discourage gift giving and discuss 

these rules with clients. However, the rules 

should permit some flexibility for individual 

circumstances. It is recommended that programs require staff members to report all 

gifts to supervisory personnel and in the case 

record. Counselors should be familiar with 

the program’s policies on these issues.

Socializing Among Clients

IOT programs differ in the degree of socializing expected outside group sessions. Some 

programs encourage clients to attend mutualhelp meetings together and support one 

another in other aspects of their lives. Other 

programs discourage contact between clients 

except within the program. Most IOTs have 

rules regarding dating, sexual involvement, 

or other pairing of clients that could undermine treatment.

•

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•

Client Relationships Involving 

Substance Use

Sometimes clients meet in an IOT program 

and decide to use drugs or alcohol together. 

Others may be acquainted before entering treatment and continue a relationship 

that includes substance use. Options for the 

counselor include the following:

Reassess the readiness of clients for treatment and recovery.

Develop a written contract for abstinence, 

and have clients sign it.

Refer clients to separate treatment 

programs.

Provide individual therapy for one client 

until the other client graduates from the 

program.

Socializing Between Staff 

and Clients

The therapeutic relationship between an 

IOT counselor and a client is built on caring, 

trust, and genuine interest in the recovery 

of the client. These three elements form a 

basic building block of the treatment alliance. To safeguard the therapeutic dyad and 

maintain the quality of the treatment environment, IOT programs typically prohibit 

staff–client activities such as socializing and 

doing favors. Program consequences for violations of these rules of professional conduct 

should be clear and applied consistently to 

all program staff, from administrators to 

support personnel. Consequences may vary, 

•

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•

The Meaning of Gifts: A Cultural Perspective

A gift has meaning both to the individual who gives it and to the one who receives it. 

Understanding and appropriately acknowledging the true meaning of a gift always require an 

awareness of the giver’s cultural background.

For example, many cultures place significant value on relationships rather than on individual priorities or achievement. The giving of a gift recognizes and reflects the value of the relationship and 

signals respect and caring. Gifts are given frequently and generally are not connected to an expectation of favor or privilege. By accepting modest and especially handmade gifts from these clients, 

IOT staff members acknowledge the respect, cultural values, and practices of these individuals.
134 Chapter 7

based on the circumstances, and can include 

supervisory reprimand and counseling, oral 

or written warnings, probation, and dismissal. In some cases, the counselor who violates 

prohibitions must be reported to his or her 

licensing or certification board.

Counselors With Dual Roles

Many IOT counselors are also members of 

mutual-help programs and must maintain 

appropriate boundaries between these two 

roles. For example, it would not be appropriate for an IOT counselor to become a client’s 

sponsor. A counselor also might meet an IOT 

program client by chance at a mutual-help 

meeting, particularly in a small community. 

Counselors should avoid attending meetings 

that current or former clients attend. When 

this is not possible, an IOT counselor should 

avoid sharing his or her personal issues at 

that meeting. If a counselor in this situation 

needs to talk, he or she should take someone 

aside after the meeting or call his or her 

sponsor. Some cities have “counselor only” 

meetings that are not listed in directories. 

The mutual-help program’s intergroup office 

or other counselors are good resources for 

locating such meetings.

Counselor Observes the Client Using Substances 

in the Community

Residents in a small, rural community occasionally enjoy dancing at the local nightspot. One evening an IOT counselor observes a client drinking at the bar.

Counselor response. The counselor leaves the establishment as soon as possible and does not 

acknowledge the client. Subsequently, in the treatment setting, the counselor meets with the 

client one on one. The counselor states the facts of the incident, expresses concern about the possible relapse, reminds the client of the agreement not to use substances, and, using motivational 

interviewing techniques, asks the client to determine how to handle the return to drinking.

The Client Is My Neighbor

The IOT counselor recognizes a new client in the waiting room as her neighbor. The neighbor is 

surprised to see the counselor.

Counselor response. The counselor asks to speak privately to the neighbor in her office. The 

counselor acknowledges the social relationship that exists between them and states that she will 

not be involved in any way with the neighbor’s treatment. The counselor also explains confidentiality regulations and indicates that the neighbor is in charge of how they relate to each other 

outside the treatment setting. The counselor also discloses the relationship to his or her supervisor to ensure that the counselor is not involved, even tangentially, in the client’s case.
Clinical Issues, Challenges, and Strategies in IOT 135

Clinicians have access to several instruments 

that help clients identify situations that pose 

high risks of relapse and understand their 

personal relapse triggers. Most instruments 

are not under copyright and can be used 

free of charge. More information about these 

tools, including information on obtaining 

copies and links to downloadable versions, 

can be found at the National Institute on 

Alcohol Abuse and Alcoholism’s Web site 

(www.niaaa.nih.gov) by entering “Alcoholism 

Treatment Assessment Instruments” into the 

site’s search engine.

Alcohol Abstinence SelfEfficacy Scale (AASE)

AASE evaluates a client’s confidence in the 

ability to abstain from drinking in 20 situations that present common drinking cues. 

The instrument comprises 40 items that 

gauge a client’s risk of relapse on four scales: 

when the client is experiencing 

Negative emotions (e.g., depression, 

frustration)

Feelings of well-being (e.g., celebrating, on 

vacation)

Physical pain (e.g., headache, fatigue)

Cravings (e.g., testing willpower, experimenting with one drink)

AASE is a paper-and-pencil instrument 

that can be administered and scored in 20 

minutes. No training is required to use it. 

It can be used to evaluate clients admitted 

to an IOT program, to guide treatment, or 

to design individualized relapse prevention 

strategies. A user-friendly version of AASE 

can be found at adai.washington.edu/

instruments/pdf/AASE.pdf.

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Alcohol Effects

Questionnaire (AEQ)

AEQ assesses the positive and negative 

effects that clients expect alcohol to have. 

Based on their beliefs about alcohol, clients 

respond “agree” or “disagree” to 40 statements. AEQ yields scores in eight different 

categories that describe the expected effects 

of alcohol: general positive feelings, social 

and physical pleasure, sexual enhancement, 

power and aggression, social expressiveness, 

relaxation and tension reduction, cognitive 

and physical impairment, and unconcern. 

Administration and scoring of the penciland-paper AEQ take 10 minutes, and no 

special training is required. Although AEQ 

has been used largely as a research instrument, it can be used therapeutically to 

assess the effects a client desires to achieve 

by drinking and to initiate discussions 

about alternative methods of attaining those 

effects. The AEQ has proved especially helpful with college students who use alcohol.

Alcohol-Specific Role

Play Test (ASRPT)

ASRPT uses role playing to gauge client 

responses to 10 different situations that pose 

a threat of relapse. Clients listen to taped 

prompts and then act out their responses, 

which are videotaped for scoring purposes. 

Five of the situations involve clients playing 

out an interaction with another person (e.g., 

a scenario in which a business contact asks 

the person in recovery to complete a deal 

over drinks at a local bar); five require clients to act out their responses to an internal 

conflict (e.g., a scenario in which the person 

in recovery has been working in the yard all 

day and suddenly thinks that a cold beer 

sounds good). The ASRPT can be administered in 20 minutes; male and female 

role-play partners and a videotape technician 

Appendix 7-A. Instruments for 

Assessing Relapse Potential
136 Chapter 7

are necessary. Training is required to give 

the test, and trained judges must score it. 

Situational Confidence 

Questionnaire (SCQ)

SCQ assesses a client’s confidence in the 

ability to cope with eight types of high-risk 

drinking situations. For each of the SCQ’s 

39 items, clients indicate on a 6-point scale 

(ranging from “not at all confident” to “very 

confident”) how they feel about their ability 

to resist the urge to drink. SCQ is available 

in paper-and-pencil and computerized versions and can be self-administered in 8 

minutes. (Scoring for the paper-and-pencil 

version takes 5 minutes; the computerized 

version is scored as soon as the questionnaire is completed.) Required minimal 

training is available from a user’s guide that 

can be purchased with SCQ.
137

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 chapter 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 

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8 Intensive Outpatient 

Treatment Approaches

In This 

Chapter...

 12-Step Facilitation 

Approach

Cognitive–

Behavioral 

Approach

Motivational 

Approaches

Therapeutic 

Community 

Approach

The Matrix Model

Community 

Reinforcement 

and Contingency 

Management 

Approaches
138 Chapter 8

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 chapter 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 programs 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 fellowships, 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 reading 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. 
Intensive Outpatient Treatment Approaches 139

Other Important Aspects

Staff

Staff members who are not in recovery themselves 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 programs, 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 compared 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 

Exhibit 8-1 

Strengths and Challenges of 12-Step Approaches

Strengths Challenges

12-Step meetings are a free, widely 

available, ongoing source of support. 

Metropolitan areas in particular offer 

many meetings with a specialized focus 

(e.g., meetings for young people, women, 

newcomers to treatment, lesbians, gay 

men, Spanish-language speakers).

The 12-Step approach emphasizes an 

array of recovery tasks in cognitive, spiritual, and health realms.

The 12-Step approach is effective 

with clients from diverse backgrounds 

(Tonigan 2003).

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It can be difficult to monitor accurately 

clients’ compliance with assigned step 

tasks, including meeting attendance.

12-Step groups’ emphasis on a higher 

power may be unacceptable to some 

clients.

Some communities may not be large 

enough to sustain 12-Step meetings or 

appropriate meetings for people with significant psychiatric disorders.

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140 Chapter 8

facilitation approach provided more favorable outcomes for most people who abuse 

substances. In particular, the study found 

that clients reporting high psychological distress, 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 problemsolving 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 problemsolving 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 treatment 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, 
Intensive Outpatient Treatment Approaches 141

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 clientcentered, empathic, but directive counseling 

strategy designed to explore and reduce a 

person’s ambivalence toward treatment. This 

approach frequently includes other problemsolving 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 substance abuse.

Believe in his or her capabilities for 

change.

Choose among available strategies and 

options.

Take responsibility for initiating and sustaining healthy personal behavior. 

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Exhibit 8-2

Strengths and Challenges of Cognitive–Behavioral Approaches

Strengths Challenges

CBT actively engages clients in therapy 

and experiential learning.

Numerous manuals on CBT are 

available.

CBT is suitable for clients from diverse 

backgrounds and with varying histories 

of alcohol and drug use.

CBT provides structured methods for 

understanding relapse triggers and preparing for relapse situations.

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•

Clients with poor reading or cognitive 

skills may need alternatives to written 

assignments.

The approach requires counselor training in CBT principles and techniques. 

Client motivation is critical because of 

the extent of homework assignments.

CBT was developed as an individual, not 

group, counseling approach.

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142 Chapter 8

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 positive 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 decision on this issue.

Identify discrepancies. The counselor 

encourages the client to focus on how current 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 

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•

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, 
Intensive Outpatient Treatment Approaches 143

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 understanding 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

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Exhibit 8-3

Strengths and Challenges of Motivational Approaches

Strengths Challenges

MI and MET are client centered and relevant to clients’ personal interests.

MI and MET focus on realistic, attainable goals.

MI and MET encourage client self-efficacy 

and self-sufficiency.

MI and MET emphasize positive, 

empathic support that does not undermine or elicit anger from clients.

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•

MI and MET rely heavily on clients’ 

capabilities and level of self-awareness.

Commonly used problem-oriented assessment instruments are incompatible with 

a motivational approach.

Although MET provides some guidance 

about effective interpersonal strategies for treating ambivalent clients, 

the approach does not specify session 

content.

Motivational approaches require significant staff training, reorientation, and 

ongoing supervision.

Motivational approaches may be difficult to combine with disease- or therapeutic community-oriented approaches 

that expect adherence to programimposed goals.

MI and MET were developed as individual approaches; their effectiveness for 

use with groups is unproved.

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144 Chapter 8

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, clients. 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 activities 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 models. TC members and staff members serve 

as positive role models by demonstrating 

expected behaviors and reflecting the values and teachings of the community. The 

strength of the community for social learning 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 

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encounter session is the main therapeutic 

group and heightens clients’ awareness 

of specific attitudes or behavioral patterns 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.

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Intensive Outpatient Treatment Approaches 145

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 previous treatment episodes. 

TC approaches should be modified for 

women, adolescents, and those with cooccurring 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 TCoriented outpatient work-release program 

Exhibit 8-4

Strengths and Challenges of the Therapeutic Community Approach

Strengths Challenges

The TC approach is effective for people 

with long histories of substance dependence and antisocial behavior.

The TC approach is particularly effective 

in teaching clients how to plan, set, and 

achieve goals and to be accountable.

The TC approach is effective in reducing recidivism among clients who have 

served time in prison.

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•

The approach may be too confrontational for some clients. 

Effective TC treatment requires extensive staff training.

Treating clients with mental disorders 

can pose difficulties.

Finding an effective mix of professional 

clinicians and recovering staff (who may 

not be trained in assessment, treatment 

planning, and counseling) can take time.

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146 Chapter 8

had lower rates of drug use and recidivism 

than offenders who participated only in the 

institutional program (Inciardi 1996). 

The Matrix Model

The Basics

The Matrix model was developed during the 

1980s as an effective way to treat the increasing number of people dependent on stimulant 

drugs, particularly cocaine. Developers 

designed the Matrix model as a more intensive intervention than the then-standard 

weekly outpatient counseling or 28-day inpatient treatment. The Matrix model is a good 

fit for clients who require comprehensive 

care.

The Matrix model, originally known as neurobehavioral treatment, integrated several 

research-based techniques (including cognitive–

behavioral, 12 Step, and motivational 

enhancement) to target clients’ behavioral, 

emotional, cognitive, and relationship issues. 

More research is needed to determine optimal combinations of treatment approaches; 

the Matrix model is one of many programs 

that combine various approaches. The 

Matrix model has been selected for discussion because its approach is comprehensive 

and manual based and assessment data are 

available.

The Matrix approach is predicated on

Establishing a strong therapeutic relationship between the client and counselor

Teaching clients how to structure time and 

initiate an orderly and healthy lifestyle

Imparting accurate, comprehensible information about acute and subacute withdrawal effects and cravings for substances

Providing opportunities to learn and 

practice relapse prevention and coping 

techniques

Involving family and significant others in 

the therapeutic and educational processes 

to gain their support for—and prevent their 

sabotaging of—treatment

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•

Encouraging clients to participate in 

community-based mutual-help groups 

Conducting random urinalyses or breath 

tests to assess treatment effectiveness

Several variations of the Matrix model have 

been developed. The original 12-month 

version began with 6 months of intensive 

treatment that included 56 individual counseling sessions (including conjoint sessions 

with the client and family members); clients 

attended treatment sessions 3 or 4 times a 

week. The individual sessions were supplemented by several types of educational, 

relapse prevention, family, and social support groups (Obert et al. 2000). The original 

cocaine-specific treatment protocol was 

followed by versions for people who used 

alcohol or opioids primarily. Because of cost 

constraints, a 16-week version of the Matrix 

model was developed that cut the number of 

individual sessions to three and emphasized 

group work. 

In all versions of Matrix model treatment, 

a primary therapist coordinates the client’s 

treatment experience. The relationship 

between the primary therapist and the client 

(and his or her family) is critical to treatment 

progress (Obert et al. 2000). 

Individual sessions focus on treatment 

planning and evaluating progress and may 

include members of the client’s family for at 

least part of the session. In addition to the 

individual sessions, the treatment protocol 

for the 16-week program includes specific 

structured groups (Obert et al. 2000):

Early recovery groups. These groups are 

for those in the first month of treatment 

and are small to maximize the attention 

each client receives. Early recovery groups 

focus on teaching clients cognitive tools for 

managing cravings and emphasize time 

management. Clients create a daily schedule and monitor their activities with group 

input and support. Early recovery groups 

assist clients in connecting with community support services.

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Intensive Outpatient Treatment Approaches 147

Family education sessions. Family education is presented as a 12-week series and 

includes both clients and family members. 

These sessions include slide presentations, 

videos, panel presentations, and group 

discussions on topics such as the biology 

of addiction, medical effects of substances, 

conditioning and addiction, and effects of 

addiction on the family.

Relapse prevention groups. These groups 

are the primary component of treatment. 

Group sessions are highly structured and 

focus on cognitive and behavioral change 

and on connecting clients to mutual-help 

programs. The group protocol includes 32 

specific topics.

Social support groups. These groups 

begin in the last month of treatment and 

focus on helping clients pursue drug-free 

activities and develop friendships with 

people who do not use substances. They 

are less structured than the other groups, 

and the content is determined by the needs 

of the group members.

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 selfesteem 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, 

Exhibit 8-5

Strengths and Challenges of Matrix Model Treatment

Strengths Challenges

The model integrates a cognitive–

behavioral approach with family involvement, psychosocial education, 12-Step 

support, and urine testing.

The model follows a manual, providing therapists with specific instructions 

and practical exercises. A version of the 

Matrix materials is available free from 

NCADI (CSAT 2006c, 2006d).

The model has been used extensively 

with people dependent on stimulants 

and has been shown to be effective.

•

•

•

Some materials may need to be modified 

for clients whose cognitive functioning is 

impaired.

The program requires special staff training and supervision.

The highly structured content may not 

appeal to all clients.

The tight structure and schedule may 

not leave time for identification and 

stabilization of other non-drug-specific 

problems.

•

•

•

•
148 Chapter 8

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 members 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 intranasally 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 clients 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, 
Intensive Outpatient Treatment Approaches 149

job, hobbies, social events—to provide the 

positive reinforcement that motivates the client 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 reinforce abstinence by systematically rewarding 

desirable behaviors and ignoring or punishing 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 program’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 targeted 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 reinforcers, 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, 

Abstinence...may 

not be sufficiently 

reinforcing to 

maintain a person’s 

motivation to stop 

using drugs...
150 Chapter 8

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. Selfreported 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 programs 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 counseling 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 substance use disorders (Bigelow and Silverman 

1999) and are incompatible with their training 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 lowcost 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 
Intensive Outpatient Treatment Approaches 151

2004). Anniversary celebrations, special 

books, reductions in clinic fees, and letters 

of support to employers and protective service 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 treating 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 counseling 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 supported 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 

Exhibit 8-6

Strengths and Challenges of Community Reinforcement and 

Contingency Management Approaches

Strengths Challenges

CR and CM have been shown to reduce 

drug use significantly when incentives 

are used.

CR and CM can be combined readily 

with other psychosocial interventions 

and pharmacotherapies.

CR and CM can be implemented with 

a variety of low-cost incentives such as 

donated goods or services.

CR and CM have proved effective for 

reducing drug use and increasing treatment compliance among clients with 

severe problems who are chronically substance dependent.

CR and CM have extensive and robust 

scientific support in both laboratory and 

clinical studies.

•

•

•

•

•

Clients may return to baseline drug use 

rates when incentives are terminated.

CM approaches can be labor intensive, 

require specialized staff or training for 

implementation, and entail frequent client attendance.

For maximal effectiveness, rewards 

must be sufficiently large—and increase 

in value—to have continuing appeal to 

clients.

Many research studies demonstrating CR 

and CM effectiveness have used small 

samples and incurred large costs for 

incentives.

Resources required for implementing CR 

and CM (e.g., onsite urine-testing capabilities or alternatives to costly incentives) may be unavailable.

Lack of emphasis on long-term supports 

is a potential drawback.

•

•

•

•

•

•
152 Chapter 8

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.
153

Many assumptions and approaches used in intensive outpatient 

treatment (IOT) programming were developed for and validated with 

middle-class, employed, adult men. This chapter presents information about how IOT can be adapted to meet the needs of specific 

populations: the justice system population, women, people with 

co-occurring mental disorders, and adolescents and young adults. 

Chapter 10 presents information on treatment approaches for other 

special groups, including minority populations. 

Justice System Population

The number of people in the justice system with a history of substance use disorders has increased dramatically over the last 20 

years because of increased drug-related crime, Federal and State legislation, and mandatory sentencing guidelines; many of these people 

are caught in a cycle of repeated incarcerations.

Between 1990 and 1999, the number of inmates sentenced to 

Federal prison for drug offenses rose more than 60 percent (Beck 

and Harrison 2001). About three-quarters of all prisoners reported 

some type of involvement with alcohol or drug abuse before their 

offenses, and an estimated 33 percent of State prisoners and 22 percent of Federal prisoners say that they had committed their current 

offenses while under the influence of drugs, with marijuana/hashish 

and cocaine/crack used most often (Mumola 1999).

Description of the Population

Justice system populations are younger than the general population, 

are overwhelmingly male, and are challenged with many psychosocial, medical, and financial problems (Brochu et al. 1999). 

9 Adapting Intensive 

Outpatient 

Treatment 

for Specific 

Populations

In This 

Chapter...

Justice System 

Population

Women

Populations With 

Co-Occurring 

Psychiatric 

Disorders

Adolescents

Young Adults
154 Chapter 9

Psychosocial issues 

People involved with the justice system 

typically have many problems related to 

employment and financial support, housing, 

education, transportation, and unresolved 

legal issues. Many inmates have not completed high school or earned a general 

equivalence diploma. Only about 55 percent 

were employed full time before their incarceration (Bureau of Justice Statistics 2000). 

Medical and psychiatric 

problems 

Offenders with a substance use disorder 

may have co-occurring psychiatric disorders. 

Approximately 16 percent of State inmates, 7 

percent of Federal 

inmates, and 16 

percent of jail 

inmates and probationers reported 

having mental illnesses, and nearly 

60 percent of these 

offenders reported 

that they were 

under the influence of alcohol or 

drugs at the time 

of their offenses 

(Ditton 1999). 

People in prison have a high incidence of 

HIV/AIDS (Maruschak 2002), tuberculosis, 

sexually transmitted diseases, and hepatitis 

C (National Institute of Justice 1999). 

Female offenders 

Between 1990 and 2000, the number of 

women involved with the justice system 

(incarcerated, on probation, or paroled) 

increased by 81 percent (Bloom et al. 2003). 

Women accounted for 15 percent of the total 

correctional population in 1998; 90 percent 

were under community supervision (Glaze 

2003; Harrison and Beck 2003). Seventy-two 

percent of the women in Federal prisons 

were convicted of drug offenses or committed their crimes while under the influence 

of drugs or alcohol (Greenfeld and Snell 

1999). Female offenders with substance use 

disorders experienced more health, educational, and employment problems; had lower 

incomes; reported more depression, suicidal 

behavior, and sexual and physical abuse; 

and had more mental and physical health 

problems than did male offenders with substance use disorders (Langan and Pelissier 

2001). More than half the female inmates in 

prisons had at least one child younger than 

18 (Mumola 2000). The National Institute of 

Corrections’ Gender-Responsive Strategies: 

Research, Practice, and Guiding Principles 

for Women Offenders (Bloom et al. 2003) 

provides more information about female 

offenders.

Double stigma 

Offenders often are affected by the stigma 

associated with involvement in the justice 

system, as well as the stigma associated 

with substance abuse. These two factors can 

impede an offender’s ability to obtain appropriate employment or housing. 

Implications for IOT

In response to the increase in drug-related 

judicial cases, several approaches for treating offenders who have a substance use 

disorder have been developed. IOT providers 

become involved in treating offenders when 

the offender is (1) referred to treatment in 

lieu of incarceration, (2) incarcerated, or (3) 

released. 

Coercion frequently is used to compel 

offenders to participate in treatment. 

Coercion may be a sentence mandating treatment or a prison policy mandating treatment 

for inmates discovered to have a substance 

use disorder while incarcerated for a nondrug-related crime. For nonincarcerated 

offenders, a sanction for refusing to participate in treatment often is incarceration. 

Research indicates that treatment adherence 

and outcomes of clients legally referred to 

A major challenge to 

IOT providers is to 

integrate substance 

abuse treatment 

with justice 

system processes.
Adapting IOT for Specific Populations 155

treatment were the same as or better than 

those of clients entering treatment of their 

own volition (Farabee et al. 1998; Marlowe et 

al. 1996, 2003).

Working With the Judicial 

System

IOT programs provide treatment for the following justice system clients:

Offenders referred to treatment in lieu 

of incarceration. IOT providers have 

developed effective partnerships with drug 

courts and Treatment Accountability for 

Safer Communities (TASC) programs to 

provide treatment (Farabee et al. 1998). 

Drug courts, begun in 1989, divert nonviolent offenders with substance use disorders 

into treatment instead of incarceration. 

Drug courts oversee the offender’s treatment, coordinate justice and treatment 

systems procedures, and monitor progress. TASC, formerly known as Treatment 

Alternatives to Street Crime, identifies 

and assesses offenders involved with drugs 

and refers them to community treatment 

services.

Offenders discharged from residential 

substance abuse treatment who need 

continuing community-based treatment.

IOT programs provide stepdown, but structured, services and transitional services 

and links to other services for offenders who are discharged from residential 

treatment.

Offenders who need treatment and are 

placed under community supervision 

(pretrial, probation, or parole). Many justice programs have been developed to support this type of treatment for people who 

are under the supervision of the justice 

system but are allowed to remain in the 

community. 

Offenders reentering the community 

after incarceration. Reentry management programs funded by various Federal 

agencies facilitate the transition and 

reintegration of prisoners released into 

•

•

•

•

the community. IOT providers, working closely with justice staff before individuals are released, engage offenders in 

treatment and support their continuing 

recovery through flexible, individualized 

approaches. TIP 30, Continuity of Offender 

Treatment for Substance Use Disorders 

From Institution to Community (CSAT 

1998b), provides more information on 

transition of prisoners to the community.

Offenders who participate in treatment 

while incarcerated. IOT can be modified for use in prisons and jails, although 

this stretches the concept of outpatient 

treatment. Institutions that can segregate 

offenders in IOT from the rest of the incarcerated population provide a more effective and supportive structure (U.S. House 

Committee on the Judiciary 2000).

Forging a Working 

Partnership

A major challenge to IOT providers is to 

integrate substance abuse treatment with 

justice system processes. Partnerships are 

being forged effectively as justice agencies 

and treatment providers recognize that, 

although they have different perspectives, 

they can work together. Both parties need to 

be flexible and interact with clients on a caseby-case basis (Farabee et al. 1998). Justice 

officials and IOT providers need to agree on 

which clients are appropriate for treatment 

and establish clear screening and admission 

criteria.

Rules for Offenders in 

Treatment 

Most justice system and IOT program partners agree that offenders in treatment must 

not commit another offense, must abstain 

from drug use, and must comply with treatment requirements. However, disagreements 

about additional rules may emerge. As a 

result, some policies and sanctions may 

work against the recovery they are designed 

to achieve. IOT program staff members can 

•
156 Chapter 9

help prevent or resolve such conflicts by discussing these matters with judges and other 

criminal justice officials. Staff members 

who are familiar with research on treatment 

outcomes are best suited to convey to others 

a realistic, convincing argument for treatment and to foster cooperation that leads 

to client recovery. Developing and agreeing 

on a process for resolving conflicts early in 

the collaboration may reconcile discordant 

opinions. For the collaboration to function 

smoothly, IOT program staff needs the discretion to make decisions about treatment, 

such as whether the offender needs a different level of care. The justice system staff 

needs to be confident that it will be informed 

of treatment progress or if sanctions are 

justified. The partners must agree on the 

following: 

Consequences for lapses in abstinence 

and continued drug use. When a client 

admits to a single episode of drug use in a 

treatment session, the counselor may view 

this as a positive development; this admission of use may indicate that the client 

has gone beyond denial and begun to work 

on treatment issues. Justice system staff, 

however, may disagree and consider any 

drug use grounds for incarceration. IOT 

staff members may agree to sanctions only 

when continued episodes of drug use indicate that the offender is not committed to 

treatment.

Consequences for use of alcohol. The 

justice system considers alcohol a legal 

substance and is concerned only with 

illegal activity resulting from its use. 

Consequently, the justice agency may not 

apply sanctions for continued alcohol use. 

In contrast, treatment providers consider 

alcohol an addictive substance and usually 

enforce no-use-of-alcohol rules. The topic 

warrants extended conversation between 

partners to develop reasonable responses 

to alcohol use. 

Discharge criteria. Agreed-on discharge 

criteria that define treatment goals, conditions indicating therapeutic discharge, and 

•

•

•

behavior meriting immediate discharge are 

needed.

Uses of drug-testing results. The justice 

system regards drug-screening test results 

as an objective measure of progress or nonadherence to treatment and can impose 

severe consequences for positive drug tests. 

Many IOT programs use drug test results 

therapeutically, to inform treatment plans 

and to deter clients from using substances. 

Both systems need to discuss how drug test 

results will be used.

Communication Between 

Systems

Clear communication between the two systems is essential. For all referrals from the 

justice system (pretrial services, probation, 

and parole), an IOT program should designate point-of-contact personnel. To ensure 

clients’ privacy rights, programs need to have 

confidentiality release forms that specify the 

information to be shared and the length of 

time the forms are in effect; all clients must 

sign these forms. These forms permit the two 

agencies to communicate information about 

the offender for monitoring purposes. 

IOT providers are advised to discuss and 

agree on the following communication issues 

with their justice system partners:

The form and timing of updates on treatment progress from the treatment program 

to the justice agency 

Reportings of critical incidents, such as 

when an offender threatens to commit a 

crime or fails to appear for treatment 

Reportings from the criminal justice agency, such as when an offender is rearrested 

or incarcerated

Memorandum of 

Understanding

Once justice system and IOT program partners agree on rules, consequences, and 

elements of communication, the agreement 

•

•

•

•
Adapting IOT for Specific Populations 157

needs to be formalized in a written memorandum of understanding (MOU). The 

suggested elements of an MOU include

Parameters of treatment, including the 

kinds of services 

Each partner’s responsibilities (e.g., the 

criminal justice agency refers and monitors 

clients; the treatment program assesses 

and treats clients)

The consequences for noncompliant 

behavior, recognizing that not every contingency can be foreseen

Identification of which agency determines the consequences of noncompliant 

behavior

The types, content, and timetable of communications and reportings required 

between the partners

Definitions of critical incidents that 

require the treatment program to notify 

the justice agency

Clinical Issues and Services

Although working with clients involved with 

the criminal justice system is challenging, 

it can be rewarding. For example, approximately 60 percent of people involved with 

drug courts remained in treatment for at 

least a year, with a minimum 48-percent 

graduation rate (Belenko 1999). Clients 

involved with the justice system have unique 

stressors, including, but not limited to, their 

precarious legal situation. Clients may need 

help with transportation, educational services, family issues, financial issues such 

as obtaining welfare and Medicaid benefits 

and arranging restitution payments, housing such as arranging temporary shelter 

and permanent housing, and job skills and 

employment counseling. Case management 

can coordinate services for justice system 

clients.

TIP 44, Substance Abuse Treatment for 

Adults in the Criminal Justice System (CSAT 

2005d), provides more information about 

treating this population.

•

•

•

•

•

•

Staff Training

Treatment is impeded when counselors have 

a negative attitude toward clients, believe 

that clients have a poor prognosis for recovery, or are reluctant to serve offenders in 

general. These issues should be included in 

staff training and cross-training. 

To provide effective substance abuse treatment to criminal justice system clients, staffs 

in both systems need cross-training (Farabee 

et al. 1999). Topics include the philosophy, 

approach, goals, objectives, and boundaries of both systems. Treatment providers 

need information 

about the responsibilities, structure, 

operations, and 

goals of the justice 

system; public 

safety and security 

concerns; and how 

involvement with 

the justice system 

affects offenders. 

Criminal justice 

system personnel need information about the dynamics 

of substance use disorders, components 

of treatment, how treatment can reduce 

recidivism, confidentiality, and co-occurring 

psychiatric disorders. 

Women

In recent years, heightened awareness and 

new funding have encouraged the development of specialized programs to address the 

treatment needs of women. The number of 

treatment facilities offering programs for 

pregnant and postpartum women rose from 

1,890 in 1995 to 2,761 in 2000, and more 

than 5,000 facilities offered special programs 

for women (Substance Abuse and Mental 

Health Services Administration 2002). The 

forthcoming TIP Substance Abuse Treatment: 

Addressing the Specific Needs of Women

(CSAT forthcoming b), TIP 25, Substance 

Abuse Treatment and Domestic Violence

For all referrals from 

the justice system...an 

IOT program should 

designate point-ofcontact personnel. 
158 Chapter 9

(CSAT 1997b), and TIP 36, Substance Abuse 

Treatment for Persons With Child Abuse and 

Neglect Issues (CSAT 2000b), provide more 

information.

Description of the Population

Even though women and men who have substance use disorders have many similarities, 

they differ in some important ways. Women 

typically begin using substances later and 

enter treatment earlier in the course of their 

illnesses than do men (Brady and Randall 

1999). Other differences with therapeutic 

implications are briefly surveyed below. 

Discussions of strategies for addressing 

women-specific treatment issues follow.

Violence

Women with substance use disorders are 

more likely than men with substance use 

disorders to have been physically or sexually 

abused as children (Bartholomew et al. 2002; 

Simpson and Miller 2002). In addition, 

women who have a substance use disorder 

are more likely to be victims of domestic violence (Chermack et al. 2001), with reported 

rates of women in treatment who have been 

victims of physical and sexual violence ranging from 75 percent (Oumiette et al. 2000) to 

88 percent (B.A. Miller 1998).

Mental disorders 

Compared with men, women with substance use disorders have nearly double the 

occurrence (30.3 percent vs. 15.7 percent) 

of serious mental illness and past year substance use disorders (Epstein et al. 2004). 

These higher rates of psychiatric comorbidity 

are particularly evident in mood and anxiety 

disorders (Zilberman et al. 2003). 

Parenting issues 

Women in treatment often bear the sole 

caretaking responsibility for their children, 

and this role can be a substantial obstacle to 

seeking and remaining in treatment. Women 

may have difficulty finding reliable and 

affordable child care. They may fear losing 

custody of their children because of their 

substance use, and this fear may deter them 

from entering treatment. At the same time, 

women (and men) who abuse substances are 

more likely to abuse or neglect their children 

(National Clearinghouse on Child Abuse and 

Neglect Information 2003). 

Welfare issues 

Some States require that individuals receiving welfare benefits be screened and treated 

for substance use disorders; failure to enroll 

in or dropping out of treatment may jeopardize benefits (Legal Action Center 1999). 

Such requirements can help retain a client in 

an IOT program, and a case manager should 

coordinate treatment with welfare staff. 

Pregnancy

Substance use during pregnancy can mean 

poor prenatal care, unregistered delivery, 

and low-weight and premature babies 

(Howell et al. 1999). Heavy or binge alcohol 

or drug use during pregnancy can result in 

negative consequences for the child such as 

neurological damage, including fetal alcohol 

syndrome (American Academy of Pediatrics 

2000).

Relationships 

A woman’s substance use disorder is often 

influenced by her partner. Women with male 

partners who use substances are retained 

in treatment for a shorter time than women 

with substance-free partners (Tuten and 

Jones 2003). Conversely, a woman’s partner 

can have a positive influence on treatment through support and participation in 

treatment.

Implications for IOT

Effective treatment for women cannot occur 

in isolation from the social, health, legal, 

and other challenges facing female clients. 

Some studies suggest that gender-specific 

treatment may be advantageous for female 
Adapting IOT for Specific Populations 159

clients (Grella et al. 1999), producing higher 

success rates in women-only groups or programs. However, research to date on the best 

treatment for women is inconclusive (Blume

1998).

Barriers to treatment entry 

and retention

Once a woman decides to seek help, she may 

face a long wait because of the lack of appropriate treatment. In addition, she faces 

gender-specific barriers and issues that may 

affect entry and retention in treatment such as

Concerns about fulfilling her responsibilities as a mother, wife, or partner

Fears of retribution from an abusive 

spouse or partner

Gender and cultural insensitivity of some 

treatment programs

Threat of legal sanction, such as loss of 

child custody

Lack of affordable or reliable child care

The disproportionate societal intolerance 

and stigma associated with substance 

abuse in women compared with men 

Ineligibility for treatment medications if 

she is pregnant or may become pregnant

Having few other women in treatment 

with her

Entry and assessment

A woman entering treatment needs to feel 

that the environment is safe and supportive. IOT program staff members who are 

understanding, respectful, optimistic, and 

nurturing can build a positive, therapeutic relationship. It may help if the intake 

counselor is a woman. The client may be 

fearful, confused, in withdrawal, or in 

denial, and staff members need to be patient 

and supportive, understanding that it is 

empowering for the client to choose when 

to provide information and what information to provide. Additional ways to facilitate 

entry include providing help with child care 

and extending program hours for working 

women.

•

•

•

•

•

•

•

•

Using a comprehensive assessment, staff 

members can identify the client’s strengths 

and weaknesses and work with her to develop specific treatment goals and a treatment 

plan. Because 

of the likelihood 

of victimization 

and presence of 

co-occurring psychiatric disorders, 

female clients need 

careful assessments 

for psychiatric 

disorders and history of childhood 

trauma and adult 

victimization. 

Chapter 5 discusses intake forms that can 

be used or modified to gather these data. 

Victimization experiences may be hidden 

beneath shame and guilt but, as trust develops, the client can discuss these events. 

Clinical Issues and Strategies

Some women-specific programs are based 

on the philosophy that supporting and 

empowering women improve treatment 

success. Some programs advocate using 

predominantly female staff in professional 

and support positions. Providing enhanced 

services that respond to the social service 

needs of women is important for effective 

substance abuse treatment for women with 

children (Marsh et al. 2000; Volpicelli et al. 

2000).

Treatment components 

specific to women

Exhibit 9-1 identifies core clinical needs and 

service elements that should be addressed in 

IOT for women (CSAT 1994d).

It is important to identify issues that the client is uncomfortable discussing in a group 

setting. As a woman feels more comfortable, 

she may be able to discuss them. Relapse 

prevention techniques may need to be modified for women. There is some evidence that 

A woman entering 

treatment needs 

to feel that the 

environment is safe 

and supportive.
160 Chapter 9

women’s relapses are related to negative 

mood, more so than men’s (Rubin et al. 

1996). Also, women may do better in womenonly counseling groups (Hodgins et al. 1997).

Exhibit 9-1

Core Treatment Needs and Service Elements for Women

Core Treatment Needs Service Elements

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 

Identify and build on the client’s strengths

History of physical, sexual, and emotional 

abuse

Avoid using harsh confrontational techniques that could retraumatize the client 

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 for licensed child care, 

including a nursery for infants and young 

children and afterschool programs for 

older children

Assist with Head Start enrollment 

Medical problems Refer for medical care, including reproductive health, pregnancy testing, and 

testing for or treating of infectious diseases

Gender discrimination and harassment Ensure that the program has policies 

against harassment and that they are 

enforced
Adapting IOT for Specific Populations 161

Therapeutic styles

Women who abuse substances may benefit 

more from supportive therapies than from 

other approaches and need a treatment environment that is safe and nurturing (Cohen 

2000). Safety includes appropriate boundaries between counselor and client, physical 

and emotional safety, and a therapeutic 

relationship of respect, empathy, and compassion (Covington 2002).

For women with low self-esteem and a 

history of abuse, harsh confrontational 

approaches may further diminish their 

self-image and retraumatize them. Less 

aggressive approaches based on understanding and trust are more likely to effect change 

(Miller and Rollnick 2002). The confrontational approach of “breaking down” a 

person in treatment and rebuilding her as a 

recovering person may be overly harsh and 

not conducive to treating women (Covington 

1999).

Woman clients can be referred to mutualhelp groups such as Women for Sobriety 

and 12-Step groups that are sensitive to the 

needs of women. Some areas have womenonly Alcoholics Anonymous (AA) and 

Narcotics Anonymous meetings, and some 

groups provide onsite child care. A Woman’s 

Way Through the Twelve Steps (Covington 

1994) and its companion workbook can 

help women adapt the 12 Steps for their use 

(Covington 2000). 

Considerations for domestic 

violence survivors

IOT providers need to consider the safety 

of the client, develop and implement a personal safety plan for her, and notify the 

proper authorities if she is in danger. TIP 

25, Substance Abuse Treatment and Domestic 

Violence (CSAT 1997b), provides additional 

information.

Treatment for pregnant 

women

Because of the possible harm to fetuses, 

it is important to provide comprehensive 

treatment services to pregnant women who 

abuse substances. IOT has produced positive 

results for pregnant women, and retention in 

treatment is facilitated by provision of support services such as child care, parenting 

classes, and vocational training (Howell et 

al. 1999). Elements of one model program 

for pregnant women include (CSAT 1993a; 

Howell et al. 1999)

A family-centered approach with pregnancy and parenting education and mother–

child play groups

Interdisciplinary staff

Counselor continuity

Physical and mental health services

Child care and transportation services

Housing services that address homelessness or unstable and unsafe housing 

conditions

Other programs have found that being 

flexible and responsive to clients’ needs 

and using nonconfrontational approaches 

improve the health of the women and newborns (Whiteside-Mansell et al. 1999). 

Staffing and Training

Making a treatment program gender sensitive requires changes in staffing, training, 

and treatment approaches. Female program 

staff and advisory board members may be 

more sensitive to the needs of female clients. 

However, male clinicians can work effectively with female clients. 

Training on issues and resources specific 

for women is necessary. Both female and 

male staff members should be trained about 

the ramifications for treatment of sexual, 

physical, and emotional abuse and partner 

violence. Training should overcome the tendency to blame the victim. Other training 

needs may include assessment techniques 

for violence or abuse, appropriate referrals 

•

•

•

•

•

•
162 Chapter 9

to mental health professionals, coordinating services with other agencies, and food 

programs that serve women and children. To 

prevent sexual harassment of female clients, 

program rules should be explicit and strictly 

enforced. Providers need to become familiar 

with the duty-to-warn requirement as it pertains to reporting child abuse and neglect 

and partner violence. 

Populations With 

Co-Occurring 

Psychiatric Disorders

In the field of substance abuse treatment, 

people with both psychiatric and substance 

use disorders are said to have co-occurring 

mental disorders. 

Description of the Population

Many clients with co-occurring disorders are 

in IOT. The Drug Abuse Treatment Outcome 

Study found that 39 percent of admissions 

to substance abuse treatment met Diagnostic 

and Statistical 

Manual of 

Mental Disorders, 

Third Edition, 

Revised (DSMIII-R) (American 

Psychiatric 

Association 1987) 

diagnostic criteria 

for an antisocial 

personality disorder, 11.7 percent 

met criteria for a 

major depressive 

episode, and 3.7 

percent met criteria for a general anxiety 

disorder (Flynn et al. 1996). Other studies 

support these findings (Compton et al. 2000; 

Merikangas et al. 1998). 

According to the Treatment Episode Data 

Set, people admitted to treatment who had 

a co-occurring psychiatric disorder were less 

likely than people admitted with only substance use disorders to be in the labor force. 

They were more likely to be women, abuse 

alcohol, and be referred through alcohol or 

drug abuse treatment providers and other 

health care providers than people admitted 

for substance abuse only (who were more 

likely to be have been referred by the criminal justice system) (Office of Applied Studies 

2003a).

Group characteristics

When a client has co-occurring disorders, 

both the client and IOT counselor are presented with many challenges, such as

Interacting symptoms that complicate 

treatment 

Increased biopsychosocial disruptions 

such as increased family problems, violent 

victimization, financial instability, homelessness, incarceration, suicidal ideation or 

attempts, and medical problems

Barriers to accessing 

treatment 

Most people with co-occurring mental and 

substance use disorders are not receiving 

appropriate care (Watkins et al. 2001). Two 

of the numerous barriers to treatment are 

limited access to treatment and poor coordination between treatment systems.

In addition, historically, substance abuse 

and psychiatric treatments were provided in 

separate settings, and it was believed that 

one disorder must be stabilized before the 

other disorder could be treated, resulting 

in fragmented services. Clients were caught 

between two systems (Drake et al. 2001). The 

different treatment approaches led to misunderstandings between mental health and 

substance abuse treatment providers. Mental 

health providers may use more motivational 

and supportive techniques and professionally trained staff, whereas substance abuse 

treatment programs use more confrontational approaches, which may be distressing 

•

•

Most people with 

co-occurring mental 

and substance use 

disorders are 

not receiving 

appropriate care.
Adapting IOT for Specific Populations 163

for clients with co-occurring disorders, and 

often combine peer support with professionally trained counselors (Minkoff 1994). 

Some substance abuse treatment providers 

and recovering peers still may harbor antimedication attitudes and not understand the 

benefit of psychotropic medications. 

Implications for IOT

Although clients with co-occurring psychiatric 

disorders may be challenging, they benefit 

from treatment (Dixon et al. 1998). Treatment 

has produced marked reductions in suicide 

attempts, mental health visits, and reports of 

depression (Karageorge 2002). Clients with 

less serious mental disorders appear to do 

well in traditional substance abuse treatment 

settings (Sloan and Rowe 1998), and outpatient treatment can be an effective setting 

for treating substance use disorder in clients 

with less serious mental disorders (Flynn et 

al. 1996). Long-term approaches seem more 

effective than short-term acute care (Bixler 

and Emery 2000). Clients with psychotic conditions, however, might pose insurmountable 

challenges for most IOT programs. 

Theoretical Background

Integrated treatment

For the past two decades, integrated treatment has been proposed as an effective 

treatment approach. Minkoff (1994) presents a theoretical framework that considers 

both disorders chronic, primary, biologically based mental illnesses that are likely 

to be lifelong, but he suggests that conjoint 

treatment could reduce symptoms of both 

disorders effectively and promote recovery. 

His general treatment principles follow: 

Recognize that the basic elements and processes of addiction treatment are the same 

for clients who have a psychiatric disorder 

as for those without one.

Include education, empathic confrontation 

of denial, relapse prevention, and 

•

•

involvement with both professional- and 

peer-led groups.

Modify standard substance abuse treatment by simplifying interventions, accommodating cognitive limitations if necessary, 

adapting step or group work, and using 

mutual-help groups for people with cooccurring psychiatric disorders.

Develop interventions specific to each 

phase of treatment. 

Provide comprehensive services that cover 

treatment of both disorders.

In a review of the literature on treating 

substance use disorders and co-occurring 

schizophrenia, Drake and colleagues (1998b) 

found that integrated treatment, especially 

when delivered for 18 months or longer, 

resulted in significant reduction in substance abuse and, in some cases, in 

substantial rates of remission, reductions in 

hospitalizations, and improvements in other 

outcomes. Many IOT programs do not treat 

clients with serious mental disorders such as 

schizophrenia on a regular basis and do not 

have the advantages of the programs cited in 

Drake and colleagues’ review (e.g., intensive 

case management, 18-month treatment window). Charney and colleagues had similar 

success treating clients with co-occurring 

depression over a 6-month period (2001). 

Treatment retention and outcome improved 

when psychiatric services were provided at 

the substance abuse treatment facility.

Integrated treatment coordinates substance 

use and mental disorder interventions to 

treat the whole client and

Recognizes the importance of ensuring 

that entry into one system provides access 

to all needed systems

Emphasizes the association between the 

treatment models for mental disorders and 

addiction

Advocates the concomitant treatment of 

both disorders

Follows a staged approach

•

•

•

•

•

•

•
164 Chapter 9

Uses treatment strategies from both the 

mental health and substance abuse treatment fields

Conceptual framework

The National Association of State Mental 

Health Program Directors and the National 

Association of State Alcohol and Drug Abuse 

Directors, with support from the Substance 

Abuse and Mental Health Services 

Administration (SAMHSA), developed a 

conceptual framework of four quadrants to 

classify service coordination and help providers categorize treatment according to the 

severity of symptoms of both disorders (see 

exhibit 9-2) (Substance Abuse and Mental 

Health Services Administration 2002).

Clients in category I often are identified in 

primary care, educational, or community settings and may need consultation services for 

prevention and early intervention services. 

Clients in categories II and III generally present or are referred for treatment for their 

• more severe disorder—either mental or substance use disorder—often leaving them with 

little or no care for the other disorder. These 

clients may be referred to IOT programs, and 

care requires collaboration between mental 

health and IOT providers. Clients in category 

IV generally need comprehensive, integrated 

treatment (Substance Abuse and Mental 

Health Services Administration 2002). 

Clinical Issues and Strategies

Modifications to clinical approaches and 

service elements to assist clients with mental disorders are essential. When financial 

or other limitations require the provision 

of care in separate settings, treatment services need to be coordinated assertively and 

efficiently.

Core treatment needs and 

service elements

Screening. All clients need to be screened 

for co-occurring psychiatric disorders to 

Exhibit 9-2

SAMHSA’s Service Coordination Framework for Co-Occurring Disorders

high

severity

high

severity

low

severity

Category III

Mental disorders less severe

Substance use disorders more severe

Locus of care

Substance use system

Category IV

Mental disorders more severe

Substance use disorders more severe

Locus of care

State hospitals, jails/prisons, emergency 

rooms, etc.

Category I

Mental disorders less severe

Substance use disorders less severe

Locus of care

Primary health care setting

Category II

Mental disorders more severe

Substance use disorders less severe

Locus of care

Mental health system

Mental Disorder

Substance Use
Adapting IOT for Specific Populations 165

determine whether they have signs and 

symptoms warranting a comprehensive 

psychological assessment. These signs and 

symptoms may be subtle, and clients may 

minimize or deny symptoms because of fear 

of stigma. 

Assessment. A thorough assessment should 

be performed either by a clinician trained in 

both areas or by clinicians from each field. 

On occasion, symptoms of acute or chronic 

alcohol and drug toxicity or withdrawal can 

mimic those of psychiatric disorders. The client should be observed closely for worsening 

conditions that warrant transfer to a more 

appropriate facility or to determine whether 

treatment for withdrawal symptoms is needed. Conversely, substance abuse can mask 

psychiatric symptoms, which may appear 

during the initial stages of abstinence. 

Programs should be organized around the 

premise that co-occurring disorders are common; assessment should proceed as soon as 

it is possible to distinguish the substanceinduced symptoms from other independent 

conditions. Particular attention should be 

paid to the following:

Psychiatric history of the client and family 

including diagnoses, previous treatment, 

and hospitalizations

Current symptoms and mental status

Medications and medication adherence

Safety issues such as thoughts of suicide, 

self-harm, or harming others

Severe psychiatric symptoms that result 

in the inability to function, communicate 

effectively, or care for oneself

This information can be augmented by 

objective measurement with assessment 

tools such as those described in the TIP 42, 

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (CSAT 2005e). 

Many programs have rigid guidelines for the 

initial mental health assessment and evaluation, including the initial psychopharmacology 

evaluation, such as requiring a certain 

length of abstinence. Programs should be 

flexible about assessment, removing these 

•

•

•

•

•

barriers when possible. Similarly, denial of 

access to evaluation or treatment for a substance use disorder because an individual is 

taking a prescribed psychotropic medication 

is inappropriate. Clients should continue 

taking medication for a serious mental disorder while being treated for their substance 

use disorders (Minkoff 2002).

Treatment engagement. Some clients with 

co-occurring psychiatric disorders, especially 

severe disorders, may have difficulty committing to and staying in treatment. Providing 

continuous support and outreach, assisting 

with immediate problems (such as housing), 

monitoring individual needs, and helping 

clients access services help develop a therapeutic treatment relationship. In the absence 

of such support, clients with co-occurring 

psychiatric disorders may be at high risk for 

dropping out (Drake and Mueser 2000). 

Treatment planning. Factors to consider 

when developing a treatment plan for these 

clients include the client’s psychiatric status, 

housing, social support, income, medication 

adherence, and symptom management. By 

understanding the client’s strengths and 

goals, IOT program staff can develop a treatment plan that is consistent with the client’s 

needs. Regular reassessments monitor the 

client’s progress in both conditions and are 

the basis for adjustments to the treatment 

plan. Increased individual sessions and 

smaller group sizes also are indicated.

Referral. Clients with psychiatric disturbances that require secure inpatient 

treatment setting, 24-hour medical monitoring, or detoxification (such as clients who 

are actively suicidal or hallucinating) should 

be referred to a facility equipped to provide 

appropriate care. The American Society of 

Addiction Medicine provides placement criteria for clients with co-occurring psychiatric 

disorders (Mee-Lee et al. 2001). 

Mental health care 

Any IOT program that serves a significant 

number of clients with co-occurring psychiatric 
166 Chapter 9

disorders should include mental health specialists and psychiatric consultants on the 

treatment team. 

Prescribing psychiatrist. It is ideal to have 

a psychiatrist with substance abuse treatment expertise on site to provide assessment 

and treatment services, on a full-time, parttime, or consultant basis (Charney et al. 

2001). This approach overcomes problems 

with offsite referral such as the client’s lack 

of transportation and the difficulty of working with another agency. However, when 

funding or other constraints prohibit providing mental health care services on site, 

other options are (1) employing a master’slevel clinical specialist who can treat clients, 

consult with other staff members on mental 

disorders, and function as the liaison with 

psychiatric consultants or (2) establishing a 

working relationship with a mental health 

care agency to provide onsite care. 

Medication provision and monitoring.

Appropriate psychotropic medications are 

essential. Pharmacological advances over 

the past decade have resulted in medications 

with improved effectiveness and fewer side 

effects. Psychotropic medications stabilize 

clients, control their symptoms, and improve 

their functioning. The IOT program counselor can

Refer the client to a psychiatrist or other 

mental health care provider for treatment 

evaluation.

Help arrange appointments with the mental health care provider and encourage the 

client to keep them.

Become familiar with common psychotropic medications, their indications, and 

their side effects.

Instruct the client on the importance of 

complying with the medication regimen.

Report symptoms and behavior to the 

prescribing psychiatrist and other staff 

members to assist in the determination of 

medication needs.

•

•

•

•

•

Use peers or peer groups to monitor medication and to support the client’s proper 

use of medication.

Monitor side effects. 

A helpful resource is Psychotherapeutic 

Medications 2003: What Every Counselor 

Should Know (Mid-America Addiction 

Technology Transfer Center 2000). 

Collaboration with mental 

health care agencies

If circumstances prevent the provision of 

mental health care services in the IOT program, a collaborative relationship with a 

mental health agency can be established. 

One way to form this relationship is through 

an MOU that ensures that psychiatric services are adequate and comprehensive. The 

MOU specifies referral procedures, responsibilities of both parties, communication 

channels, payment requirements, emergency 

contacts, and other necessary procedures. 

TIP 46, Substance Abuse: Administrative 

Issues in Outpatient Treatment (CSAT 2006f), 

provides more information about setting up 

formal mechanisms for working with other 

agencies.

Case management services provide assistance with service coordination when clients 

with co-occurring disorders require treatment in two or more systems of care. TIP 

27, Comprehensive Case Management for 

Substance Abuse Treatment (CSAT 1998a),

provides extensive details about case 

management. 

Modified program structure 

Treating clients with co-occurring psychiatric 

disorders in an IOT program often necessitates modifying the program structure or 

approach.

Separate treatment tracks in IOT. Separate 

tracks for clients with both disorders allow 

clients to be grouped together to address 

issues pertinent to them in group sessions. 

This arrangement particularly helps clients 

•

•
Adapting IOT for Specific Populations 167

with severe co-occurring psychiatric disorders. Establishing a separate track may 

entail organizational change as the agency 

modifies its scheduling, staffing, and training needs.

Staged approaches. Staged approaches provide successive interventions geared to the 

client’s current stage of motivation and 

recovery and address varying levels of 

severity and disability of the co-occurring 

disorders (Drake et al. 1998a; Minkoff 1989). 

The model developed by Osher and Kofoed 

(1989) includes four overlapping stages—

engagement, persuasion, active treatment, 

and relapse prevention—that integrate treatment principles from both fields. The model 

advocates treatment components consisting 

of low-intensity, highly structured programs; 

case management services; provision of 

appropriate detoxification; toxicology screening; family involvement; and participation in 

mutual-help groups. Other staged approaches are described in Minkoff (1989) and 

Prochaska and DiClemente (1992). 

Working with clients with 

co-occurring psychiatric 

disorders 

When mental and substance use disorders 

co-occur, both disorders require specific and 

appropriately intensive primary treatment 

and need to be individualized for each client 

according to diagnosis, phase of treatment, 

level of functioning, and assessment of level 

of care based on acuteness, severity, medical 

safety, motivation, and availability of recovery support (Minkoff 2002).

The treatment of clients with substance 

use and high-severity psychiatric disorders 

(schizophrenia or schizoaffective disorder) 

differs from the treatment of clients who 

have anxiety or mood disorders and a substance use disorder. Clients with severe 

disorders often are the most difficult to treat. 

Examples of approaches that attempt to 

integrate and modify psychiatric and substance abuse treatments to meet the needs of 

the client are (1) a skills-based approach, (2) 

dual-recovery therapy, (3) assertive community treatment, and (4) money-management 

therapy (Ziedonis and D’Avanzo 1998). 

The treatment of clients with substance use 

and mood or anxiety disorders incorporates 

approaches such as cognitive–behavioral 

therapy, which addresses both disorders. 

Several other components, such as relaxation training, stress management, and skills 

training, are emphasized in the treatment of 

both types of disorders (Petrakis et al. 2002). 

Some clients may have cognitive deficits that 

make it difficult for them to comprehend 

written material or 

to comply with program assignments. 

Materials can be 

adapted to express 

ideas and concepts simply and 

concretely, incorporating stepped 

assignments and 

using visual aids 

to reinforce information. TIP 29, 

Substance Use 

Disorder Treatment 

for People 

With Physical 

and Cognitive 

Disabilities (CSAT 1998e), provides more 

information on accommodating clients with 

disabilities.

The therapeutic relationship 

Establishing a trusting, therapeutic relationship is essential during the engagement 

process and throughout treatment. TIP 42, 

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (CSAT 2005e), suggests the following guidelines for developing 

a therapeutic relationship with clients with 

both disorders:

Maintain a belief that recovery is possible.

Manage countertransference.

•

•

Pharmacological 

advances... 

have resulted 

in medications 

with improved 

effectiveness and 

fewer side effects. 
168 Chapter 9

Monitor psychiatric symptoms.

Provide additional structure and support.

Use supportive and empathic counseling.

Use culturally appropriate methods.

The clinician’s ease in establishing and 

maintaining a therapeutic alliance is affected by comfort with the client. IOT program 

clinicians may find working with some 

clients with psychiatric illnesses unsettling 

or feel threatened by them and may have 

difficulty forming a therapeutic alliance 

with them. Consultation with a supervisor 

is important, and with experience, training, 

supervision, and mentoring, the problem can 

be overcome. 

Confrontational approaches may be ineffective for clients with co-occurring psychiatric 

disorders because they may be unable to 

tolerate stressful interpersonal 

challenges. When 

counseling clients 

with co-occurring 

psychiatric disorders, it is helpful 

if the counselor is 

empathic and firm 

at the same time. 

By setting limits on 

negative behaviors, 

counselors provide structure for clients. Another assertive 

intervention involves counselors’ supplying 

feedback that consists of a straightforward 

and factual presentation of the client’s 

conflicting thoughts or problem behavior. 

Provided in a caring manner, such feedback 

can be both “confrontive” and caring. The 

ability to do this well is often critical in 

maintaining the therapeutic alliance with a 

client who has co-occurring psychiatric disorders (see chapter 5 in TIP 42 [CSAT 2005e]). 

TIP 35, Enhancing Motivation for Change in 

Substance Abuse Treatment (CSAT 1999c, p. 

41), provides more information.

Clients with co-occurring psychiatric disorders may become demoralized and 

•

•

•

•

despairing because of the complexity of 

having two disorders and the slow pace of 

improvement in symptoms and functioning. 

Inspiring hope is a necessary task of the IOT 

program clinician. Some suggestions include

Demonstrating an understanding and 

acceptance of the client

Helping the client clarify the nature of his 

or her difficulties

Communicating to the client that the clinician will help the client help himself or 

herself

Expressing empathy and a willingness to 

listen to the client

Assisting the client in solving external 

problems immediately

Fostering hope for positive change

Group treatment 

Group treatment, a mainstay of IOT, is 

used widely and effectively with clients 

with co-occurring disorders (Weiss et al. 

2000), including clients with schizophrenia 

(Addington and el-Guebaly 1998). Several 

approaches can be used: 12-Step based, 

educational, supportive, and social skills 

improvement. These group interventions 

have demonstrated success in increasing 

treatment engagement and abstinence rates 

and decreasing the need for hospitalization (Drake et al. 1998a). Some examples of 

groups follow: 

Psychoeducational groups increase clients’ awareness of both problems in a safe 

and positive environment. 

Psychiatric disorders groups present topics such as signs and symptoms of mental 

disorders, use of medications, and the 

effects of mental disorders on substance 

use problems. 

Medication management groups provide 

a forum for clients to learn about medication and its side effects and help the 

counselor develop solutions to compliance 

problems. 

Social skills training groups provide 

opportunities to learn how to handle 

•

•

•

•

•

•

•

•

•

•

Group treatment... 

is used widely and 

effectively with 

clients with cooccurring disorders.
Adapting IOT for Specific Populations 169

common social situations by teaching clients to solicit support, develop drug and 

alcohol refusal skills, and develop effective 

strategies to cope with pressures to discontinue their prescribed psychiatric medication. Group participants role play situations and practice appropriate responses. 

Reinforcing the difference between substances of abuse and treatment medications is another simple but important 

activity of these groups.

Onsite support groups are led by an IOT 

staff facilitator and provide an arena for 

discussing problems and practicing new 

coping skills.

Group treatment may need to be modified 

and augmented with individual counseling 

sessions for clients with both disorders. The 

clients’ ability to participate in counseling 

depends on their level of functioning, stability of symptoms, response to medication, 

and mental status. Some clients cannot tolerate the emotional intensity of interpersonal 

interactions in group sessions or may have 

difficulty focusing or participating. Many 

clients with a serious mental illness (schizophrenia, schizoid and paranoid personality) 

have difficulty participating in groups but 

can be incorporated gradually into a group 

setting at their own pace. Clients with less 

severe psychiatric disorders may have little 

problem participating in group sessions. 

Some suggestions for working with groups of 

clients with co-occurring disorders include

Orally communicate in a brief, simple, 

concrete, and repetitive manner.

Affirm accomplishments instead of using 

disapproval or sanctions.

Address negative behavior rapidly in a 

positive manner.

Be sensitive and responsive to needs of the 

client.

Shorten sessions.

Organize smaller groups.

Use more focused, but gentle directional 

techniques.

•

•

•

•

•

•

•

•

Mutual-help groups in the 

community 

The consensus panel encourages the use 

of “double trouble” mutual-help recovery 

groups for people with co-occurring psychiatric disorders. Because all attendees have 

a co-occurring psychiatric disorder, they 

are less likely to be subject to the misunderstanding and conflicting messages about 

their psychiatric symptoms or use of psychotropic medications that sometimes occur in 

traditional 12-Step-oriented groups (Magura 

et al. 2003). These groups do not provide 

clinical or counseling interventions; members help one another achieve and maintain 

recovery and be responsible for their personal recovery. 

Various dual recovery organizations have 

been established by people in recovery and 

usually are based on the AA model but 

adapted for people with both disorders, 

including

Double Trouble in Recovery 

(www.doubletroubleinrecovery.org)

Dual Disorders Anonymous 

Dual Recovery Anonymous 

(www.draonline.org)

Dual Diagnosis Anonymous 

The research on traditional 12-Step groups 

is not definitive, but attendance at such 

groups may be beneficial for some clients 

with co-occurring psychiatric disorders (Kelly 

et al. 2003). However, clients with severe 

mental disorders may have difficulty attending these groups (Jordan et al. 2002). Some 

people with co-occurring disorders attend 

both dual disorder and traditional mutualhelp groups (Laudet et al. 2000b). In one 

study, most AA respondents had positive 

attitudes toward people with co-occurring 

disorders and 93 percent indicated that such 

individuals should continue taking their 

psychotropic medications (Meissen et al. 

1999). AA has published The A.A. Member—

Medications and Other Drugs (Alcoholics 

Anonymous World Services 1991), a helpful 

booklet that discusses AA members’ use of 

•

•

•

•
170 Chapter 9

medications when prescribed by a physician 

knowledgeable about alcoholism (visit www.

alcoholics-anonymous.org to order). 

Relapse prevention 

In addition to learning techniques to prevent 

relapse to substance abuse, clients with cooccurring psychiatric disorders may benefit 

from learning to recognize worsening psychiatric symptoms, manage symptoms, or seek 

support from a “buddy” or a mutual-help 

group. Some providers suggest that clients keep 

“mood logs” to increase their awareness of 

how they feel and the situational factors that 

trigger negative feelings or symptoms. Other 

techniques include affect or emotion management, including how to identify, contain, 

and express feelings appropriately. Several 

relapse prevention interventions for clients 

with both disorders have been developed 

(Evans and Sullivan 2000; Weiss et al. 2000). 

Other issues

Family education and support. Clients 

with co-occurring disorders frequently have 

unsatisfactory relationships with their families. Some clients with psychiatric disorders 

remain dependent on their families for an 

extended period, creating complicated family dynamics. Other clients may be estranged 

from or have strained relationships with 

family members, partners, or children. 

Groups for family members can be a venue 

for education and support. Psychoeducation 

combines fundamental information, guidance, and support and allows for low-key 

engagement and continued assessment 

opportunities. Family members and significant others need to understand the 

implications of both disorders and the ways 

that one disorder, if not properly monitored 

and treated, can worsen the symptoms of the 

other. 

At times more intensive family intervention 

may require removing clients from stressful family relationships and helping them 

toward independence. Some families may 

be in need of intensive family therapy and 

should be referred for appropriate care. 

Peer networks. Developing supportive 

peer networks to replace friends who use 

substances is an important component 

of recovery and needs to be addressed in 

treatment. When a client’s family is not supportive, other, more supportive networks can 

be sought. 

Discharge planning and 

continuing care 

Because people with co-occurring psychiatric 

disorders have two chronic conditions, they 

often require long-term care that supports 

their progress and can respond quickly to a 

relapse of either disorder. Some clients may 

need to continue intensive mental health care 

but can manage their substance use disorder 

by participation in support groups. Other 

clients may need minimal mental health care 

but require some form of continued formal 

substance abuse treatment. Participation in 

continuing care tends to improve treatment 

outcomes (Moggi et al. 1999).

Cross-Training 

Ideally, an interdisciplinary staff that provides both substance abuse treatment and 

psychiatric services works as an integrated 

unit, and providers have training and expertise in both fields. Cross-training about the 

differing views of treatment and challenges 

helps staff members from both fields reach 

a common perspective and approach for 

treating clients with co-occurring psychiatric 

disorders. 

A helpful training resource is the MidAmerica Addiction Technology Transfer 

Center’s A Collaborative Response: 

Addressing the Needs of Consumers With 

Co-Occurring Substance Use and Mental 

Health Disorders, an eight-session curriculum designed to promote a cross-disciplinary 

understanding between mental and substance use disorder clinicians (available at 
Adapting IOT for Specific Populations 171

www.mattc.org). SAMHSA’s Strategies for 

Developing Treatment Programs for People 

With Co-Occurring Substance Abuse and 

Mental Disorders (Substance Abuse and 

Mental Health Services Administration 

2003) provides information on starting 

a program for treating people with both 

disorders.

Adolescents

It is important to recognize that youth are 

not little adults, and IOT for adolescents 

should differ from that provided for adult 

populations (Deas et al. 2000). Adolescents 

experience many developmental changes, 

may require habilitation rather than rehabilitation, may be considered dependents 

legally, and may require parental consent for 

treatment. 

Treatment for adolescents requires a comprehensive approach that addresses their 

social, medical, and psychological needs. 

The best candidates for adolescent IOT are 

youth who are experiencing problems as a 

result of recent, moderate-to-heavy use of 

legal or illegal substances, who have functional but ineffective coping skills, and who 

need a marginally structured setting, not 

complete removal from their living situation 

(CSAT 1999f).

TIP 31, Screening and Assessing Adolescents 

for Substance Use Disorders (CSAT 1999d), 

and TIP 32, Treatment of Adolescents With 

Substance Use Disorders (CSAT 1999f), 

provide additional information about screening and treating adolescents for substance 

abuse.

Description of the Population

Developmental changes

Adolescence is a period characterized by 

physical, emotional, and cognitive changes. 

Developmental tasks include the many 

transformations that move adolescents from 

childhood to adulthood. Physical changes 

include rapid growth, development of secondary sex characteristics, and fluctuations 

in hormonal levels. Cognitively, adolescents 

often have shorter 

attention spans 

than adults, have 

limited perspectives on the future, 

may be inconsistent in applying 

abstract thinking 

skills, and may be 

impulsive. During 

adolescence, morals, values, and ideals continue to develop, 

and intellectual interests expand. During 

late adolescence, youth become more introspective and sensitive to the consequences of 

their actions (CSAT 1999f) and improve their 

capacity for setting goals. 

Development of substance 

abuse in adolescents

Many factors are associated with the onset of 

substance use problems in adolescents including genetic background, parental substance 

use and troubled family relations, individual 

characteristics such as cognitive dysfunction, 

and to some extent peer influence (Weinberg 

et al. 1998). Risk factors for developing a 

substance use disorder include a history of 

personality problems such as aggression or 

an affective disorder, school failure, distant 

or hostile relations with parents or guardians, 

family disruption, or a history of victimization (Weinberg et al. 1998). 

Implications for IOT

Adolescents reach IOT by a number of paths, 

including parental request, school referral, 

and juvenile justice system mandate. The 

IOT provider must be prepared to meet 

developmental, family, psychiatric, behavioral, and other treatment challenges that 

may resemble those of adult clients only 

superficially. 

 IOT for adolescents 

should differ from 

that provided for 

adult populations.
172 Chapter 9

Adolescents need thorough biopsychosocial, 

medical, and psychological assessments 

and may need educational, medical, mental health, and social services. Unlike adult 

clients, adolescents are likely to be entering 

treatment for the first time, may have little 

knowledge of the treatment process, and 

need more orientation than adults. 

The assessment process involves a comprehensive evaluation of the adolescent’s 

risks, needs, strengths, and motivation. 

Psychosocial assessment instruments 

appropriate for adolescents should be 

used. Information to gather includes school 

records, class schedule, and school involvement; relationships with peers; sexual 

activity and pressures; relationship with 

family members; mental and physical health 

status; history of abuse and trauma; and 

involvement with the juvenile justice system. 

Family assessment 

The adolescent’s family consists of the 

main caregivers (usually parents) and anyone the client considers family. Family 

issues to assess include family structure 

and functioning, financial and housing statuses, substance use history and treatment 

episodes, mental and physical health, the 

family’s feelings about the adolescent, and 

family members’ problems with violence 

and involvement in the legal system. The 

strengths and resources available to the 

family need to be identified as well. IOT program staff members may want to interview 

the adolescent in private initially and then 

meet with family members.

Psychiatric assessment 

Every client can benefit from a thorough psychiatric assessment by a mental health 

professional trained in adolescent care. As 

many as 60 percent of adolescents with a 

substance use disorder also have co-occurring 

psychiatric disorders (Armstrong and 

Costello 2002), such as anxiety, mood disorders (Kandel et al. 1999), or attention 

deficit/hyperactivity disorder (Weinberg et 

al. 1998). Adolescents should be assessed for 

suicide risk as well. 

Diagnosis 

Although some adolescents may meet the 

diagnostic criteria for substance dependence, 

many are in the early stage of involvement 

with alcohol or drugs. The Diagnostic and 

Statistical Manual of Mental Disorders, 

Fourth Edition, Text Revision (American 

Psychiatric Association 2000) does not contain diagnostic criteria specific to adolescent 

substance dependence, and some adult 

diagnostic criteria, such as withdrawal symptoms and alcohol-related medical problems, 

present differently in adolescents. For these 

reasons, the DSM criteria have limitations 

when applied to adolescents (Martin and 

Winters 1998).

Clinical Issues and Strategies

Family involvement 

Because outpatient family therapy may offer 

benefits superior to other outpatient treatments (Williams et al. 2000), IOT providers 

are encouraged to work with the family 

as much as possible. Chapter 6 on family 

therapy in this TIP and TIP 39, Substance 

Abuse Treatment and Family Therapy (CSAT 

2004c), provide more information.

Engaging the family. The IOT counselor can 

engage family members by

Emphasizing how critical family members 

are to the adolescent’s recovery

Requiring (whenever possible) that a family member accompany the adolescent to 

the initial intake interview and including 

time for the family assessment during that 

meeting

Encouraging family attendance at the 

program’s family education and therapy 

sessions 

•

•

•
Adapting IOT for Specific Populations 173

Helping family members participate in 

developing and reinforcing the behavioral 

contract (see below)

Supporting family members in encouraging the adolescent to attend treatment

Treatment of the family. Family-oriented 

interventions have long been used to 

treat adolescents who abuse substances. 

Szapocznik and colleagues (1983, 1986) 

helped establish the effectiveness of family 

therapy in treating adolescents. The premise 

of family therapy is that the family plays a 

role in creating conditions leading to adolescent drug use and that family elements 

help adolescents recover (Liddle et al. 2001). 

Evidence shows that youth who receive family therapy have less drug use at treatment 

completion than those who receive peer 

group therapy or whose families participate 

in parent education or a multifamily intervention (Liddle et al. 2001).

Some family-based approaches are as follows: 

Multidimensional family therapy and 

multisystemic therapy expand classic family therapy models to focus on promoting 

change in four areas: (1) the adolescent, (2) 

family members, (3) family interaction patterns, and (4) influences from outside the 

family (Liddle 1999, 2002). 

Family cognitive–behavioral therapy integrates traditional family systems theory 

with techniques of cognitive–behavioral 

therapy. This approach considers adolescent substance abuse as a conditioned 

behavior that is reinforced by cues and 

contingencies within the family (Latimer et 

al. 2003). 

The adolescent community reinforcement 

approach focuses on teaching adolescents 

coping skills and changing environmental 

influences related to continued substance 

use (Godley et al. 2001). 

The family support network intervention increases parental support of an 

adolescent’s recovery through developing a 

support group for parents, provides home 

therapy sessions combined with group 

•

•

•

•

•

•

sessions, and 

can be used with 

any standard 

adolescent treatment approach 

(Hamilton et al. 

2001).

The family intervention program 

(see exhibit 

9-3) addresses 

many problems 

experienced by 

families with an 

adolescent who 

uses substances. It includes the family 

and systems that affect the family, such as 

schools and the community. 

The behavioral contract

Adolescents who abuse substances may 

behave in disruptive, destructive, or sometimes criminal ways, such as skipping school, 

having poor school performance, violating curfew, being argumentative with or 

withdrawing from family members, joining 

gangs, or committing crimes.

To address these behaviors, a behavioral 

contract can be a valuable therapeutic tool. 

The clinician works with the adolescent (and 

his or her family) to develop a contract that 

specifies treatment goals, acceptable and 

unacceptable behaviors, and the rewards or 

consequences associated with each. 

The conditions defined in the contract help 

the youth and the family understand the 

treatment process and what is expected of 

them. Once the contract is completed, the 

client and each family member indicate 

their agreement by signing the contract. 

IOT program staff uses the contract to guide 

discussions during family group sessions, to 

monitor progress, and to minimize the undermining of treatment by family members. 

•

As many as 60 

percent of adolescents 

with a substance use 

disorder also have cooccurring psychiatric 

disorders...
174 Chapter 9

Case management services 

for adolescents

The IOT provider may need to provide extensive case management services. The case 

manager works with schools to monitor a 

youth’s compliance with the behavioral contract; coordinates medical, mental health, 

and social services; and works with the juvenile justice system, if needed. Caseloads are 

best kept to about 8 to 10 adolescents per 

staff member.

Group work strategies for 

adolescents

Treating adolescents involves bringing 

together youth from different areas, backgrounds, and developmental levels. Many 

practitioners recommend, if possible, that 

the groups consist of adolescents of the same 

gender, with similar levels of motivation for 

change, and of similar age. Clients in middleto-late adolescence (ages 16 to 18) usually 

have different life experiences, developmental levels, and concerns than do younger 

adolescents. There is limited evidence of 

the effectiveness of treating adolescents in 

groups, perhaps because of the complexities 

just mentioned. The consensus panel reports 

that, with this population, approaches 

emphasizing structured discussions around 

a topic introduced by the counselor are 

more successful than open-ended sessions. 

Same-gender groups can provide a safe 

environment in which to explore such issues 

as sexuality, intimacy, self-esteem, and relationships. If programs do not have enough 

adolescent clients to have a treatment group, 

a gender-specific group session can be held 

weekly to discuss sensitive issues. 

To foster productive group work, it is helpful 

to enforce clear, specific, concrete rules. IOT 

program staff can post the rules in the session room and ask each participant to sign 

a copy. Rules should prohibit bullying and 

teasing. Groups also commonly prohibit nostalgic stories of substance use.

Group members frequently are asked to sign 

a confidentiality statement promising that 

information shared in the group will not be 

repeated outside group. Other suggestions 

for treating adolescents in groups are

Exhibit 9-3

The Family Intervention Program

Source: Fishman and Andes 2001.

This approach partners a family therapist with a community resource specialist. The 

specialist helps the family establish healthy community networks. Working as a team, the 

therapist and specialist conduct five family therapy sessions and perform the following:

Assess the family system; explore the family’s resources, concerns, and goals; and 

create a treatment plan.

Explore relationships among family members, identify areas of difficulty and stress, 

and determine the effect on the family system.

Determine the effect of other systems, such as schools, on the family.

Focus on the family’s concerns and goals and include others who can help resolve 

problems.

Work on how the family can resolve issues without staff help and develop a followup plan.

1.

2.

3.

4.

5.
Adapting IOT for Specific Populations 175

Including activities and keeping discussions short

Varying session content, activity level, and 

purpose

Including frequent breaks

CSAT’s Cannabis Youth Treatment Series 

offers many specific ideas for use with adolescents (Godley et al. 2001; Hamilton et 

al. 2001; Liddle 2002; Sampl and Kadden 

2001; Webb et al. 2002). 

A co-counselor is helpful in running groups 

for adolescents because of the complexity of 

adolescent issues and behavior management 

challenges. 

Clinical considerations

Providing incentives acknowledges the efforts 

of youth and encourages them to persevere. 

Incentives should be meaningful to the 

youth, such as gift certificates from a music 

store, movie theater, or clothing store. 

Other key points about treating adolescents 

include the following:

A cognitive–behavioral model and motivational enhancement techniques are useful.

Not all adolescents who use substances are 

dependent, and prematurely diagnosing or 

labeling adolescents or pressuring them to 

accept that they have an addictive disease 

may not work.

Many adolescents respond better to motivational interviewing than to confrontation.

Exhibit 9-4 lists characteristics and behaviors of adolescents in treatment and 

practical treatment suggestions. 

Staff Training

IOT program staff members need to understand adolescent development and treatment 

needs. Clinicians working with youth should

Be flexible and able to interact warmly 

with adolescents.

Observe clear and appropriate personal 

boundaries.

•

•

•

•

•

•

•

•

Be able to set firm behavioral limits in a 

nonjudgmental or nonpunitive manner.

Know about the substances and combinations that adolescents use, the slang in use, 

and the physical and behavioral effects of 

any new drugs.

Have substantial knowledge of the school 

system.

Understand family dynamics.

Core program staff members should include 

a clinical coordinator who is trained in 

adolescent treatment. Skills development 

training for staff should occur regularly on 

topics appropriate for adolescent treatment. 

Young Adults

Some caregivers may find it difficult to recognize or accept that young adults (ages 18 

to 24) are no longer legal dependents. Even 

though a youth still may live at home or be 

in school, parental responsibility changes 

and the young adult can make his or her 

own choices. Counselors may find that they 

need to help both the young adult client 

and parents realize that the client can make 

choices and is responsible for actions. Some 

young adult clients may be totally on their 

own, with little family contact. 

The use of alcohol or drugs at an early age 

may have delayed normal development. 

Although these young clients are legally 

adults, they may not have grown into young 

adult social roles.

The young adult may be ready clinically for 

placement in an adult treatment group or 

may be placed more appropriately in an adolescent program. A thorough assessment is 

needed to determine appropriate placement. 

IOT Programming for 

Young Adults

To engage and retain these clients, IOT programming can incorporate techniques used 

in adolescent programs. To involve young 

adult clients in treatment, it is important to 

•

•

•

•
176 Chapter 9

Exhibit 9-4

Characteristics and Behaviors of 

Adolescents and Treatment Suggestions

Characteristics and Behaviors 

of Adolescents in Treatment 

Suggestions for Improving the Treatment 

Experience for Adolescents

Inconsistent ability for abstract 

thinking

Limit abstract, future-oriented activities

Use mentors 

Avoid scare tactics and labels

Impulsive, often with short 

attention spans

Design activities to teach self-control skills; allow 

practice time

Need to belong and identify 

with others; vulnerability to 

peer influence

Create opportunities for group members to bond

Help clients establish positive peer groups and develop skills in resisting negative peer pressure

Promote positive peer feedback in group

Frequent emotional 

fluctuations

Validate feelings

Acknowledge the pressures and stresses of 

adolescence

Help youth improve stress management skills

Lack of involvement in healthy 

recreational activities 

Help clients develop daily schedules

Help youth find new recreational activities not involving substance use such as games, sports, hobbies, and 

religious or spiritual groups

Tendency toward pessimistic or 

fatalistic attitudes

Recognize fatalist attitudes such as “I’m going to die 

soon, anyway,” and “Drugs are the only way out for 

me”

Validate clients’ anger, hopelessness, or perceived 

obstacles to success, but challenge youth to think 

positively 
Adapting IOT for Specific Populations 177

reach out to them through family, colleges, 

employers, and the court system. Treatment 

should be relevant to young adult concerns, 

interests, and social activities and be flexible 

enough to adapt to the client’s developmental deficits. The following issues are relevant:

Education and employment. Educational 

and job skill levels need to be assessed and 

addressed. Some clients who have grown 

up in poverty have witnessed the futility 

of working at a low-paying job versus the 

financial benefits of selling illicit drugs. 

These clients need special attention. 

Family roles. Some clients may have children and family responsibilities and need 

assistance in obtaining child care and 

developing parenting skills.

Separating from parents. Young adults 

in treatment often have parents who are 

•

•

•

unwilling to set limits, which fosters dependence and intense attachment on the part 

of the clients. Parents need to understand 

that their enabling behavior is a barrier to 

their young adult’s recovery. Young adult 

clients often require life skills development. Treatment should focus on habilitation, rather than rehabilitation.

Peer relationships. Some clients may 

need assistance in developing and maintaining healthy peer networks and family 

relationships. 

Mentoring. A positive adult role model 

provides a meaningful example.

Community service. Young adults in treatment can contribute to society and should 

be encouraged to participate in and volunteer for community or faith-based events.

•

•

•

179

Intensive outpatient treatment (IOT) programs increasingly are 

called on to serve individuals with diverse backgrounds. Roughly 

one-third of the U.S. population belongs to an ethnic or racial minority group. More than 11 percent of Americans, the highest percentage 

in history, are now foreign born (Schmidley 2003). 

Culture is important in substance abuse treatment because clients’ 

experiences of culture precede and influence their clinical experience. Treatment setting, coping styles, social supports, stigma 

attached to substance use disorders, even whether an individual 

seeks help—all are influenced by a client’s culture. Culture needs 

to be understood as a broad concept that refers to a shared set of 

beliefs, norms, and values among any group of people, whether 

based on ethnicity or on a shared affiliation and identity. 

In this broad sense, substance abuse treatment professionals can be 

said to have a shared culture, based on the Western worldview and 

on the scientific method, with common beliefs about the relationships 

among the body, mind, and environment (Jezewski and Sotnik 2001). 

Treating a client from outside the prevailing United States culture 

involves understanding the client’s culture and can entail mediating 

among U.S. culture, treatment culture, and the client’s culture.

This chapter contains

An introduction to current research that supports the need for 

individualized treatment that is sensitive to the client’s culture

Principles in the delivery of culturally competent treatment services

Topics of special concern, including foreign-born clients, women 

from other cultures, and religious considerations

Clinical implications of culturally competent treatment

Sketches of diverse client populations, including

Hispanics/Latinos 

African-Americans

Native Americans

•

•

•

•

•

–

–

–

10 Addressing Diverse 

Populations in 

Intensive Outpatient 

Treatment

In This 

Chapter...

What It Means To 

Be a Culturally 

Competent 

Clinician

Principles in 

Delivering 

Culturally 

Competent IOT 

Services

Issues of Special 

Concern

Clinical 

Implications 

of Culturally 

Competent 

Treatment

Sketches of 

Diverse IOT Client 

Populations
180 Chapter 10

Asian Americans and Pacific Islanders

Persons with HIV/AIDS

Lesbian, gay, and bisexual (LGB) 

populations

Persons with physical and cognitive 

disabilities

Rural populations

Homeless populations

Older adults

Resources on culturally competent treatment for various populations

What It Means To Be a 

Culturally Competent 

Clinician

It is agreed widely in the health care field 

that an individual’s culture is a critical factor to be considered in treatment. 

The Surgeon General’s report, Mental 

Health: Culture, Race, and Ethnicity, states, 

“Substantive data from consumer and family 

self-reports, ethnic match, and ethnic-specific 

services outcome studies suggest that tailoring services to the specific needs of these 

[ethnic] groups will improve utilization and 

outcomes” (U.S. Department of Health and 

Human Services 2001, p. 36). The Diagnostic 

and Statistical Manual of Mental Disorders, 

Fourth Edition (DSM-IV) (American 

Psychiatric Association 1994) calls on clinicians to understand how their relationship 

with the client is affected by cultural differences and sets up a framework for reviewing 

the effects of culture on each client.

Mental Health: Culture, Race, and Ethnicity

is the first comprehensive report on the 

status of mental health treatment for minority groups in the United States. This report 

synthesizes research data from a variety of 

disciplines and concludes that

Disparities in mental health services exist 

for racial and ethnic minorities. These 

groups face many barriers to availability, 

accessibility, and use of high-quality care.

–

–

–

–

–

–

–

•

•

The gap between research and practice is 

worse for racial and ethnic minorities than 

for the general public, with problems evident in both research and practice settings. 

No ethnic-specific analyses have been done 

in any controlled clinical trials aimed at 

developing treatment guidelines.

In clinical practice settings, racial and ethnic minorities are less likely than Whites to 

receive the best evidence-based treatment. 

(It is worth noting, however, that given the 

requirements established by funders and 

managed care, clients at publicly funded 

facilities are perhaps more likely than 

those at many private treatment facilities 

to receive evidence-based care.)

Because verbal communication and the 

therapeutic alliance are distinguishing features of treatment for both substance use 

and mental disorders, the issue of culture is 

significant for treatment in both fields. The 

therapeutic alliance should be informed by 

the clinician’s understanding of the client’s 

cultural identity, social supports, self-esteem, 

and reluctance about treatment resulting 

from social stigma. A common theme in culturally competent care is that the treatment 

provider—not the person seeking treatment—

is responsible for ensuring that treatment is 

effective for diverse clients.

Meeting the needs of diverse clients involves 

two components: (1) understanding how to 

work with persons from different cultures 

and (2) understanding the specific culture of 

the person being served (Jezewski and Sotnik 

2001). In this respect, being a culturally 

competent clinician differs little from being 

a responsible, caring clinician who looks 

past first impressions and stereotypes, treats 

clients with respect, expresses genuine interest in clients as individuals, keeps an open 

mind, asks questions of clients and other 

providers, and is willing to learn. 

This chapter cannot provide a thorough 

discussion of attributes of people from various cultures and how to attune treatment 

to those attributes. The information in this 

•

•
Addressing Diverse Populations in IOT 181

chapter provides a starting point for exploring these important issues in depth. More 

detailed information on these groups, plus 

discussions of substance abuse treatment 

considerations, is found in the resources 

listed in appendix 10-A (page 197). The following resources may be especially helpful 

in understanding the broad concepts of cultural competence: 

Mental Health: Culture, Race, and 

Ethnicity (U.S. Department of Health and 

Human Services 2001) (www.mentalhealth.

org/cre/default.asp). Chapter 2 discusses 

the ways in which culture influences mental disorders and mental health services. 

Subsequent chapters explain the historical and sociocultural context in which 

treatment occurs for four major groups—

African-Americans, American Indians 

and Alaska Natives, Asian Americans and 

Pacific Islanders, and Hispanic/Latino 

Americans. 

Chapter 4 of TIP 46, Substance Abuse: 

Administrative Issues in Outpatient 

Treatment (CSAT 2006f). This chapter 

describes steps that an IOT administrator 

can take to prepare an IOT organization to 

treat diverse clients more competently and 

sensitively. Chapter 4 also lists resources 

not found in the appendix at the end of 

this chapter.

The forthcoming TIP Improving Cultural 

Competence in Substance Abuse Treatment

(CSAT forthcoming a) includes an inservice training guide.

Principles in Delivering 

Culturally Competent 

IOT Services

The Commonwealth Fund Minority Health 

Survey found that 23 percent of AfricanAmericans and 15 percent of Latinos felt 

that they would have received better treatment if they were of another race. Only 6 

percent of Whites reported the same feelings 

(La Veist et al. 2000). Against this backdrop, 

•

•

•

it clearly is important for providers to have 

a genuine understanding of their clients 

from other cultures, as well as an awareness 

of how personal or professional biases may 

affect treatment. 

Most IOT counselors are White and come 

from the dominant Western culture, but 

nearly half of clients seeking treatment are 

not White (Mulvey 

et al. 2003). This 

stark fact supports 

the argument that 

clinicians consider 

treatment in the 

context of culture. 

Counselors often 

feel that their own 

social values are 

the norm—that 

their values are typical of all cultures. 

In fact, U.S. culture differs from most other 

cultures in a number of ways. IOT clinicians 

and program staff members can benefit from 

learning about the major areas of difference 

and from understanding the common ways 

in which clients from other cultures may differ from the dominant U.S. culture.

Treatment Principles

Members of racial and ethnic groups are not 

uniform. Each group is highly heterogeneous 

and includes a diverse mix of immigrants, 

refugees, and multigenerational Americans 

who have vastly different histories, languages, 

spiritual practices, demographic patterns, 

and cultures (U.S. Department of Health 

and Human Services 2001). 

For example, the cultural traits attributed 

to Hispanics/Latinos are at best generalizations that could lead to stereotyping and 

alienation of an individual client. Hispanics/

Latinos are not a homogeneous group. For 

example, distinct Hispanic/Latino cultural 

groups—Cuban Americans, Puerto Rican 

Americans, Mexican Americans, and Central 

and South Americans—do not think and act 

...an individual’s 

culture is a 

critical factor to 

be considered in 

treatment. 
182 Chapter 10

alike on every issue. How recently immigration occurred, the country of origin, current 

place of residence, upbringing, education, 

religion, and income level shape the experiences and outlook of every individual who 

can be described as Hispanic/Latino. 

Many people also have overlapping identities, with ties to multiple cultural and social 

groups in addition 

to their racial or 

ethnic group. For 

example, a Chinese 

American also 

may be Catholic, 

an older adult, 

and a Californian. 

This individual 

may identify 

more closely with 

other Catholics 

than with other 

Chinese Americans. 

Treatment providers need to be careful not to make facile 

assumptions about clients’ culture and values based on race or ethnicity.

To avoid stereotyping, clinicians must 

remember that each client is an individual. 

Because culture is complex and not easily 

reduced to a simple description or formula, 

generalizing about a client’s culture is a 

paradoxical practice. An observation that 

is accurate and helpful when applied to a 

large group of people may be misleading 

and harmful if applied to an individual. It 

is hoped that the utility of offering broad 

descriptions of cultural groups outweighs the 

potential misunderstandings. When using 

the information in this chapter, counselors 

need to find a balance between understanding clients in the context of their culture 

and seeing clients as merely an extension of 

their culture. Culture is only a starting point 

for exploring an individual’s perceptions, 

values, and wishes. How strongly individuals 

share the dominant values of their culture 

varies and depends on numerous factors, 

including their education, socioeconomic status, and level of acculturation to U.S. society. 

Differences in Worldview

A first step in mediating among various 

cultures in treatment is to understand the 

Anglo-American culture of the United States. 

When compared with much of the rest of the 

world, this culture is materialistic and competitive and places great value on individual 

achievement and on being oriented to the 

future. For many people in U.S. society, life 

is fast paced, compartmentalized, and organized around some combination of family 

and work, with spirituality and community 

assuming less importance. 

Some examples of this worldview that differ 

from that of other cultures include

Holistic worldview. Many cultures, such 

as Native-American and Asian cultures, 

view the world in a holistic sense; that is, 

they see all of nature, the animal world, 

the spiritual world, and the heavens as 

an intertwined whole. Becoming healthy 

involves more than just the individual and 

his or her family; it entails reconnecting 

with this larger universe.

Spirituality. Spiritual beliefs and ceremonies often are central to clients from some 

cultural groups, including Hispanics/

Latinos and American Indians. This spirituality should be recognized and considered during treatment. In programs for 

Native Americans, for example, integrating 

spiritual customs and rituals may enhance 

the relevance and acceptability of services.

Community orientation. The AngloAmerican culture assumes that treatment focuses on the individual and the 

individual’s welfare. Many other cultures 

instead are oriented to the collective good 

of the group. For example, individual 

identity may be tied to one’s forebears and 

descendants, with their welfare considered 

in making decisions. Asian-American and 

Native-American clients may care more 

about how the substance use disorder 

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•

•

Culture is only 

a starting point 

for exploring 

an individual’s 

perceptions, values, 

and wishes.
Addressing Diverse Populations in IOT 183

harms their family group than how they 

are affected as individuals. 

Extended families. The U.S. nuclear family consisting of parents and children is 

not what most other cultures mean by family. For many groups, family often means 

an extended family of relatives, including 

even close family friends. IOT programs 

need a flexible definition of family, accepting the family system as it is defined by the 

client.

Communication styles. Cultural misunderstandings and communication problems between clients and clinicians may 

prevent clients from minority groups from 

using services and receiving appropriate care (U.S. Department of Health and 

Human Services 2001). Understanding 

manifest differences in culture, such as 

clothing, lifestyle, and food, is not crucial 

(with the exception of religious restrictions 

on dress and diet) to treating clients. It 

often is the invisible differences in expectations, values, goals, and communication 

styles that cause cultural differences to be 

misinterpreted as personal violations of 

trust or respect. However, one cannot know 

an individual’s communication style or 

values based on that person’s group affiliation (see appendix 10-A for more information and resources on cross-cultural 

communication).

Multidimensional learning styles. The 

Anglo-American culture emphasizes learning through reading and teaching. This 

method sometimes is described as linear 

learning that focuses on reasoned facts. 

Other cultures, especially those with an 

oral tradition, do not believe that written 

information is more reliable, valid, and 

substantial than oral information. Instead, 

learning often comes through parables 

and stories that interweave emotion and 

narrative to communicate on several levels 

at once. The authority of the speaker may 

be more important than that of the message. Expressive, creative, and nonverbal 

interventions that are characteristic of a 

specific cultural group can be helpful in 

•

•

•

treatment. Cultures with this kind of rich 

oral tradition and learning pattern include 

Hispanics/Latinos, African-Americans, 

American Indians, and Pacific Islanders.

Common issues affecting the counselor–

client relationship include the following:

Boundaries and authority issues. Clients 

from other cultures often perceive the 

counselor as a person of authority. This 

may lead to the client’s and counselor’s 

having different ideas about how close the 

counselor–client relationship should be.

Respect and dignity. For most cultures, particularly those that have been 

oppressed, being treated with respect and 

dignity is supremely important. The AngloAmerican culture tends to be informal in 

how people are addressed; treating others 

in a friendly, informal way is considered 

respectful. Anglo Americans generally prefer casual, informal interactions even when 

newly acquainted. However, some other 

cultures view this informality as rudeness 

and disrespect. For example, some people 

feel disrespected at being addressed by 

their first names. 

Attitudes toward help from counselors. 

There are wide differences across cultures 

concerning whether people feel comfortable accepting help from professionals. 

Many cultures prefer to handle problems 

within the extended family. The clinician and client also may harbor different 

assumptions about what a clinician is supposed to do, how a client should act, and 

what causes illness (U.S. Department of 

Health and Human Services 2001). 

Issues of Special 

Concern

The IOT consensus panel recommends that 

IOT programs look at the following areas of 

special concern: 

Whether the program is prepared to adequately serve foreign-born clients living 

within their catchment area 

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184 Chapter 10

Whether the special needs of their minority or foreign-born women clients are being 

addressed adequately

Whether the program needs to make any 

content adjustments out of respect for the 

religious orientation of current or potential 

clients 

Foreign-Born Clients

In 2002, according to the U.S. Census 

Bureau, about 32.5 million U.S. residents 

were foreign born, of whom 52 percent 

came from Latin America and 26 percent 

from Asia (Schmidley 2003). Eleven percent 

were born in another country and may be 

speaking or learning English as a second language. Migration is a stressful life event, and 

immigrants are at risk for substance abuse 

because of stress, isolation, and the lack of 

social support they experience in adjusting 

to their new country.

The reason for a person’s immigration is 

considered an important factor in the level 

of stress that immigrants experience as they 

settle into a new life. Refugees typically have 

been forced to abandon their countries and 

former lives, leaving their belongings behind, 

to relocate to a different and sometimes 

unwelcoming new world in which language, 

social structures, and community resources 

may be totally unfamiliar (Jezewski and 

Sotnik 2001). This displacement can be particularly difficult for older refugees.

Clinical considerations

Having a personal history of abuse and 

trauma is recognized as a major factor in 

substance use disorders and in the inability 

to maintain recovery. A large percentage of 

Asian-American and Hispanic-American 

immigrants show clinical evidence of posttraumatic stress disorder (PTSD) as a result 

of exposure to severe trauma, such as 

genocide, war, torture, or extreme threat of 

death or serious injury (U.S. Department of 

Health and Human Services 2001). In some 

samples, up to 70 percent of refugees from 

•

•

Vietnam, Cambodia, and Laos met diagnostic criteria for PTSD, compared with about 

4 percent with a prevalence for PTSD in the 

U.S. population as a whole (U.S. Department 

of Health and Human Services 1999). For 

this reason, treatment for foreign-born clients often needs to address both substance 

use and the client’s background of abuse 

and violence.

Other clinical issues include the following:

Mistrust of authority. Immigrants and refugees from many regions of the world feel 

extreme mistrust of government based on 

the atrocities committed in their countries 

of origin or fear of deportation by U.S. 

authorities. This mistrust can be a barrier 

to entering treatment and to obtaining 

services.

Extreme sense of stigma. Clients from 

other cultures view mental disorders, 

including substance abuse, much more 

negatively than does the general U.S. 

population (U.S. Department of Health 

and Human Services 1999). In some Asian 

cultures, this stigma is so strong that a 

person’s substance dependence is thought 

to reflect poorly on the family lineage, 

diminishing the marriage and economic 

prospects for the client and for other family members.

Level of acculturation. Providers should 

take into account a client’s level of acculturation in assessment and treatment. 

Generally speaking, foreign-born persons 

have rates of substance use lower than 

U.S.-born counterparts; the more acculturated the person is to the United States, the 

more that person’s use approaches U.S. 

substance-using norms. Among Hispanics/

Latinos, substance use disorders are less 

frequent in those who were born outside the United States (Turner and Gil 

2002). For example, foreign-born Cuban 

Americans have lower lifetime use of alcohol and start drinking later in life than do 

U.S.-born Cuban Americans (Vega et al. 

1993). However, being born in the United 

States does not mean necessarily that a 

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•

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Addressing Diverse Populations in IOT 185

person is acculturated. In a later study, 

Vega and colleagues (1998) found that the 

highest rates of substance abuse among 

Hispanic/Latino adolescents were seen in 

those who were born in the United States 

but had low acculturation levels. The 

researchers attributed these results to the 

fact that these adolescents faced the language problems of foreign-born Hispanics/

Latinos and the acculturation conflicts of 

U.S.-born Hispanics/Latinos.

Implications for IOT providers

IOT providers who want to reach out to 

foreign-born clients in their community 

and serve them better should become more 

knowledgeable about the history and experiences of the newcomers. One way to start 

is by researching and reading about these 

cultural groups. Providers also should get 

to know newcomer populations by visiting 

community refugee and immigrant organizations, such as their Mutual Assistance 

Associations. Representatives of these associations can identify the need for substance 

abuse treatment among their constituents, as 

well as provide advice and suggestions about 

designing culturally specific services.

Providers can consider setting up an IOT 

group in the immigrants’ native language. 

For example, it has been found that linguistic Spanish-only groups are helpful for 

recently arrived Hispanic/Latino immigrants. One note on language: In addition to 

native-language treatment groups, programs 

should provide services in English for those 

clients who want them. Many immigrants 

understand that not knowing English can be 

a barrier, and they are motivated to improve 

their English-language skills.

Some suggestions for programs that establish language-specific groups include the 

following:

A program catering to a language-specific 

population needs to facilitate communication in that language. All documents in the 

program should be adapted. The program 

•

also can have a phone message in the clients’ native language, with calls returned 

by a counselor who speaks the language.

The important issues that immigrants 

face need to be addressed as part of the 

treatment program. These issues include 

cultural differences between the dominant 

culture and their native culture, sense of 

displacement, lack of community, language 

problems, accessing social services, and 

finding employment.

The clients’ cultural attitudes and values 

about substance use should shape program 

content. Clients need to acquire an understanding of how their native cultural attitudes differ from the values of U.S. society, 

which involves understanding U.S. laws, 

social expectations, and way of life. 

Using the terminology of the treatment 

field becomes a challenge because many 

words are difficult to translate and the 

meanings can vary according to the culture. Often, the counselor needs to translate both a word 

and its meaning 

in the English 

language and 

U.S. culture. 

For example, 

in Russian the 

concept of denial 

is positive. This 

concept generally translates 

into Russian as “It is good to deny that you 

have a problem.” Likewise, “defenses” also 

translates as a positive concept. The word 

“defense” in Russian refers to a tool for 

addressing rude or disrespectful behavior 

from another person. In translation, these 

words carry the connotation of “To be 

defended and in denial are good tools to 

handle one’s problems.”

Immigrant clients may need many social 

and educational support services that may 

be difficult for the clients to access because 

of language and cultural barriers. Often 

clients are not familiar with the existence, 

range, and purpose of these needed 

•

•

•

•

...mistrust can be a 

barrier to entering 

treatment and to 

obtaining services.
186 Chapter 10

supports, and some fear or are confused 

by the complexities of government procedures; their access to these services may be 

impeded by the documentation processes 

that bureaucracies often require. IOT case 

management can broker needed support 

services. One model for doing this, called 

culture brokering, consists of conflict 

resolution and problemsolving strategies 

designed to help two cultures communicate 

and cooperate. In the context of cultural 

competence, the two cultures are represented by clients who are foreign born or 

disabled and treatment providers. (See 

cirrie.buffalo.edu/cbrokering.html for more 

information.)

Women From Other Cultures

Immigrant women face the same barriers 

to treatment that confront many AngloAmerican women—restricted availability 

of child care, low income, unsupportive 

spouses, lack of health insurance benefits, 

and lack of education and job skills—but 

have the added barrier of being outsiders to 

the culture. 

View the woman’s behavior and treatment goals in the context of her culture.

Treatment needs to be sensitive to the 

cultural mores and female roles in that 

woman’s culture and to the client’s level 

of acculturation. Some societies can be 

paternalistic and dominated by men, with 

women expected to play traditional roles 

as wives and mothers. A woman client 

may have values and attitudes that reflect 

that culture. Her substance use disorder, 

her attitudes about her addiction, and her 

perception of her recovery options occur 

within that cultural framework. It is therefore important to understand the client’s 

level of comfort with what is expected in 

treatment. Treatment goals should depend 

on the woman’s hopes and should conform 

to the cultural role she wants for herself.

Expect to work within complex, conflicting value systems. Women from maledominated cultures often are raised to be 

•

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Cultural Issues in a Russian-Language IOT Program

The ChangePoint IOT Program for Russian immigrants in Portland, Oregon, usually has about 

15 clients in treatment at a time. Clients are immigrants from all over Russia, and most are religious refugees. The newcomers generally stay in family groups that immigrate together, so these 

clients have close family connections.

Clients learn about the social and legal expectations regarding substance use in the United 

States. The group work focuses on the cultural attitudes that these Russian clients bring to their 

substance use and treatment. Examples of differing U.S.–Russian cultural values that the program helps clients understand include

Acceptable levels of alcohol use. Alcohol use among Russian clients is higher than average for 

the United States. In Russia, drinking enormous quantities of alcohol is tolerated provided the 

person behaves appropriately. 

Legal expectations. Russians tend to view the law in a “black or white” context. In Russia, 

there is zero tolerance for any blood alcohol level (BAL) when driving. When clients hear that a 

BAL below 0.08 is legal in the United States, they think, “I can drink and drive as long as I’m 

under 0.08 or as long as I’m careful.”

Attitudes about money and treatment. Russian clients may assume that the program will 

understand if they cannot pay their bills on time. Russian people expect that they will be paid 

regularly, often lend money to family and friends, and feel a high level of trust that they will be 

paid back. This translates into an expectation that the program also will trust them to pay their 

bills at some time in the future.

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Addressing Diverse Populations in IOT 187

gentle, passive, and selfless in serving their 

husbands and families. Some counselors 

may want to push such women toward 

independence and self-assertion but 

should be aware that these attributes may 

not be personally or culturally desirable 

for foreign-born female clients.

Often, treatment must be more intensive for poor immigrant women than for 

immigrant women with more economic 

resources. Treatment programs that enhance 

women’s economic autonomy through 

social and employment support are effective in reducing substance use (Gregoire 

and Snively 2001). As with many women in 

treatment, foreign-born women may need 

transportation to their medical and legal 

appointments, as well as to substance abuse 

treatment sessions. Other services should 

include

Domestic violence intervention. Staff 

members need to understand the factors in 

clients’ home life that interfere with recovery, such as domestic violence or having a 

significant other who also uses substances.

Multidisciplinary meetings with other 

caregivers. The IOT staff can organize 

multidisciplinary meetings for the client 

that involve all referring agencies. Staff 

from the referring agencies should be 

encouraged to attend and develop a plan 

to address any issues that may be interfering with the client’s treatment. 

Parenting classes. Parenting classes help 

women meet some of the stipulations 

required by State departments of child and 

family services. In addition, some childrearing practices in other cultures may not 

be acceptable in American culture, and 

classes offer the chance for women to learn 

more acceptable practices. 

Religious Orientation

IOT providers need to ensure that their 

program is welcoming to people from all religious faiths and that no treatment practices 

are a barrier to those from non-Christian 

•

•

•

religions. Programs should address specifically the following issues:

Religious acceptance and tolerance 

within the program. Local religious leaders can educate substance abuse treatment 

providers about traditions and practices. 

Providers, in turn, can educate religious 

leaders about services that are available. 

In the years immediately following the 

attacks of September 11, 2001, American 

Muslims experienced increased incidents 

of bias, discrimination, overt hostility, 

abuse, and violence. Collaborating with 

local imams can help treatment providers 

and the religious community reach out 

and aid people more effectively (Goodman 

2002). Intolerance by other clients in treatment should not be condoned and needs 

to be addressed. (For a brief introduction 

on responding to the mental health needs 

of Arab Americans and American Muslims 

in the wake of terrorism, see Goodman 

[2002].)

Knowledge of religious customs.

Providers need to understand and accommodate the religious customs of individual 

clients. A culturally sensitive IOT program 

should ask about clients’ dietary preferences, 

special holidays, and religious customs 

(e.g., daily prayers).

Preparing clients for mutual-help programs. Non-Christian clients who are 

referred to mutual-help programs for 

continuing care should be informed that 

meetings often incorporate elements of 

Christianity. As an example, the Lord’s 

Prayer, which comes from the Christian 

Bible, frequently is selected for closing 

Alcoholics Anonymous (AA) meetings. 

Because this is a Christian prayer, it potentially is offensive to the religious point 

of view of such groups as Jews, Muslims, 

Hindus, and Buddhists. Jewish mutualhelp meetings exist in many communities. The Web site of Jewish Alcoholics, 

Chemically Dependent Persons and 

Significant Others at www.jacsweb.org provides additional information. Many areas 

of the country have secular mutual-help 

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188 Chapter 10

meetings. Providers should become familiar with these meetings, so they can direct 

their non-Christian clients to them. 

Support from religious leaders. Clients 

whose religious faith is central to their 

lives should be encouraged to seek help 

from their religious leaders and from fellow believers.

Clinical Implications of 

Culturally Competent 

Treatment

IOT programs should take the following 

steps to ensure culturally competent treatment for their clients:

Assess the program for policies and practices that might pose barriers to culturally 

competent treatment for diverse populations. Removing these barriers could entail 

something as simple as rearranging furniture to accommodate clients in wheelchairs 

or as involved as hiring a counselor who 

is from the same cultural group as the 

population the program serves. Chapter 4 

of TIP 46, Substance Abuse: Administrative 

Issues in Outpatient Treatment (CSAT 

2006f), provides more information about 

assessing program needs.

Ensure that all program staff receive training about the meaning and benefits of cultural competence in general and about the 

specific cultural beliefs and practices of client populations that the program serves.

Incorporate family and friends into treatment to support the client. Although family involvement is often a good idea in 

an IOT program, it may be particularly 

effective given the importance of family in 

many cultures. Some clients left families 

and friends behind when they came to the 

United States. Helping these clients build 

support systems is critical. 

Provide program materials on audiotapes, 

in Braille, or in clients’ first languages. All 

materials should be sympathetic to the culture of clients being served.

•

•

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•

•

Ensure that client materials are written at 

an appropriate reading level. People who 

are homeless and those for whom English 

is a second language may need materials 

written at an elementary school reading 

level.

Include a strong outreach component. 

People who are unfamiliar with U.S. culture may be unaware that substance abuse 

treatment is available or how to access it.

Hire counselors and administrators 

and appoint board members from the 

diverse populations that the program 

serves. Chapter 4 of TIP 46, Substance 

Abuse: Administrative Issues in Outpatient 

Treatment (CSAT 2006f), provides more 

information about recruiting and hiring 

diverse staff members.

Incorporate elements from the culture of 

the populations being served by the program (e.g., Native-American healing rituals 

or Talking Circles).

Partner with agencies and groups that 

deliver community services to provide 

enhanced IOT services, such as child care, 

transportation, medical screening and 

services, parenting classes, English-as-asecond-language classes, substance-free 

housing, and vocational assistance. These 

services may be necessary for some clients 

to be able to stay in treatment.

Provide meals at the program facility. This 

may bring some clients (e.g., those who are 

elderly or homeless) into treatment and 

induce them to stay.

Make case management services available 

for clients who need them.

Emphasize structured programming, as 

opposed to open-ended discussion, in 

group therapy settings. 

Base treatment on clients’ strengths. 

Experienced providers report that this 

approach works well with clients from 

many cultures and is the preferred 

approach for clients struggling with selfesteem or empowerment. 

Use a motivational framework for treatment, which seems to work well with clients from many cultures. Basic principles 

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Addressing Diverse Populations in IOT 189

of respect and collaboration are the basis 

of a motivational approach, and these 

qualities are valued by most cultures.

Encourage clients to participate in mutualhelp programs to support their recovery. 

Although the mutual-help movement’s 

roots are in White, Protestant, middle-class 

American culture, data show that members 

of minorities benefit from mutual-help 

programs to the same extent as do Whites 

(Tonigan 2003).

Sketches of Diverse 

IOT Client Populations

The following demographic sketches focus 

on diverse clients who may be part of an 

IOT caseload. These descriptions characterize entire groups (e.g., number of people, 

geographic distribution, rates of substance 

use) and include generalized cultural characteristics of interest to the clinician. This 

type of cultural overview is only a starting 

point for understanding an individual. To 

serve adequately clients from the diverse 

groups described here, IOT providers need to 

get to know their clients and educate themselves. Appendix 10-A (page 197) contains 

an annotated list of resources on cultural 

competence in general, as well as resources 

listed by population group. These resources 

include free publications available from government agencies—in particular the Center 

for Substance Abuse Treatment and the 

Center for Substance Abuse Prevention—and 

describe population-specific treatment guidelines and strategies. 

Hispanics/Latinos

Hispanics/Latinos include individuals 

from North, Central, and South America, 

as well as the Caribbean. Hispanic people 

can be of any race, with forebears who may 

include American Indians, Spanish-speaking 

Caucasians, and people from Africa. Great 

disparities exist among these subgroups in 

•

education, economic status, and labor force 

participation. In 2002, the Hispanic/Latino 

population totaled 37.4 million, more than 

13 percent of the total U.S. population, 

and it is now 

the largest ethnic group in the 

Nation. Mexican 

Americans are the 

largest subgroup, 

representing more 

than two-thirds 

of all Hispanics/

Latinos in the 

United States 

(Ramirez and de la 

Cruz 2003). 

Two-thirds of the Hispanic/Latino people 

in the United States were born here. As a 

group, they are the most urbanized ethnic 

population in the country. Although poverty rates for Hispanics/Latinos are high 

compared with those of Whites, by the third 

generation virtually no difference in income 

exists between Hispanic/Latino and nonHispanic/Latino workers who have the same 

level of education (Bean et al. 2001). 

Celebrations and religious ceremonies are 

an important part of the culture, and use 

of alcohol is expected and accepted in these 

celebrations and ceremonies. In the interest 

of family cohesion and harmony, traditional 

Hispanic/Latino families tend not to discuss 

or confront the alcohol problems of family 

members. Among Hispanics/Latinos with a 

perceived need for treatment of substance 

use disorders, 23 percent reported the need 

was unmet—nearly twice the number of 

Whites who reported unmet need (Wells 

et al. 2001). Studies show that Hispanics/

Latinos with substance use disorders receive 

less care and often must delay treatment, 

relative to White Americans (Wells et al. 

2001). De La Rosa and White’s (2001) review 

of the role social support systems play in 

substance use found that family pride and 

parental involvement are more influential 

All [program] 

materials should be 

sympathetic to the 

culture of clients 

being served.
190 Chapter 10

among Hispanic/Latino youth than among 

White or African-American youth. The 

2000 Substance Abuse and Mental Health 

Services Administration’s (SAMHSA’s) 

National Household Survey on Drug 

Abuse (NHSDA) 

found that nearly 

40 percent of 

Hispanics/Latinos 

reported alcohol 

use. Five percent of 

Hispanics reported 

use of illicit substances, with the 

highest rate occurring among Puerto 

Ricans and the 

lowest rate among 

Cubans (Office of 

Applied Studies 2001). Hispanics/Latinos 

accounted for 9 percent of admissions to 

substance abuse treatment in 2000 (Office of 

Applied Studies 2002).

Spanish-language treatment groups are helpful for recently arrived Hispanic/Latino 

immigrants. Programs in areas with a large 

population of foreign-born Hispanics/

Latinos should consider setting up such 

groups, using Spanish-speaking counselors. 

AA has Spanish-language meetings in many 

parts of the country, especially in urban 

areas. 

African-Americans 

African-Americans make up 13 percent of 

the U.S. population and include 36 million residents who identify themselves as 

Black, more than half of whom live in a 

metropolitan area (McKinnon 2003). The 

African-American population is extremely 

diverse, coming from many different cultures 

in Africa, Bermuda, Canada, the Caribbean, 

and South America. Most African-Americans 

share the experience of the U.S. history of 

slavery, institutionalized racism, and segregation (Brisbane 1998). 

Foreign-born Africans living in America 

have had distinctly different experiences 

from U.S.-born African-Americans. As one 

demographer points out, “Foreign-born 

African-Americans and native-born AfricanAmericans are becoming as different from 

each other as foreign-born and native-born 

Whites in terms of culture, social status, 

aspirations and how they think of themselves” (Fears 2002, p. A8). Nearly 8 percent 

of African-Americans are foreign born; many 

have grown up in countries with majority 

Black populations ruled by governments consisting of mostly Black Africans. 

The 2000 NHSDA found that 34 percent 

of African-Americans reported alcohol use, 

compared with 51 percent of Whites and 40 

percent of Hispanics/Latinos. Only 9 percent 

of African-American youth reported alcohol use, compared with at least 16 percent 

of White, Hispanic/Latino, and NativeAmerican youth (Office of Applied Studies 

2001). Six percent of African-Americans 

reported use of illicit substances, compared 

with 6 percent of Whites and 5 percent of 

Hispanics/Latinos (Office of Applied Studies 

2001). African-Americans accounted for 24 

percent of admissions to substance abuse 

treatment in 2000 (Office of Applied Studies 

2002). Among African-Americans with a perceived need for substance abuse treatment, 

25 percent reported the need was unmet—

more than twice the number of Whites who 

reported unmet need (Wells et al. 2001).

Native Americans

The Bureau of Indian Affairs recognizes 

562 different Native-American tribal entities. (The term “Native American” as it is 

used here encompasses American Indians 

and Alaska Natives.) Each tribe has unique 

customs, rituals, languages, beliefs about 

creation, and ceremonial practices. On the 

2000 census, about 2.5 million Americans 

listed themselves as Native Americans and 

1.6 million Americans listed themselves as at 

least partly Native American, accounting for 

...only 20 percent of 

American Indians and 

Alaska Natives live on 

reservations or trust 

lands...
Addressing Diverse Populations in IOT 191

4.1 million people or 1.5 percent of the U.S. 

population (Ogunwole 2002). 

Currently only 20 percent of American 

Indians and Alaska Natives live on reservations or trust lands, where they have 

access to treatment from the Indian Health 

Service. More than half live in urban areas 

(Center for Substance Abuse Prevention 

2001). The 2000 NHSDA found that 35 percent of Native Americans reported alcohol 

use. Thirteen percent of Native Americans 

reported use of illicit substances (Office of 

Applied Studies 2001). Among all youth ages 

12 to 17, the use of illicit substances was 

most prevalent among Native Americans—22 

percent (Office of Applied Studies 2001). 

Native Americans begin using substances 

at higher rates and at a younger age than 

any other group (U.S. Government Office 

of Technology Assessment 1994). Native 

Americans accounted for 3 percent of admissions to substance abuse treatment in 2000 

(Office of Applied Studies 2002). More than 

three-quarters of all Native-American admissions for substance use are due to alcohol. 

Alcoholism, often intergenerational, is a serious problem among Native Americans (CSAT 

1999b). One study found that rates for alcohol dependence among Native Americans 

were higher than the U.S. average (Spicer et 

al. 2003) but not as high as often had been 

reported. Thirty percent of men in culturally distinct tribes from the Northern Plains 

and the Southwest were alcohol dependent, 

compared with the national average of 20 

percent of men. Among the Northern Plains 

community, 20 percent of women were alcohol dependent, compared with the national 

average of 8.5 percent. Only 8.7 percent of 

all women in the Southwest were found to be 

alcohol dependent. 

Among Native Americans, there is a movement toward using Native healing traditions 

and healers for the treatment of substance 

use disorders. Spiritually based healing is 

unique to each tribe or cultural group and is 

based on that culture’s traditional ceremonies and practices. 

Asian Americans and Pacific 

Islanders

Asian Americans and Pacific Islanders 

are the fastest growing minority group in 

the United States, making up more than 4 

percent of the U.S. population and totaling more than 12 million. They account for 

more than one-quarter of the U.S. foreignborn population. The vast majority live in 

metropolitan areas (Reeves and Bennett 

2003); more than half live in three States: 

California, New York, and Hawaii (Mok et al. 

2003). Nearly 9 out of 10 Asian Americans 

either are foreign born or have at least one 

foreign-born parent (U.S. Census Bureau 

2003). Asian Americans represent many 

distinct groups and have extremely diverse 

cultures, histories, and religions. 

Pacific Islanders are peoples indigenous to 

thousands of islands in the Pacific Ocean. 

Pacific Islanders number about 874,000 or 

0.3 percent of the population. Fifty-eight 

percent of these individuals reside in Hawaii 

and California (Grieco 2001).

Grouping Asian Americans and Pacific 

Islanders together can mask the social, cultural, linguistic, and psychological variations 

that exist among the many ethnic subgroups 

this category represents. Very little is known 

about interethnic differences in mental disorders, seeking help, and use of treatment 

services (U.S. Department of Health and 

Human Services 2001).

The 2000 NHSDA found that 28 percent 

of Asian Americans and Pacific Islanders 

reported alcohol use. Only 7 percent of 

adolescent Asian Americans and Pacific 

Islanders reported alcohol use, compared 

with at least 16 percent of White, Hispanic/

Latino, and Native-American youth (Office 

of Applied Studies 2001). Three percent 

of Asian Americans and Pacific Islanders 

reported use of illicit substances (Office of 

Applied Studies 2001). As a group Asian 

Americans and Pacific Islanders have the 

lowest rate of illicit substance use, but 

significant intragroup differences exist. 
192 Chapter 10

Koreans (7 percent) and Japanese (5 percent) 

use illicit substances at much greater rates 

than Chinese (1 percent) and Asian Indians 

(2 percent) (Office of Applied Studies 2001). 

Asian Americans and Pacific Islanders 

accounted for less than 1 percent of admissions to substance abuse treatment in 2000 

(Office of Applied Studies 2002).

Persons With HIV/AIDS

In the United States, more than 918,000 people are reported as having AIDS (Centers for 

Disease Control and Prevention 2004). HIV 

is still largely a disease of men who have sex 

with men and people who inject drugs; these 

groups together account for nearly four-fifths 

of all cases of HIV/AIDS (Centers for Disease 

Control and Prevention 2004). Minorities 

have a much higher incidence of infection 

than does the general population. Although 

African-Americans make up only 13 percent 

of the U.S. population, they accounted for 

50 percent of new HIV infections in 2004 

(Centers for Disease Control and Prevention 

2004). HIV is spreading most rapidly among 

women and adolescents. In 2000, females 

accounted for nearly half of new HIV cases 

reported among 13- to 24-year-olds. Among 

13- to 19-year-olds, females accounted for 

more than 60 percent of new cases (Centers 

for Disease Control and Prevention 2002). 

HIV/AIDS is increasing rapidly among 

African-American and Hispanic/Latino 

women. Although they represent less than a 

quarter of U.S. women, these groups account 

for more than four-fifths of the AIDS cases 

reported among women; African-American 

women account for 64 percent of this total 

(Centers for Disease Control and Prevention 

2004). Gay people who abuse substances 

also are at high risk because they are more 

likely to engage in risky sex after alcohol or 

drug use (Greenwood et al. 2001). 

The development of new medications—and 

combinations of medications—has had a 

significant effect on the length and quality of life for many people who live with 

HIV/AIDS. However, these new treatment 

protocols require clients to take multiple 

medications on a complicated regimen. 

Clients with HIV often present with a cluster 

of problems, including poverty, indigence, 

homelessness, mental disorders, and other 

medical problems. 

Lesbian, Gay, and Bisexual 

Clients

LGB individuals come from all cultural 

backgrounds, ethnicities, racial groups, and 

regions of the country. Cultural groups differ in how they view their LGB members. In 

Hispanic culture, matters of sexual orientation tend not to be discussed openly. LGB 

members of minority groups often find themselves targets of discrimination within their 

minority culture and of racism in the general 

culture. 

Because of inconsistent research methods 

and instruments that do not ask about 

sexual orientation, no reliable information is 

available on the number of people who use 

substances among LGB individuals (CSAT 

2001). Studies indicate, however, that LGB 

individuals are more likely to use alcohol 

and drugs, more likely to continue heavy 

drinking into later life, and less likely to 

abstain from using drugs than is the general 

population. They also are more likely to have 

used many drugs, including such drugs as 

Ecstasy, ketamine (“Special K”), amyl nitrite 

(“poppers”), and gamma hydroxybutyrate 

during raves and parties. These drugs affect 

judgment, which can increase risky sexual 

behavior and may lead to HIV/AIDS or 

hepatitis (Centers for Disease Control and 

Prevention 1995; Greenwood et al. 2001; 

Woody et al. 1999).

Persons With Physical and 

Cognitive Disabilities

Nearly one-sixth of all Americans (53 million) have a disability that limits their 
Addressing Diverse Populations in IOT 193

functioning. More than 30 percent of those 

with disabilities live below the poverty line 

and generally spend a large proportion of 

their incomes to meet their disability-related 

needs (LaPlante et al. 1996). Most people 

with disabilities can and want to work. But 

those with skills tend to be underemployed 

or unemployed. The combination of depression, pain, vocational difficulties, and 

functional limitations places people with 

physical disabilities at increased risk of substance use disorders (Hubbard et al. 1996). 

Those with cognitive or physical disabilities 

are more likely than the general population 

to have a substance use disorder but less 

likely to receive effective treatment (Moore 

and Li 1998). Many community-based treatment programs do not currently meet the 

Federal requirements of the Americans with 

Disabilities Act. An IOT program is likely to 

have clients who present with a variety of 

disabilities. Experienced clinicians report 

that an appreciable number of individuals 

with substance use disorders have unrecognized learning disabilities that can impede 

successful treatment. People who have the 

same disability may have differing functional capacities and limitations.

Treating substance use disorders in persons with disabilities is an emerging field 

of study. Culture brokering is a treatment 

approach that was developed to mediate 

between the culture of a foreign-born person 

and the health care culture of the United 

States. This model helps rehabilitation providers understand the role that culture plays 

in shaping the perception of disabilities 

and treatment (Jezewski and Sotnik 2001). 

Culture brokering is an extension of techniques that IOT providers already practice, 

including assessment and problemsolving.

Rural Populations

In 2000, nearly 20 percent of the U.S. 

population (55.4 million people) lived in 

nonmetropolitan areas; the nonmetropolitan population 

increased 10.2 

percent from 1990 

to 2000 (Perry and 

Mackun 2001). The 

economic base and 

ethnic diversity of 

these populations, 

not just their isolation, are critical 

factors. This population includes 

people of AngloEuropean heritage 

in Appalachia and 

in farming and ranching communities of the 

Midwest and West, Hispanic/Latino migrant 

farm workers across the South, and Native 

Americans on reservations.

Despite this diversity, rural communities 

from different parts of the country have commonalities: low population density, limited 

access to goods and services, and considerable familiarity with other community 

members. People living in rural situations 

also share broad characteristics that affect 

treatment. These characteristics are

Overall higher resistance to seeking help 

because of pride in self-sufficiency

Concerns about confidentiality and 

resistance to participating in group work 

because in small communities “everyone 

knows everyone else”

A sense of strong individuality and privacy, sometimes coupled with difficulty in 

expressing emotions

A culturally embedded suspicion of treatment for substance use and mental disorders, although this varies widely by area

Among adults older than age 25, the rate of 

alcohol use is lower in rural areas than in 

metropolitan areas. But rates of heavy alcohol use among youth ages 12 to 17 in rural 

areas are almost double those seen in metropolitan areas (Office of Applied Studies 

2001). Women in rural areas have higher 

•

•

•

•

Treating substance use 

disorders in persons 

with disabilities is an 

emerging field 

of study.
194 Chapter 10

rates of alcohol use and alcoholism than 

women in metropolitan areas (American 

Psychological Association 1999). However, in 

one study, urban residents received 

substance abuse treatment at more than 

double the rate of their rural counterparts 

(Metsch and McCoy 1999). Researchers 

attribute this disparity to the relative unavailability and unacceptability of substance abuse 

treatment in rural areas of the United States 

(Metsch and McCoy 1999).

Homeless Populations

Approximately 600,000 Americans are homeless on any given night. One census count 

of people who are homeless found about 41 

percent were White, 40 percent were AfricanAmerican, 11 percent were Hispanic, and 8 

percent were Native American. Compared 

with all U.S. adults, people who are homeless are disproportionately African-American 

and Native American (Urban Institute et al. 

1999). Homeless populations include groups 

of people who are 

Transient. These individuals may stay 

temporarily with others or have a living 

pattern that involves rotating among a 

group of friends, relatives, and acquaintances. These individuals are at high risk 

of suddenly finding themselves on the 

street. For some, continued living in other 

people’s residences may be contingent on 

providing sex or drugs.

Recently displaced. Some people may 

be employed but have been evicted from 

their homes. Their housing instability may 

be related to financial problems resulting 

from substance use.

Chronically homeless. These individuals 

may have severe substance use and mental 

disorders and are difficult to attract into 

traditional treatment settings. Reaching 

these individuals requires the IOT program to bring its services to the homeless 

through a variety of creative outreach and 

programming initiatives.

•

•

•

Approximately two-thirds of people who are 

homeless report having had an alcohol, 

drug, or mental disorder in the previous 

month (Urban Institute et al. 1999). Threequarters of people who are homeless and 

need substance abuse treatment do not 

receive it (Magura et al. 2000). For 50 percent of people who are homeless and 

admitted to treatment, alcohol is the primary 

substance of abuse, followed by opioids (18 

percent) and crack cocaine (17 percent) 

(Office of Applied Studies 2003b). Twentythree percent of people who are homeless 

and in treatment have co-occurring disorders, compared with 20 percent who are not 

homeless (Office of Applied Studies 2003b). 

People who are homeless are more than 

three times as likely to receive detoxification 

services as people who are not homeless (45 

percent vs. 14 percent) (Office of Applied 

Studies 2003b).

In addition to the resources found in appendix 10-A, the following clinical guidelines 

will assist providers in treating people who 

are homeless:

Clients who are homeless often drop out of 

treatment early. Meeting survival needs of 

clients who are homeless is integral to successful outcomes. An IOT program needs 

to provide safe shelter, warmth, and food, 

in addition to the components of effective 

treatment provided to other clients who 

use substances, including extensive continuing care (Milby et al. 1996).

Individuals who are homeless benefit 

from intensive contact early in treatment. 

Clients who attend treatment an average of 

4.1 days per week are more successful than 

those attending fewer days (Schumacher et 

al. 1995).

The Alcohol Dependence Scale, the 

Alcohol Severity Index, and the personal 

history form have been found to be reliable and valid screening tools for this 

population (Joyner et al. 1996). Reliability 

is higher when items are factual and based 

on a recent time interval and when individuals are interviewed in a protected setting.

•

•

•
Addressing Diverse Populations in IOT 195

Case management must be available to 

ease access to and coordinate the variety of 

services needed by clients who are homeless and abuse substances. Case management should arrange for stable, safe, and 

drug-free housing. The availability of 

housing is a powerful influence on recovery. Making such housing contingent on 

abstinence has been shown to be a useful 

strategy (Milby et al. 1996). Case management also should coordinate medical care, 

including psychiatric care, with vocational 

training and education to help individuals 

sustain a self-sufficient life. 

Providers should work with homeless 

shelters to provide treatment services. 

Strategies include (1) working with staff 

members at shelters and with public housing authorities to find and arrange for 

housing, (2) locating the IOT program within a homeless shelter or at least providing 

core elements of IOT at the shelter, and (3) 

placing a substance abuse treatment specialist at the shelter as a liaison with the 

IOT program. 

Older Adults

The number of older adults needing treatment for substance use disorders is expected 

to increase from 1.7 million in 2001 to 4.4 

million by 2020. This increase is the result of 

a projected 50-percent increase in the number of older adults as well as a 70-percent 

increase in the rate of treatment need among 

older adults (Gfroerer et al. 2003). America’s 

aging cohort of baby boomers (people born 

between 1946 and 1964) is expected to 

place increasing demands on the substance 

abuse treatment system in the coming years, 

requiring a shift in focus to address their 

special needs. This older generation will be 

more ethnically and racially diverse and 

have higher substance use and dependence 

rates than current older adults (Korper and 

Council 2002).

As a group, older people tend to feel shame 

about substance use and are reluctant to 

seek out treatment. Many relatives of older 

•

•

individuals with substance use disorders also 

are ashamed of the problem and rationalize 

the substance use or choose not to address it. 

Diagnosing and treating substance use disorders are more complex in older adults than 

in other populations because older people 

have more—and more interconnected—physical and mental health problems. Barriers to 

effective treatment include lack of transportation, shrinking social support networks, 

and financial constraints.

Oslin and colleagues (2002) find that older 

adults had greater attendance and lower 

incidence of relapse than younger adults in 

treatment and conclude that older adults 

can be treated successfully in mixed-age 

groups, provided that they receive ageappropriate individual treatment. When 

treating older clients, IOT programs need 

to be involved actively with the local network of aging services, including home- and 

community-based long-term care providers. 

Older individuals who do not see themselves 

as abusers—particularly those who misuse 

over-the-counter or 

prescription drugs 

or do not understand the problems 

caused by alcohol 

and drug interactions—need to be 

reached through 

wellness, health 

promotion, social 

service, and other 

settings that serve 

older adults. In 

addition, IOT programs can broaden the 

multicultural resources available to them by 

working through the aging service network to 

link up with diverse language, cultural, and 

ethnic resources in the community.

IOT programs that develop geriatric expertise can provide an essential service by 

making consultation available to staff 

members at IOT programs that face similar 

challenges, along with inservice training, 

coordination of interventions, and care 

...older adults ha[ve] 

greater attendance 

and lower incidence 

of relapse than 

younger adults...
196 Chapter 10

conferences designed to solve problems and 

develop care plans for individuals. There 

also may be opportunities to make this 

expertise available to caregivers and participants in settings where older adults receive 

interdisciplinary care (e.g., a support group 

for family caregivers or a discussion group 

for participants at a social daycare or adult 

day health center).
Addressing Diverse Populations in IOT 197

Many resources listed below are volumes in 

the TIP and Technical Assistance Publication 

(TAP) Series published by CSAT. TIPs and 

TAPs are free and can be ordered from 

SAMHSA’s National Clearinghouse for Alcohol 

and Drug Information (NCADI) at www.ncadi.

samhsa.gov or (800) 729-6686 (TDD, [800] 

487-4889). The full text of each TIP can be 

searched and downloaded from www.samhsa.

gov/centers/csat2002/publications.html.

The Health Resources and Services 

Administration lists cultural competence 

assessment tools, resources, curricula, and 

Web-based trainings at www.hrsa.gov/

culturalcompetence.

General

The Journal of Ethnicity in Substance Abuse—

This quarterly journal (formerly Drugs 

and Society) explores culturally competent 

strategies in individual, group, and family 

treatment of substance abuse. The journal 

also investigates the beliefs, attitudes, and 

values of people who abuse substances to 

understand the origins of substance abuse 

for different populations. Visit www.

haworthpress.com/web/JESA to find out 

more.

Cultural Issues in Substance Abuse Treatment

(CSAT 1999b)—This booklet contains 

population-specific discussions of treatment 

for Hispanic Americans, African-Americans, 

Asian Americans and Pacific Islanders, and 

American Indians and Alaska Natives, along 

with general guidelines on cultural competence. Order from SAMHSA’s NCADI.

Chapter 4, “Preparing a Program To Treat 

Diverse Clients,” in TIP 46, Substance Abuse: 

Administrative Issues in Outpatient Treatment

(CSAT 2006f)—This chapter includes an 

introduction to cultural competence and 

why it matters to treatment programs, as 

well as information on assessing a diverse 

population’s treatment needs and conducting 

outreach to attract clients and involve the 

community. This chapter also includes a list 

of resources for assessment and training, in 

addition to culture-specific resources.

The forthcoming TIP Improving Cultural 

Competence in Substance Abuse Treatment

(CSAT forthcoming a)—This volume addresses screening, assessment, and treatment 

planning; case management; counseling for 

specific cultural groups; and engaging and 

retaining diverse clients in the context of cultural competence.

“Alcohol Use Among Special Populations”

(National Institute on Alcohol Abuse and 

Alcoholism 1998)—This special issue of 

the journal Alcohol Health & Research 

World (now called Alcohol Research & 

Health) includes articles on alcohol use 

in Asian Americans and Pacific Islanders, 

African-Americans, Alaska Natives, Native 

Americans, and Hispanics/Latinos. Authors 

also address such topics as alcohol availability and advertising in minority communities, 

special populations in AA, and alcohol 

consumption in India, Mexico, and Nigeria. 

Visit pubs.niaaa.nih.gov/publications/arh22-

4/toc22-4.htm to download the articles.

Mental Health: Culture, Race, and Ethnicity

(U.S. Department of Health and Human 

Services 2001)—This publication describes 

the disparities in mental health services 

that affect minorities, presents evidence of 

the need to address those disparities, and 

documents promising strategies to eliminate 

them. Visit www.mentalhealth.samhsa.gov/

cre/default.asp to download a copy of this 

publication.

Cultural Competence Works: Using Cultural 

Competence To Improve the Quality of Health 

Care for Diverse Populations and Add Value 

to Managed Care Arrangements (Health 

Resources and Services Administration 

2001)—This booklet bases its recommendations for implementing cultural competence 

Appendix 10-A. Cultural Competence Resources
198 Chapter 10

on practices already in place in health care 

programs across the country. Along with its 

general discussions of culturally competent 

care, the publication includes descriptions of 

the programs from which the recommendations are drawn and a list of resources. Visit 

minority-health.pitt.edu/archive/00000278 to 

download a copy of this publication.

Counseling the Culturally Different: Theory 

and Practice, Third Edition (Sue and Sue 

1999)—This book offers a conceptual framework for counseling across cultural lines 

and includes treatment recommendations 

for specific cultural groups, with individual 

chapters on counseling Hispanics/Latinos, 

African-Americans, Asian Americans, and 

Native Americans and special sections on 

women, gay and lesbian people, and persons 

who are elderly and disabled.

Bridges to Recovery: Addiction, Family 

Therapy, and Multicultural Treatment

(Krestan 2000)—This volume of essays 

discusses substance abuse treatment for 

Native-American, African-American, West 

Indian, Asian-American, Mexican-American, 

and Puerto Rican families.

The Cultural Context of Health, Illness, and 

Medicine (Loustaunau and Sobo 1997)—This 

book, written by a sociologist and an anthropologist, examines the ways in which cultural 

and social factors shape understandings of 

health and medicine. Although its discussions are not specific to substance abuse, 

they address the effect of social structures on 

health, differing conceptions of wellness, and 

cross-cultural communication.

Pocket Guide to Cultural Health Assessment,

Third Edition (D’Avanzo and Geissler 

2003)—This quick reference guide has individual sections on 186 countries, each of 

which lists demographic information (e.g., 

population, ethnic and religious descriptions, languages spoken), political and social 

information, and health care beliefs. 

American Cultural Patterns: A Cross-Cultural 

Perspective, Second Edition (Stewart and 

Bennett 1991)—This book focuses on aspects 

of American culture that are central to 

understanding how American society functions. The authors examine perceptions, 

thought processes, language, and nonverbal 

behaviors and their effect on cross-cultural 

communication. 

Promoting Cultural Diversity: Strategies for 

Health Care Professionals (Kavanagh and 

Kennedy 1992)—This text discusses strategies 

for learning about diversity and techniques 

for communicating effectively with culturally 

diverse populations. Case studies are used to 

illustrate the practical applications of crosscultural communication.

Hispanics/Latinos

Materials for clients

NCADI has publications and videotapes for 

clients, parents, and employers available in 

Spanish. Visit www.ncadi.samhsa.gov.

The National Institute on Drug Abuse 

(NIDA) offers a number of publications in 

Spanish. Visit www.nida.nih.gov.

Relapse prevention workbooks in Spanish 

can be purchased at www.tgorski.com.

The Hazelden Foundation offers a collection 

of Spanish fellowship books and videotapes 

approved by AA and Narcotics Anonymous. 

Visit www.hazelden.org.

Materials for counselors

CSAP Substance Abuse Resource Guide: 

Hispanic/Latino Americans (Center for 

Substance Abuse Prevention 1996b; www.

ncadi.samhsa.gov/govpubs/MS441/)—This 

resource guide provides information and 

referrals to help prevention specialists, educators, and community leaders better meet 

the needs of the Hispanic/Latino community. Order from SAMHSA’s NCADI.

Quality Health Services for Hispanics: The 

Cultural Competency Component (National 
Addressing Diverse Populations in IOT 199

Alliance for Hispanic Health 2000)—This 

book includes sections on the culture, language, and history of Hispanics/Latinos 

in the United States, Hispanic/Latino 

health status, guidelines for education and 

outreach, recommendations for working 

cross-culturally, and case studies. Visit 

www.ask.hrsa.gov/detail.cfm?id=PC00029 to 

order this volume.

“Counseling Latino Alcohol and Other 

Substance Users/Abusers: Cultural 

Considerations for Counselors” (Gloria 

and Peregoy 1996)—This article discusses 

Hispanic/Latino cultural values as they 

relate to substance use and presents a substance abuse counseling model for use with 

Hispanic/Latino clients. 

“Drugs and Substances: Views From a 

Latino Community” (Hadjicostandi and 

Cheurprakobkit 2002)—The researchers 

explore perceptions and use of licit and illicit 

substances in a Hispanic/Latino community. 

The primary concerns of the community are 

the increasing availability and use of substances among Hispanic/Latino youth.

“Acculturation and Latino Adolescents’ 

Substance Use: A Research Agenda for the 

Future” (De La Rosa 2002)—This article 

reviews literature on the effects of acculturation to Western values on Hispanic/Latino 

adolescents’ mental health and substance 

use, discusses the role that acculturationrelated stress plays in substance use, and 

suggests directions for treatment and further 

research.

“Cultural Adaptations of Alcoholics 

Anonymous To Serve Hispanic Populations” 

(Hoffman 1994)—This article evaluates two 

specific adaptations to 12-Step fellowship: 

one adapts conceptions of machismo and the 

other is less confrontational. 

African-Americans

Chemical Dependency and the African 

American: Counseling and Prevention 

Strategies, Second Edition (Bell 2002)—This 

book from the co-founder of the Institute on 

Black Chemical Abuse explores the dynamics 

of race, culture, and class in treatment and 

examines substance abuse and recovery in 

the context of racial identity.

Cultural Competence for Health Care 

Professionals Working With African-American 

Communities: Theory and Practice (Center 

for Substance Abuse Prevention 1998a)—This 

book provides tips for health care workers. 

Order from SAMHSA’s NCADI or download 

at www.hawaii.edu/hivandaids/links.htm.

Relapse Prevention Counseling for African 

Americans: A Culturally Specific Model

(Williams and Gorski 1997)—This book 

examines the way that cultural factors 

interact with relapse prevention efforts in 

African-Americans.

Relapse Prevention Workbook for African 

Americans: Hope and Healing for the Black 

Substance Abuser (Williams and Gorski 

1999)—This workbook leads readers through 

clinical exercises designed to help them 

avoid relapse due to race-related issues.

“Drug Treatment Effectiveness: AfricanAmerican Culture in Recovery” (Bowser and 

Bilal 2001)—This article endeavors to explain 

African-Americans’ high rates of substance 

abuse and low rates of recovery. Culture 

is seen as both a problem and a solution; 

some African-American coping strategies act 

as barriers, but successful treatment programs incorporate African-American cultural 

elements. 

Native Americans

Materials for clients

GONA (Gathering of Native Americans) is a 

community development and empowerment 

training process that uses Native-American 

trainers. A GONA curriculum provides 

structure for Native-American community 

gatherings and is available from SAMHSA. 

Visit p2001.health.org/CTI05/Cti05ttl.htm.
200 Chapter 10

A significant recovery movement for 

Native-American people is the Red Road 

to Recovery developed by Gene Thin Elk, a 

Lakota elder. Many individuals, especially in 

urban areas, have achieved and maintained 

sobriety by following the Red Road. The Red 

Road to Recovery addresses the cognitive, 

affective, and experiential needs of Native 

Americans who are rebuilding their lives 

from substance use and mental disorders 

and presents a system of cultural values that 

promote an abstinent and balanced lifestyle. 

The following Web sites offer information on 

GONA, the Red Road to Recovery, and other 

Native-American recovery resources:

www.naigso-aa.org. This Web site of the 

Native-American Indian General Service 

Office of Alcoholics Anonymous includes 

a link to information on Talking Circles. 

Talking Circles are common practice in 

Native-American treatment settings. 

www.whitebison.org. This Web site 

offers information about the Wellbriety 

Movement (a Native-American recovery 

movement that emphasizes health and 

abstinence), which includes information 

about Wellbriety for youth, children of 

people who abuse alcohol, and people in 

prison. The site also includes a Talking 

Circle chat room, training information 

and materials, and books, videotapes, and 

audiotapes on recovery. 

Materials for counselors

Health Promotion and Substance Abuse 

Prevention Among American Indian and 

Alaska Native Communities: Issues in 

Cultural Competence (Center for Substance 

Abuse Prevention 2001)—This volume frames 

the development of substance abuse prevention and treatment efforts in the context of 

health disparities that have affected NativeAmerican and Alaskan-Native communities 

in rural and urban settings, as well as on reservations. Grounded in traditional healing 

practices, the volume examines innovative 

approaches to substance abuse prevention. 

Order from SAMHSA’s NCADI.

•

•

Substance Abuse Resource Guide: American 

Indians and Native Alaskans (Center for 

Substance Abuse Prevention 1998b)—A substance abuse resource guide for American 

Indians and Alaska Natives, including books, 

articles, classroom materials, posters, and 

Web sites. Order from SAMHSA’s NCADI.

“Addiction and Recovery in Native America: 

Lost History, Enduring Lessons” (Coyhis and 

White 2002)—This journal article provides 

recommendations for treatment based on 

the history of addiction in Native-American 

communities.

Promising Practices and Strategies To Reduce 

Alcohol and Substance Abuse Among 

American Indians and Alaska Natives

(American Indian Development Associates 

2000)—This report collects descriptions of 

successful substance abuse prevention efforts 

by Native-American groups. It also includes a 

literature review and list of Federal resources. 

Visit www.ojp.usdoj.gov/americannative/

promise.pdf to download the report.

“Morning Star Rising: Healing in Native 

American Communities” (Nebelkof et al. 

2003)—This special issue of the Journal of 

Psychoactive Drugs is devoted to healing 

in Native-American communities, with 13 

articles on various aspects of prevention 

and treatment. Contact Haight-Ashbury 

Publications at (415) 565-1904.

Walking the Same Land—This videotape 

presents young Indians who are returning to 

traditional cultural ways to strengthen their 

recovery from substance abuse. It includes 

aboriginal men from Australia and Mohawk 

men from New York. Order from SAMHSA’s 

NCADI.

Asian Americans and Pacific 

Islanders

Asian and Pacific Islander American Health 

Forum (www.apiahf.org/resources/

index.htm)— This site provides links to information and resources.
Addressing Diverse Populations in IOT 201

Asian Community Mental Health Services 

(www.acmhs.org)—This site provides links to 

information and describes a substance abuse 

treatment program in Oakland, California.

Substance Abuse Resource Guide: Asian 

and Pacific Islander Americans (Center for 

Substance Abuse Prevention 1996a; ncadi.

samhsa.gov/govpubs/MS408)—This guide contains resources appropriate for use in Asian 

and Pacific Islander communities. It also contains facts and figures about substance use and 

prevention within this diverse group.

Asian American Mental Health: Assessment 

Theories and Methods (Kurasaki et al. 

2002)—This compendium of essays highlights 

conceptual, theoretical, methodological, and 

practice issues related to Asian-American 

mental health assessment. This text focuses 

on important questions about the cultural nature of diagnostic and assessment 

processes.

Responding to Pacific Islanders: Culturally 

Competent Perspectives for Substance Abuse 

Prevention (Center for Substance Abuse 

Prevention 1999)—This book examines the 

culture-specific factors that affect substance 

abuse prevention in Pacific Islander communities. Order from SAMHSA’s NCADI.

“Communicating Appropriately With Asian 

and Pacific Islander Audiences” (Center for 

Substance Abuse Prevention 1997)—This 

Technical Assistance Bulletin discusses population characteristics, lists cultural factors 

related to substance use in nine distinct 

ethnic groups, and presents guidelines on 

developing effective prevention materials for 

these populations. Visit ncadi.samhsa.gov/

govpubs/MS701 to download the bulletin. 

Opening Doors: Techniques for Talking With 

Southeast Asian Clients About Alcohol and 

Other Drug Issues—This program is available 

on videocassette in Vietnamese and Khmer 

with English subtitles. Order from SAMHSA’s 

NCADI, and visit store.health.org/catalog/

productDetails.aspx?ProductID=15136 to 

view it on the Web.

Persons With HIV/AIDS

TIP 37, Substance Abuse Treatment for 

Persons With HIV/AIDS (CSAT 2000c)—This 

TIP discusses the medical aspects of HIV/

AIDS (epidemiological data, assessment, 

treatment, and prevention), the legal and 

ethical implications of treatment, the 

counseling of patients with HIV/AIDS, the 

integration of treatment and enhanced services, and funding sources for programs.

The Hawaii AIDS Education and Training 

Center has numerous resources available for 

download at www.hawaii.edu/hivandaids/

links.htm.

LGB Populations

The Web site of the National Association of 

Lesbian and Gay Addiction Professionals 

is a clearinghouse for information and 

resources, including treatment programs and 

mutual-help groups, organized by State. Visit 

www.nalgap.org.

Substance Abuse Resource Guide: Lesbian, 

Gay, Bisexual, and Transgender Populations 

(Center for Substance Abuse Prevention 

2000)—This publication lists books, fact 

sheets, magazines, newsletters, videos, 

posters, reports, Web sites, and organizations that increase understanding of issues 

important to lesbian, gay, bisexual, and 

transgender clients. Download the resource 

guide from ncadi.samhsa.gov/referrals/

resguides.aspx?InvNum=MS489.

A Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, and 

Transgender Individuals (CSAT 2001)—This 

book addresses issues of interest to clinicians 

and administrators. It discusses treatment 

approaches for this population, ways to 

improve services to LGB clients, steps for 

starting LGB-sensitive programs, organizational missions, and strategies for building 

alliances to provide services. Order from 

SAMHSA’s NCADI.
202 Chapter 10

Counseling Lesbian, Gay, Bisexual, and 

Transgender Substance Abusers: Dual 

Identities, Second Edition (Finnegan and 

McNally 2002)—This guide examines different counseling approaches and provides 

practical treatment suggestions for LGB populations. The book includes an organization 

audit of attitudes and practices, plus a list of 

resources and other suggested readings.

Addiction and Recovery in Gay and Lesbian 

Persons (Kus 1995)—This book examines the 

incidence of substance use among gay and 

lesbian people and special concerns when 

treating this population, including HIV/

AIDS, homophobia, gay and lesbian mutualhelp groups, and special needs of rural gay 

and lesbian clients.

Addictions in the Gay and Lesbian 

Community (Guss 2000)—This volume 

includes personal experiences of substance 

use and recovery and research into the 

sources of and treatment for substance use 

disorders in gay and lesbian clients. The 

book also includes techniques for assessing and treating LGB clients, including 

adolescents.

Persons With Physical and 

Cognitive Disabilities

IOT programs should link with local groups 

that offer specialized housing, vocational 

training, and other supports for people who 

are disabled. The Centers for Independent 

Living (CILs) are organizations run by and 

for persons with disabilities to provide 

mutual-help and advocacy. CILs and Client 

Assistance Programs were developed to provide a third party to broker the interaction 

between clients and the service system. The 

Special Olympics may be able to help locate 

recreational activities appropriate for individual clients.

Materials for clients

For a catalog of AA literature available on 

audiocassettes, in Braille, and in large print, 

as well as a list of closed-caption videotapes, 

AA books in American Sign Language on 

videotape, and easy-to-read literature, contact Alcoholics Anonymous General Service 

Office, P.O. Box 459, Grand Central Station, 

New York, NY 10163 or orders@aa.org.

Materials for counselors

Coping With Substance Abuse After TBI—This 

report answers basic questions about substance use and traumatic brain injury (TBI) 

and includes recommendations from clients 

with TBI who are now abstinent. Download 

the publication at www.mssm.edu/

tbicentral/resources/publications/

tbi_consumer_reports.shtml.

TIP 29, Substance Use Disorder Treatment 

for People With Physical and Cognitive 

Disabilities (CSAT 1998e)—This volume 

discusses screening, treatment planning, 

and counseling for clients with disabilities. 

The book includes a compliance guide for 

the Americans with Disabilities Act, a list 

of appropriate terms to use when referring 

to people with disabilities, and screening 

instruments for use with this population, including an Education and Health 

Survey and an Impairment and Functional 

Limitation Screen.

TIP 27, Comprehensive Case Management for 

Substance Abuse Treatment (CSAT 1998a)—

This TIP discusses various models of case 

management and provides information on 

linking with service providers and evaluation. 

Chapter 5 explores the use of case management services with special needs populations.

TIP 38, Integrating Substance Abuse 

Treatment and Vocational Services (CSAT 

2000a)—This volume examines the role that 

employment plays in recovery from substance use disorders, with special attention 

to referral relationships and their capacity to 

expand the services available to clients and 

enhance the resources available to programs.

Substance Abuse Resources and Disability 

Issues Program at Wright State School 
Addressing Diverse Populations in IOT 203

of Medicine (www.med.wright.edu/citar/

sardi)—This Web site offers products for 

professionals and persons with disabilities, 

including a training manual with an introduction on substance abuse and the deaf 

culture, as well as a Web course on substance abuse and disability. 

National Center for the Dissemination of 

Disability Research’s Guide to Substance 

Abuse and Disability Resources (www.ncddr.

org/du/products/saguide)—This Web site 

provides links to books, journal articles, 

newsletters, training manuals, audiotapes, 

and videotapes on substance abuse and individuals who are disabled.

Minnesota Chemical Dependency Program 

for Deaf and Hard of Hearing Individuals 

(www.mncddeaf.org)—This Web site includes 

links to articles on substance abuse treatment of individuals who are deaf and to 

manuals and videotapes for use in treatment.

Co-Occurring and Other Functional Disorders 

Cluster Cultural Diversity Training Guide

(www.med.wright.edu/citar/sardi/

publications.html)—This guide recommends 

topics and methods for initial staff training 

in cultural diversity for programs serving clients who are disabled and includes a list of 

references on multicultural counseling.

Ohio Valley Center for Brain Injury 

Prevention and Rehabilitation (www.

ohiovalley.org/abuse)—This Web site 

includes guidelines for treating people with 

substance use disorders and traumatic brain 

injury and links to other resources.

Center for International Rehabilitation 

Research and Information Exchange (cirrie.

buffalo.edu/mseries.html)—This Web site 

includes downloadable versions of cultural 

guides that describe the demographics and 

attitudes toward disability of 11 countries, 

including countries in Asia, Central America, 

and the Caribbean. The site also includes 

a booklet that describes culture brokering, 

a practice in which counselors mediate 

between cultures to improve service delivery.

Rural Populations

TAP 17, Treating Alcohol and Other Drug 

Abusers in Rural and Frontier Areas (CSAT 

1995b)—The papers in this volume describe 

providers’ experiences across a variety of 

treatment issues relevant to rural substance 

abuse treatment, including domestic violence, enhanced service delivery, building 

coalitions and networks, and practical measures to improve treatment. 

TAP 20, Bringing Excellence to Substance 

Abuse Services in Rural and Frontier America 

(CSAT 1996)—The papers in this volume 

examine innovative strategies and policies for treating substance use disorders in 

rural and frontier America. Topics include 

rural gangs and crime, needs assessment 

approaches, coalitions and partnerships, 

and minorities and women in treatment.

Rural Substance Abuse: State of Knowledge 

and Issues (Robertson et al. 1997)—This 

NIDA Research Monograph examines rural 

substance abuse from many perspectives, 

looking at substance use among youth and at 

the health, economic, and social consequences 

of substance use. The final section of the 

book addresses ethnic and migrant populations, including rural Native Americans, 

African-Americans, and Mexican Americans. 

Visit www.nida.nih.gov/PDF/Monographs/

Monograph168/Download168.html to download the monograph.

Homeless Populations

National Resource Center on Homelessness 

and Mental Illness (www.nrchmi.samhsa.gov/

pdfs/bibliographies/Cultural_Competence.

pdf)—This Web site has an annotated, online 

bibliography of journal articles, resource 

guides, reports, and books that address cultural competence. Many resources discuss 

substance use disorders. 

“The Effectiveness of Social Interventions 

for Homeless Substance Abusers” (American 

Society of Addiction Medicine 1995)—This special issue of the Journal of Addictive Diseases
204 Chapter 10

includes 11 articles that examine important 

aspects of treating people who are homeless, 

including retaining clients, residential versus 

nonresidential treatment, enhanced services, 

treating mothers who are homeless, and clients with co-occurring disorders.

The U.S. Department of Housing and Urban 

Development has compiled a list of local 

agencies by State and other resources to 

assist people who are homeless. Visit www.

hud.gov/homeless/index.cfm.

The U.S. Department of Health and Human 

Services offers assistance and resources 

for people who are homeless. For example, 

the Health Care for the Homeless Program 

provides grants to community-based organizations in urban and rural areas for projects 

aimed at improving access for the homeless 

to primary health care, mental health care, 

and substance abuse treatment. Visit aspe.

hhs.gov/homeless/index.shtml.

Substance Abuse Treatment: What Works for 

Homeless People? A Review of the Literature 

(Zerger 2002)—This report links research 

on homelessness and substance abuse with 

clinical practice and examines various treatment modalities, types of interventions, 

and methods for engaging and retaining 

people who are homeless. Download the 

report from National Health Care for the 

Homeless Council’s Web site at www.nhchc.

org/Publications/SubstanceAbuseTreatment

LitReview.pdf.

National Resource Center on Homelessness 

and Mental Illness (www.nrchmi.samhsa.gov)—

This Web site lists trainings and workshops 

(such as the National Training Conference on 

Homelessness for People With Mental Illness 

and/or Substance Use Disorders), technical 

assistance, and fact sheets and other publications on homelessness.

Older Adults

TIP 26, Substance Abuse Among Older Adults

(CSAT 1998d)—This volume discusses the 

relationship between aging and substance 

abuse and offers guidance for screening, 

assessing, and treating substance use disorders in older adults.

Substance Abuse Relapse Prevention for 

Older Adults: A Group Treatment Approach

(CSAT 2005c)—This manual presents a 

relapse prevention intervention that uses a 

cognitive–behavioral and self-management 

approach in a counselor-led group setting 

to help older adults overcome substance use 

disorders. Order from SAMHSA’s NCADI.

Substance Abuse by Older Adults: Estimates 

of the Future Impact on the Treatment 

System (Korper and Council 2002)—This 

report examines substance abuse treatment 

services for older adults in the context of 

increased demand in the future and calls 

for better documentation of substance abuse 

among older adults and prevention and 

treatment strategies that are tailored to subgroups of older adults, such as immigrants 

and racial and ethnic minorities. Download 

the report at www.drugabusestatistics.

samhsa.gov/aging/toc.htm.

Alcohol and Aging (Beresford and Gomberg 

1995)—This book for clinicians covers topics such as diagnosis and treatment, mental 

disorders, interactions of alcohol and prescription medications, and the biochemistry 

of intoxication for older adults.

Alcoholism and Aging: An Annotated 

Bibliography and Review (Osgood et al. 

1995)—This volume surveys 30 years of 

research on older adults who use alcohol, 

providing abstracts of articles, books and 

book chapters, and research studies on the 

prevalence, effects, diagnosis, and treatment 

of alcohol use in older adults.

Administration on Aging (www.aoa.gov/prof/

adddiv/adddiv.asp)—This Web site offers 

information on cultural competence, including resources on aging and ethnic minorities 

and the booklet, Achieving Cultural 

Competence: A Guidebook for Providers 

of Services to Older Americans and Their 

Families, which can be downloaded at www.

aoa.gov/prof/adddiv/cultural/addiv_cult.asp.
205

Appendix A—

Bibliography

Addington, J., and el-Guebaly, N. Group treatment for substance 

abuse in schizophrenia. Canadian Journal of Psychiatry

43(8):843–845, 1998. 

Alcoholics Anonymous World Services. The A.A. Member—

Medications and Other Drugs. New York: Alcoholics Anonymous 

World Services, 1991. 

Allen, J.P., and Columbus, M., eds. Assessing Alcohol Problems: A 

Guide for Clinicians and Researchers. Treatment Handbook 

Series 4. NIH Publication No. 95–3723. Bethesda, MD: National 

Institute on Alcohol Abuse and Alcoholism, 1995. 

Amass, L., and Kamien, J.B. A tale of two cities: Financing two 

voucher programs for substance abusers through community 

donations. Experimental and Clinical Psychopharmacology

12(2):147–155, 2004. 

American Academy of Pediatrics. Fetal alcohol syndrome and 

alcohol-related neurodevelopmental disorders. Pediatrics 

106:358–361, 2000. 

American Indian Development Associates. Promising Practices 

and Strategies To Reduce Alcohol and Substance Abuse Among 

American Indians and Alaska Natives. Washington, DC: Office of 

Justice Programs, 2000. 

American Medical Association. Role of Self-Help in Addiction 

Treatment. Res. 713, A-98. 1998. www.ama-assn.org/ama1/pub/

upload/mm/388/referral_treatment.pdf [accessed April 26, 

2004].

American Psychiatric Association. Diagnostic and Statistical 

Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). 

Washington, DC: American Psychiatric Association, 1987. 
206 Appendix A

American Psychiatric Association. Diagnostic 

and Statistical Manual of Mental 

Disorders, Fourth Edition (DSM-IV). 

Washington, DC: American Psychiatric 

Association, 1994. 

American Psychiatric Association. Practice 

Guidelines for Treatment of Patients 

With Substance Use Disorders: Alcohol, 

Cocaine, Opioids. Washington, DC: 

American Psychiatric Association, 1995. 

American Psychiatric Association. Diagnostic 

and Statistical Manual of Mental 

Disorders, Fourth Edition, Text Revision 

(DSM-IV-TR). Washington, DC: American 

Psychiatric Association, 2000. 

American Psychological Association (APA).

APA Rural Initiative: 1999 Year in 

Review. Washington, DC: APA, 1999. 

www.apa.org/rural/report99.html 

[accessed February 11, 2004].

American Society of Addiction Medicine. 

The effectiveness of social interventions 

for homeless substance abusers (special 

issue). Journal of Addictive Diseases 14(4), 

1995. 

American Society of Addiction Medicine. 

Relationship Between Treatment and 

Self Help: A Joint Statement of the 

American Society of Addiction Medicine 

and the American Academy of Addiction 

Psychiatry, 1997. www.asam.org/ppol/

aaap.htm [accessed February 11, 2004]. 

Armstrong, T.D., and Costello, E.J. 

Community studies on adolescent 

substance use, abuse, or dependence 

and psychiatric comorbidity. Journal 

of Consulting and Clinical Psychology

70:1224–1239, 2002.

Avants, S.K.; Margolin, A.; Kosten, T.R.; 

Rounsaville, B.J.; and Schottenfeld, R.S. 

When is less treatment better? The role 

of social anxiety in matching methadone 

patients to psychosocial treatments. 

Journal of Consulting and Clinical 

Psychology 66(6):924–931, 1998. 

Barker, R.L. The Social Work Dictionary,

Fourth Edition. Washington, DC: 

National Association of Social Workers, 

1999. 

Bartholomew, N.G.; Rowan-Szal, G.A.; 

Chatham, L.R.; Nucatola, D.C.; and 

Simpson, D.D. Sexual abuse among 

women entering methadone treatment. 

Journal of Psychoactive Drugs 34(4):347–

354, 2002.

Bean, F.D.; Trejo, S.J.; Crapps, R.; and 

Tyler, M. The Latino Middle Class: Myth, 

Reality, and Potential. Los Angeles, CA: 

Tomás Rivera Policy Institute, 2001. 

Beck, A.J., and Harrison, P.M. Prisoners 

in 2000. Bureau of Justice Statistics 

Bulletin. Washington, DC: Office of 

Justice Programs, August 2001. www.ojp.

gov:80/bjs/abstract/p00.htm [accessed 

February 11, 2004].

Belenko, S. Research on drug courts: A critical review, 1999 update. National Drug 

Court Institute Review 2(2):1–59, 1999. 

Bell, P. Chemical Dependency and the 

African American: Counseling and 

Prevention Strategies, Second Edition. 

Center City, MN: Hazelden Publishing, 

2002. 

Beresford, T., and Gomberg, E., eds. Alcohol 

and Aging. New York: Oxford University 

Press, 1995. 

Bigelow, G.E., and Silverman, K. Theoretical 

and empirical foundations of contingency management treatments for drug 

abuse. In: Higgins, S.T., and Silverman, 

K., eds. Motivating Behavior Change 

Among Illicit-Drug Abusers: Research on 

Contingency Management Interventions.

Washington, DC: American Psychological 

Association, 1999, pp. 15–31. 

Bixler, J.B., and Emery, B.D. Successful programs for individuals with co-occurring 

mental health and substance abuse disorders: Examples from five states. A 

Report of the Joint NASMHPD-NASADAD 
Bibliography 207

Task Force on Co-Occurring Mental 

Health and Substance Abuse Disorders.

Alexandria, VA: National Association of 

State Mental Health Program Directors 

and National Association of State 

Alcohol and Drug Abuse Directors, 2000. 

Bloom, F.; Owen, B.; and Covington, S. 

Gender-Responsive Strategies: Research, 

Practice, and Guiding Principles for 

Women Offenders. Washington, DC: 

National Institute of Corrections, June 

2003. nicic.org/pubs/2003/018017.pdf 

[accessed February 11, 2004].

Blume, S.B. Understanding addictive disorders in women. In: Graham, A.W.; 

Shultz, T.K.; and Wilford, B.B., eds. 

Principles of Addiction Medicine, Second 

Edition. Chevy Chase, MD: American 

Society of Addiction Medicine, Inc., 

1998, pp.1173–1190. 

Bowser, B.P., and Bilal, R. Drug treatment 

effectiveness: African-American culture 

in recovery. Journal of Psychoactive 

Drugs 33(4):391–402, 2001. 

Boylin, W.M., and Doucette, J. Multifamily 

therapy in substance abuse treatment 

with women. American Journal of Family 

Therapy 25(1):39–47, 1997. 

Bradley, B.P.; Gossop, M.; Phillips, G.T.; 

and Legarda, J.J. The development of an 

opiate withdrawal scale (OWS). British 

Journal of the Addictions 82:1139–1142, 

1987. 

Brady, K.T., and Randall, C.L. Gender differences in substance use disorders. 

Psychiatric Clinics of North America

22(2):241–252, 1999. 

Brems, C.; Johnson, M.E.; and Namyniuk, 

L.L. Clients with substance abuse and 

mental health concerns: A guide for 

conducting intake interviews. Journal 

of Behavioral Health Services Research

29(3):327–334, 2002.

Brisbane, F.L. Introduction: Diversity 

among African Americans. In: Center 

for Substance Abuse Prevention (CSAP). 

Cultural Competence for Health Care 

Professionals Working With AfricanAmerican Communities: Theory and 

Practice. CSAP Cultural Competence 

Series 7. DHHS Publication No. (SMA) 

98–3238. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1998, pp. 1–8. 

Brochu, S.; Guyon, L.; and Desjardins, L. 

Comparative profiles of addicted adult 

populations in rehabilitation and correctional services. Journal of Substance 

Abuse Treatment 6(2):173–182, 1999. 

Brown, T.G.; Seraganian, P.; Tremblay, J.; 

and Annis, H. Matching substance abuse 

aftercare treatments to client characteristics. Addictive Behavior 27:585–604, 

2002. 

Budney, A.J., and Higgins, S.T. A Community 

Reinforcement Plus Vouchers Approach: 

Treating Cocaine Addiction. Manual 2: 

Therapy Manuals for Drug Addiction 

Series. NIH Publication No. 98–4309. 

Rockville, MD: National Institute on 

Drug Abuse, 1998. 

Bureau of Justice Assistance. Integrating 

Drug Testing Into a Pretrial Services 

System: 1999 Update. Washington, DC: 

Office of Justice Programs, July 1999. 

bja.ncjrs.org/publications/#1 [accessed 

April 8, 2004].

Bureau of Justice Statistics. Correctional 

Populations in the United States, 1997.

Washington, DC: Office of Justice 

Programs, November 2000. www.ojp.

usdoj.gov/bjs/abstract/cpus97.htm 

[accessed February 11, 2004]. 

Busto, U.E.; Sykora, K.; and Sellers, E.M. 

A clinical scale to assess benzodiazepine withdrawal. Journal of Clinical 

Psychopharmacology 9:412–416, 1989.

Campbell, J.C. Prediction of homicide of and 

by battered women. In: Campbell, J.C., 

ed. Assessing Dangerousness: Violence 

by Sexual Offenders, Batterers, and 
208 Appendix A

Child Abusers. Thousand Oaks, CA: Sage 

Publications, 1995, pp. 96–113. 

Carey, K.B., and Correia, C.J. Severe mental illness and addictions: Assessment 

considerations. Addictive Behaviors

23(6):735–748, 1998.

Carroll, K.M. Integrating psychotherapy 

and pharmacotherapy in substance 

abuse treatment. In: Rodgers, F.; Keller, 

D.S.; and Morgenstern, J., eds. Treating 

Substance Abuse: Theory and Technique. 

New York: Guilford Press, 1996a, pp. 

286–318. 

Carroll, K.M. Relapse prevention as a psychosocial treatment: A review of controlled clinical trials. Experimental and 

Clinical Psychopharmacology 4(1):46–54, 

1996b. 

Carroll, K.M. A Cognitive–Behavioral 

Approach: Treating Cocaine Addiction.

Manual 1: Therapy Manuals for Drug 

Addiction Series. NIH Publication 

No. 94–4308. Rockville, MD: National 

Institute on Drug Abuse, 1998. 

Carroll, K.M.; Nich, C.; Ball, S.A.; McCance, 

E.; and Rounsaville, B.J. Treatment of 

cocaine and alcohol dependence with 

psychotherapy and disulfiram. Addiction

93(5):713–727, 1998. 

Catalano, R.F.; Gainey, R.R.; Fleming, C.B.; 

Haggerty, K.P.; and Johnson, N.O. An 

experimental intervention with families 

of substance abusers: One-year followup of the Focus on Families project. 

Addiction 94(2):241–254, 1999. 

Catalano, R.F.; Haggerty, K.P.; Gainey, R.R.; 

and Hoppe, M. Reducing parental risk 

factors for children’s substance misuses: 

Preliminary outcomes with opiateaddicted parents. Substance Use & 

Misuse 32(6):699–721, 1997. 

Center for Substance Abuse Prevention. 

Substance Abuse Resource Guide: 

Asian and Pacific Islander Americans.

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1996a. ncadi.samhsa/gov/pubs/govpubs/

MS408 [accessed March 4, 2004].

Center for Substance Abuse Prevention. 

Substance Abuse Resource Guide: 

Hispanic/Latino Americans. Rockville, 

MD: Substance Abuse and Mental 

Health Services Administration, 1996b. 

ncadi.samhsa.gov/govpubs/MS441 

[accessed March 4, 2004].

Center for Substance Abuse Prevention. 

Communicating appropriately with 

Asian and Pacific Islander audiences. 

Technical Assistance Bulletin, June 

1997. ncadi.samhsa.gov/govpubs/MS701 

[accessed February 11, 2004].

Center for Substance Abuse Prevention. 

Cultural Competence for Health Care 

Professionals Working With AfricanAmerican Communities: Theory and 

Practice. Cultural Competence Series 7. 

DHHS Publication No. (SMA) 98–3238. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1998a. 

Center for Substance Abuse Prevention: 

Substance Abuse Resource Guide: 

American Indians and Alaska Natives.

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1998b. ncadi.samhsa.gov/govpubs/

MS419 [accessed March 4, 2004].

Center for Substance Abuse Prevention. 

Responding to Pacific Islanders: 

Culturally Competent Perspectives for 

Substance Abuse Prevention. Cultural 

Competence Series 8. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, 1999. 

Center for Substance Abuse Prevention. 

Substance Abuse Resource Guide: 

Lesbian, Gay, Bisexual, and Transgender 

Populations. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2000. ncadi.samhsa.gov/
Bibliography 209

referrals/resguides.aspx?InvNum=MS489 

[accessed February 11, 2004].

Center for Substance Abuse Prevention. 

Health Promotion and Substance Abuse 

Prevention Among American Indian 

and Alaska Native Communities: Issues 

in Cultural Competence. Cultural 

Competence Series 9. DHHS Publication 

No. (SMA) 99–3440. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, 2001. 

Centers for Disease Control and Prevention. 

Increasing morbidity and mortality associated with abuse of methamphetamine—

United States, 1991–1994. Morbidity and 

Mortality Weekly Report 44(47):882–886, 

1995. 

Centers for Disease Control and Prevention. 

HIV/AIDS Surveillance Report 14:1–48, 

2002. 

Centers for Disease Control and Prevention. 

HIV/AIDS Surveillance Report 16:1–46, 

2004.

Charney, D.A.; Paraherakis, A.M.; and Gill, 

K.J. Integrated treatment of comorbid 

depression and substance use disorders. 

Journal of Clinical Psychiatry 62(9):672–

677, 2001. 

Chermack, S.T.; Walton, M.A.; Fuller, B.E.; 

and Blow, F.C. Correlates of expressed 

and received violence across relationship types among men and women substance abusers. Psychology of Addictive 

Behaviors 15(2):140–151, 2001. 

Chick, J.; Lehert, P.; and Landron, F. Does 

acamprosate improve reduction of drinking as well as aiding abstinence? Journal 

of Psychopharmacology 17(4):397–402, 

2003.

Claus, R.E., and Kindleberger, L.R. 

Engaging substance abusers after centralized assessment: Predictors of treatment entry and dropout. Journal of 

Psychoactive Drugs 34:25–31, 2002. 

Cohen, M. Counseling Addicted Women: A 

Practical Guide. Thousand Oaks, CA: 

Sage Publications, 2000.

Compton, W.M., III; Cottler, L.B.; Phelps, 

D.L.; Ben Abdallah, A.; and Spitznagel, 

E.L. Psychiatric disorders among drug 

dependent subjects: Are they primary 

or secondary? American Journal on 

Addictions 9(2):126–134, 2000. 

Conner, K.R.; Shea, R.R.; McDermott, M.P.; 

Grolling, R.; Tocco, R.V.; and Baciewicz, 

G. The role of multifamily therapy in 

promoting retention in treatment of alcohol and cocaine dependence. American 

Journal on Addictions 7(1):61–73, 1998.

Connors, G.J., and Dermen, K.H. 

Characteristics of participants in Secular 

Organizations for Sobriety (SOS). 

American Journal of Drug and Alcohol 

Abuse 22:281–295, 1996.

Connors, G.J.; Donovan, D.M.; and 

DiClemente, C.C. Substance Abuse 

Treatment and the Stages of Change: 

Selecting and Planning Interventions. 

New York: Guilford Press, 2001a. 

Connors, G.J.; Tonigan, J.S.; and Miller, 

W.R. A longitudinal model of intake 

symptomatology, AA participation, and 

outcome: Retrospective study of the 

Project MATCH outpatient and aftercare 

samples. Journal of Studies on Alcohol

62:817–825, 2001b. 

Cornish, J.W.; Metzger, D.; Woody, G.E.; 

Wilson, D.; McLellan, A.T.; Vandergrift, 

B.; and O’Brien, C.P. Naltrexone pharmacotherapy for opioid dependent federal probationers. Journal of Substance 

Abuse Treatment 14(6):529–534, 1997.

Covington, S. A Woman’s Journey Home: 

Challenges for Female Offenders and 

Their Children. Washington, DC: Urban 

Institute, 2002. 

Covington, S.S. A Woman’s Way Through the 

Twelve Steps. Center City, MN: Hazelden 

Information Education, 1994. 
210 Appendix A

Covington, S.S. Helping Women Recover: 

A Program for Treating Addiction. San 

Francisco: Jossey-Bass, 1999. 

Covington, S.S. A Woman’s Way Through the 

Twelve Steps Workbook. Center City, MN: 

Hazelden Information Education, 2000.

Coyhis, D., and White, W.L. Addiction and 

recovery in Native America: Lost history, 

enduring lessons. Counselor 3(5):16–20, 

2002. 

Crnkovic, A.E., and DelCampo, R.L. A systems approach to the treatment of chemical addiction. Contemporary Family 

Therapy 20(1):25–36, 1998. 

Crowley, T.J. Research on contingency management treatment of drug dependence: 

Clinical implications and future directions. In: Higgins, S.T., and Silverman, 

K., eds. Motivating Behavior Change 

Among Illicit-Drug Abusers: Research on 

Contingency Management Interventions.

Washington, DC: American Psychological 

Association, 1999, pp. 345–370. 

CSAT (Center for Substance Abuse 

Treatment). Pregnant, SubstanceUsing Women. Treatment Improvement 

Protocol (TIP) Series 2. DHHS 

Publication No. (SMA) 95–3056. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1993a, reprinted 1995. 

CSAT (Center for Substance Abuse 

Treatment). Screening for Infectious 

Diseases Among Substance Abusers.

Treatment Improvement Protocol (TIP) 

Series 6. DHHS Publication No. (SMA) 

93–2048. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1993b. 

CSAT (Center for Substance Abuse 

Treatment). Assessment and Treatment 

of Cocaine-Abusing MethadoneMaintained Patients. Treatment 

Improvement Protocol (TIP) Series 10. 

DHHS Publication No. (SMA) 94–3004. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1994a. 

CSAT (Center for Substance Abuse 

Treatment). Assessment and Treatment 

of Patients With Coexisting Mental Illness 

and Alcohol and Other Drug Abuse.

Treatment Improvement Protocol (TIP) 

Series 9. DHHS Publication No. (SMA) 

94–2078. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1994b. 

CSAT (Center for Substance Abuse 

Treatment). Intensive Outpatient 

Treatment for Alcohol and Other Drug 

Abuse. Treatment Improvement Protocol 

(TIP) Series 8. DHHS Publication 

No. (SMA) 94–2077. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, 1994c. 

CSAT (Center for Substance Abuse 

Treatment). Practical Approaches in 

the Treatment of Women Who Abuse 

Alcohol and Other Drugs. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, 1994d. 

CSAT (Center for Substance Abuse 

Treatment). Screening and Assessment 

for Alcohol and Other Drug Abuse Among 

Adults in the Criminal Justice System.

Treatment Improvement Protocol (TIP) 

Series 7. DHHS Publication No. (SMA) 

94–2076. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1994e. 

CSAT (Center for Substance Abuse 

Treatment). Simple Screening Instruments 

for Outreach for Alcohol and Other Drug 

Abuse and Infectious Diseases. Treatment 

Improvement Protocol (TIP) Series 11. 

DHHS Publication No. (SMA) 94–2094. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1994f. 

CSAT (Center for Substance Abuse 

Treatment). Detoxification From 

Alcohol and Other Drugs. Treatment 
Bibliography 211

Improvement Protocol (TIP) Series 19. 

DHHS Publication No. (SMA) 95–3046. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1995a. 

CSAT (Center for Substance Abuse 

Treatment). Treating Alcohol and Other 

Drug Abusers in Rural and Frontier 

Areas: 1994 Award for Excellence Papers.

Technical Assistance Publication (TAP) 

Series 17. DHHS Publication No. (SMA) 

95–3054. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1995b. 

CSAT (Center for Substance Abuse 

Treatment). The Tuberculosis Epidemic: 

Legal and Ethical Issues for Alcohol and 

Other Drug Abuse Treatment Providers. 

Treatment Improvement Protocol (TIP) 

Series 18. DHHS Publication No. (SMA) 

95–3047. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1995c. 

CSAT (Center for Substance Abuse 

Treatment). Bringing Excellence to 

Substance Abuse Services in Rural 

and Frontier America: 1996 Award for 

Excellence Papers. Technical Assistance 

Publication (TAP) Series 20. DHHS 

Publication No. (SMA) 97–3134. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1996. 

CSAT (Center for Substance Abuse 

Treatment). A Guide to Substance Abuse 

Services for Primary Care Clinicians.

Treatment Improvement Protocol (TIP) 

Series 24. DHHS Publication No. (SMA) 

97–3139. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1997a. 

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Treatment 

and Domestic Violence. Treatment 

Improvement Protocol (TIP) Series 25. 

DHHS Publication No. (SMA) 97–3163. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1997b.

CSAT (Center for Substance Abuse 

Treatment). Comprehensive Case 

Management for Substance Abuse 

Treatment. Treatment Improvement 

Protocol (TIP) Series 27. DHHS 

Publication No. (SMA) 98–3222. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1998a.

CSAT (Center for Substance Abuse 

Treatment). Continuity of Offender 

Treatment for Substance Use Disorders 

From Institution to Community. 

Treatment Improvement Protocol (TIP) 

Series 30. DHHS Publication No. (SMA) 

98–3245. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1998b. 

CSAT (Center for Substance Abuse 

Treatment). Naltrexone and Alcoholism 

Treatment. Treatment Improvement 

Protocol (TIP) Series 28. DHHS 

Publication No. (SMA) 98–3206. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1998c. 

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Among 

Older Adults. Treatment Improvement 

Protocol (TIP) Series 26. DHHS 

Publication No. (SMA) 98–3179. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1998d. 

CSAT (Center for Substance Abuse 

Treatment). Substance Use Disorder 

Treatment for People With Physical 

and Cognitive Disabilities. Treatment 

Improvement Protocol (TIP) Series 29. 

DHHS Publication No. (SMA) 98–3249. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1998e. 
212 Appendix A

CSAT (Center for Substance Abuse 

Treatment). Brief Interventions and 

Brief Therapies for Substance Abuse. 

Treatment Improvement Protocol (TIP) 

Series 34. DHHS Publication No. (SMA) 

99–3353. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1999a. 

CSAT (Center for Substance Abuse 

Treatment). Cultural Issues in Substance 

Abuse Treatment. DHHS Publication 

No. (SMA) 99–3278. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, 1999b.

CSAT (Center for Substance Abuse 

Treatment). Enhancing Motivation for 

Change in Substance Abuse Treatment. 

Treatment Improvement Protocol (TIP) 

Series 35. DHHS Publication No. (SMA) 

99–3354. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1999c. 

CSAT (Center for Substance Abuse 

Treatment). Screening and Assessing 

Adolescents for Substance Use Disorders. 

Treatment Improvement Protocol (TIP) 

Series 31. DHHS Publication No. (SMA) 

99–3282. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1999d. 

CSAT (Center for Substance Abuse 

Treatment). Treatment for Stimulant 

Use Disorders. Treatment Improvement 

Protocol (TIP) Series 33. DHHS 

Publication No. (SMA) 99–3296. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1999e.

CSAT (Center for Substance Abuse 

Treatment). Treatment of Adolescents 

With Substance Use Disorders. Treatment 

Improvement Protocol (TIP) Series 32. 

DHHS Publication No. (SMA) 99–3283. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

1999f. 

CSAT (Center for Substance Abuse 

Treatment). Integrating Substance Abuse 

Treatment and Vocational Services.

Treatment Improvement Protocol (TIP) 

Series 38. DHHS Publication No. (SMA) 

00–3470. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2000a. 

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Treatment 

for Persons With Child Abuse and Neglect 

Issues. Treatment Improvement Protocol 

(TIP) Series 36. DHHS Publication 

No. (SMA) 00–3357. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, 2000b. 

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Treatment 

for Persons With HIV/AIDS. Treatment 

Improvement Protocol (TIP) Series 37. 

DHHS Publication No. (SMA) 00–3410. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2000c. 

CSAT (Center for Substance Abuse 

Treatment). A Provider’s Introduction 

to Substance Abuse Treatment for 

Lesbian, Gay, Bisexual, and Transgender 

Individuals. DHHS Publication 

No. (SMA) 01–3498. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, 2001. 

CSAT (Center for Substance Abuse 

Treatment). Clinical Guidelines for the 

Use of Buprenorphine in the Treatment 

of Opioid Addiction. Treatment 

Improvement Protocol (TIP) Series 40. 

DHHS Publication No. (SMA) 04–3939. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2004a.

CSAT (Center for Substance Abuse 

Treatment). The Confidentiality of 

Alcohol and Drug Abuse Patient Records 

Regulation and the HIPAA Privacy Rule: 

Implications for Alcohol and Substance 

Abuse Programs. DHHS Publication No. 
Bibliography 213

(SMA) 04-3947. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2004b. www.hipaa.

samhsa.gov/download2/

SAMHSAHIPAAComparisonClearedPDF

Version.pdf [accessed April 5, 2005]. 

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Treatment 

and Family Therapy. Treatment 

Improvement Protocol (TIP) Series 39. 

DHHS Publication No. (SMA) 04–3957. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2004c. 

CSAT (Center for Substance Abuse 

Treatment). Acamprosate: A new medication for alcohol use disorders. Substance 

Abuse Treatment Advisory 4(1), 2005a.

CSAT (Center for Substance Abuse 

Treatment). Medication-Assisted 

Treatment for Opioid Addiction in 

Opioid Treatment Programs. Treatment 

Improvement Protocol (TIP) Series 43. 

DHHS Publication No. (SMA) 05-4048. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2005b.

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Relapse 

Prevention for Older Adults: A Group 

Treatment Approach. DHHS Publication 

No. 05-4053. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2005c.

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Treatment 

for Adults in the Criminal Justice System. 

Treatment Improvement Protocol (TIP) 

Series 44. DHHS Publication No. (SMA) 

05–4056. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2005d.

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Treatment 

for Persons With Co-Occurring Disorders.

Treatment Improvement Protocol (TIP) 

Series 42. DHHS Publication No. (SMA) 

05–3922. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2005e.

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse 

Treatment: Group Therapy. Treatment 

Improvement Protocol (TIP) Series 41. 

DHHS Publication No. (SMA) 05–3991. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2005f.

CSAT (Center for Substance Abuse 

Treatment). Client’s Handbook: Matrix 

Intensive Outpatient Treatment for 

People With Stimulant Use Disorders. 

DHHS Publication No. (SMA) 06–4154. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2006a.

CSAT (Center for Substance Abuse 

Treatment). Client’s Treatment 

Companion: Matrix Intensive Outpatient 

Treatment for People With Stimulant Use 

Disorders. DHHS Publication No. (SMA) 

06–4155. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2006b.

CSAT (Center for Substance Abuse 

Treatment). Counselor’s Family 

Education Manual: Matrix Intensive 

Outpatient Treatment for People 

With Stimulant Use Disorders. DHHS 

Publication No. (SMA) 06–4153. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2006c.

CSAT (Center for Substance Abuse 

Treatment). Counselor’s Treatment 

Manual: Matrix Intensive Outpatient 

Treatment for People With Stimulant Use 

Disorders. DHHS Publication No. (SMA) 

06–4152. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2006d.
214 Appendix A

CSAT (Center for Substance Abuse 

Treatment). Detoxification and 

Substance Abuse Treatment. Treatment 

Improvement Protocol (TIP) Series 45. 

DHHS Publication No. (SMA) 06–4131. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2006e. 

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse: 

Administrative Issues in Outpatient 

Treatment. Treatment Improvement 

Protocol (TIP) Series 46. DHHS 

Publication No. (SMA) 06–4151. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2006f.

CSAT (Center for Substance Abuse 

Treatment). Therapeutic Community 

Curriculum: Participant’s Manual. 

DHHS Publication No. (SMA) 06-4122. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2006g.

CSAT (Center for Substance Abuse 

Treatment). Therapeutic Community 

Curriculum: Trainer’s Manual. DHHS 

Publication No. (SMA) 06-4121. Rockville, 

MD: Substance Abuse and Mental Health 

Services Administration, 2006h.

CSAT (Center for Substance Abuse 

Treatment). Improving Cultural 

Competence in Substance Abuse 

Treatment. Treatment Improvement 

Protocol (TIP) Series. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, forthcoming a.

CSAT (Center for Substance Abuse 

Treatment). Substance Abuse Treatment: 

Addressing the Specific Needs of Women.

Treatment Improvement Protocol 

(TIP) Series. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, forthcoming b.

da Costa, C.L.; Younes, R.N.; and Lourenco, 

M.T. Stopping smoking: A prospective, 

randomized, double-blind study comparing nortriptyline to placebo. Chest 

122:403–408, 2002. 

Daley, D.C. Relapse Prevention Workbook 

for Recovering Alcoholics and Drug 

Dependent Persons, Third Edition. 

Holmes Beach, FL: Learning 

Publications, 2001. 

Daley, D.C. Dual Disorders: Relapse 

Prevention Workbook, Second Edition. 

Center City, MD: Hazelden Foundation, 

2003. 

Daley, D.C., and Marlatt, G.A. Managing 

Your Drug or Alcohol Problem: Therapist 

Guide. San Antonio, TX: Psychological 

Corporation, 1997. 

Daley, D.C.; Marlatt, G.A.; and Spotts, C.E. 

Relapse prevention: Clinical models 

and specific intervention strategies. In: 

Graham, A.W.; Schultz, T.K.; MayoSmith, M.F.; Ries, R.K.; and Wilford, 

B.B., eds. Principles of Addiction 

Medicine, Third Edition. Chevy Chase, 

MD: American Society of Addiction 

Medicine, 2003, pp. 467–485. 

Daley, D.C.; Mercer, D.; and Carpenter, G. 

Drug Counseling for Cocaine Addiction: 

The Collaborative Cocaine Treatment 

Study Manual. Manual 4: Therapy 

Manuals for Drug Addiction Series. NIH 

Publication No. 99–4380. Rockville, MD: 

National Institute on Drug Abuse, 1999. 

Daley, D.C., and Thase, M.E. Dual Disorders 

Recovery Counseling: Integrated 

Treatment for Substance Use and Mental 

Health Disorders. Independence, MO: 

Independence Press, 2002. 

D’Avanzo, C., and Geissler, E. Pocket 

Guide to Cultural Health Assessment, 

Third Edition. Mosby’s Pocket Series. 

Philadelphia: Elsevier, 2003. 

Deas, D.; Riggs, P.; Langenbucher, J.; 

Goldman, M.; and Brown, S. Adolescents 

are not adults: Developmental considerations in alcohol users. Alcoholism, 
Bibliography 215

Clinical and Experimental Research

24:232–237, 2000.

De La Rosa, M. Acculturation and Latino 

adolescents’ substance use: A research 

agenda for the future. Substance Use & 

Misuse 37(4):429–456, 2002. 

De La Rosa, M.R., and White, M.S. A review 

of the role of social support systems 

in the drug use behavior of Hispanics. 

Journal of Psychoactive Drugs 33(3):233–

240, 2001. 

De Leon, G. Therapeutic communities for 

addictions: A theoretical framework. 

International Journal of the Addictions 

30(12):1603–1645, 1995. 

De Leon, G. The Therapeutic Community: 

Theory, Model, and Method. New York: 

Springer Publishing, 2000. 

De Leon, G., and Jainchill, N. Circumstance, 

motivation, readiness, and suitability as 

correlates of treatment tenure. Journal of 

Psychoactive Drugs 18:203–208, 1986. 

De Leon, G.; Melnick, G.; Kressel, D.; and 

Jainchill, N. Circumstances, motivation, 

readiness, and suitability (the CMRS 

Scales): Predicting retention in therapeutic community treatment. American 

Journal of Drug and Alcohol Abuse 

20(4):495–515, 1994. 

DiClemente, C.C., and Hughes, S.O. Stages 

of change profiles in outpatient alcoholism treatment. Journal of Substance 

Abuse 2:217–235, 1990. 

Ditton, P.M. Mental health and treatment 

of inmates and probationers. Bureau 

of Justice Statistics Special Report.

Washington, DC: Office of Justice 

Programs, July 1999. www.ojp.usdoj.

gov/bjs/abstract/mhtip.htm [accessed 

February 11, 2004].

Dixon, L.; McNary, S.; and Lehman, A. 

Remission of substance use disorder 

among psychiatric inpatients with 

mental illness. American Journal of 

Psychiatry 155(2):239–243, 1998. 

Drake, R.E.; Essock, S.M.; Shaner, A.; Carey, 

K.B.; Minkoff, K.; Kola, L.; Lynde, D.; 

Osher, F.C.; Clark, R.E.; and Rickards, 

L. Implementing dual diagnosis services 

for clients with severe mental illness. 

Psychiatric Services 52:469–476, 2001. 

Drake, R.E.; McHugo, G.J.; Clark, R.E.; 

Teague, G.B.; Xie, H.; Miles, K.; and 

Ackerson, T.H. Assertive community 

treatment for patients with co-occurring 

severe mental illness and substance 

use disorder: A clinical trial. American 

Journal of Orthopsychiatry 68(2):201–

215, 1998a.

Drake, R.E.; Mercer-McFadden, C.; Mueser, 

K.T.; McHugo, G.J.; and Bond, G.R. 

Review of integrated mental health and 

substance abuse treatment for patients 

with dual disorders. Schizophrenia 

Bulletin 24(4):589–608, 1998b. 

Drake, R.E., and Mueser, K.T. Psychosocial 

approaches to dual diagnosis. 

Schizophrenia Bulletin 26:105–118, 

2000. 

Edwards, J.T. Treating Chemically 

Dependent Families: A Practical Systems 

Approach for Professionals. Minneapolis, 

MN: Johnson Institute, 1990. 

Edwards, M.D., and Steinglass, P. Family 

therapy treatment outcomes for alcoholism. Journal of Marital and Family 

Therapy 21(4):475–509, 1995. 

Ehrman, R.N.; Robbins, S.J.; and Cornish, 

J.W. Results of a baseline urine test predict levels of cocaine use during treatment. Drug and Alcohol Dependence

62(1):1–7, 2001. 

Eisen, M.; Keyser-Smith, J.; Dampeer, J.; 

and Sambrano, S. Evaluation of substance use outcomes in demonstration 

projects for pregnant and postpartum 

women and their infants: Findings from 
216 Appendix A

a quasi-experiment. Addictive Behaviors

25(1):123–129, 2000. 

Epstein, E.E., and McCrady, B.S. Behavioral 

couples treatment of alcohol and drug 

use disorders: Current status and innovations. Clinical Psychology Review

18(6):689–711, 1998.

Epstein, J.; Barker, P.; Vorburger, M.; and 

Murtha, C. Serious Mental Illness and 

Its Co-Occurrence With Substance Use 

Disorders, 2002. Analytic Series A-24. 

DHHS Publication No. (SMA) 04–3905. 

Rockville, MD: Office of Applied Studies, 

Substance Abuse and Mental Health 

Services Administration, 2004. www.

oas.samhsa.gov/CoD/Cod.htm [accessed 

August 17, 2004].

Evans, K., and Sullivan, J.M. Dual Diagnosis: 

Counseling the Mentally Ill Substance 

Abuser, Second Edition. New York: 

Guilford Press, 2000. 

Fals-Stewart, W., and Birchler, G.R. A 

national survey of the use of couples 

therapy in substance abuse treatment. 

Journal of Substance Abuse Treatment 

20:277–283, 2001. 

Fals-Stewart, W.; Birchler, G.R.; and 

O’Farrell, T.J. Behavioral couples 

therapy for male substance-abusing 

patients: Effects on relationship adjustment and drug-using behavior. Journal 

of Consulting and Clinical Psychology 

64:959–972, 1996. 

Farabee, D.; Prendergast, M.; and Anglin, 

M.D. The effectiveness of coerced treatment for drug-abusing offenders. Federal 

Probation 62:3–10, 1998. 

Farabee, D.; Prendergast, M.; Cartier, J.; 

Wexler, H.; Knight, K.; and Anglin, M.D. 

Barriers to implementing effective correctional drug treatment programs. Prison 

Journal 79:150–162, 1999. 

Farabee, D.; Rawson, R.; and McCann, 

M. Adoption of drug avoidance activities among patients in contingency 

management and cognitive–behavioral 

treatments. Journal of Substance Abuse 

Treatment 23(4):343–350, 2002.

Fears, D. A Diverse—and Divided—Black 

Community. Washington Post, February 

24, 2002, pp. A1, A8. 

Festinger, D.S.; Lamb, R.J.; Marlowe, D.B.; 

and Kirby, K.C. From telephone to 

office: Intake attendance as a function of 

appointment delay. Addictive Behaviors 

27(1):131–137, 2002. 

Finnegan, D.G., and McNally, E.B. 

Counseling Lesbian, Gay, Bisexual, and 

Transgender Substance Abusers: Dual 

Identities, Second Edition. Binghamton, 

NY: Haworth Press, 2002.

Finney, J.W.; Hahn, A.C.; and Moos, R.H. 

The effectiveness of inpatient and outpatient treatment for alcohol abuse: 

The need to focus on mediators and 

moderators of setting effects. Addiction

91(12):1773–1796; discussion 1803–

1820, 1996. 

Fiorentine, R. After drug treatment: Are 12-

Step programs effective in maintaining 

abstinence? American Journal of Drug 

and Alcohol Abuse 25(1):93–116, 1999. 

First, M.B.; Spitzer, R.L.; Gibbon, M.; and 

Williams, J.B.W. Structured Clinical 

Interview for DSM-IV Axis I Disorders 

(SCID-I), Clinician Version. Washington, 

DC: American Psychiatric Association, 

1997. 

Fishman, H.C., and Andes, F. Enhancing 

family therapy: The addition of a community resource specialist. Journal of 

Marital and Family Therapy 27(1):111–

116, 2001. 

Fishman, J.; Reynolds, T.; and Riedel, E. A 

retrospective investigation of an intensive 

outpatient substance abuse treatment 

program. American Journal of Drug and 

Alcohol Abuse 25(2):185–196, 1999. 
Bibliography 217

Flynn, P.M.; Craddock, S.G.; Luckey, J.W.; 

Hubbard, R.L.; and Dunteman, G.H. 

Comorbidity of antisocial personality 

and mood disorders among psychoactive 

substance-dependent treatment clients. 

Journal of Personality Disorders 10(1):56–

67, 1996.

Folstein, M.F.; Folstein, S.E.; and McHugh, 

P.R. Mini-Mental State: A practical 

method for grading the cognitive state 

of patients for the clinician. Journal of 

Psychiatric Research 12:189–198, 1975. 

Forman, R. One AA meeting doesn’t fit all: 

Six keys to prescribing 12-Step programs. 

Current Psychiatry, October 2002, pp. 1, 

10, 16–24.

Frank, E.; Winkleby, M.A.; Altman, D.G.; 

Rockhill, B.; and Fortmann, S.P. 

Predictors of physician’s smoking cessation advice. JAMA 266:3139–3144, 1991. 

Fudala, P.J.; Yu, E.; MacFadden, W.; 

Boardman, C.; and Chiang, C.N. Effects 

of buprenorphine and naloxone in 

morphine-stabilized opioid addicts. Drug 

and Alcohol Dependence 50:1–8, 1998. 

Fuller, R.K., and Gordis, E. Refining 

the treatment of alcohol withdrawal: 

Editorial. JAMA 272:557–558, 1994. 

Gastfriend, D.R. Placement matching: 

Challenges and technical progress. In: 

Proceedings: Tenth Annual Meeting & 

Symposium, December 2–5, 1999. Prairie 

Village, KS: American Academy of 

Addiction Psychiatry, 1999, pp. 18–19. 

www.aaap.org/meetings/proceedings.pdf 

[accessed February 11, 2004]. 

Gaston, L. Reliability and criterion-related 

validity of the California Psychotherapy 

Alliance Scales—patient version. 

Psychological Assessment 3:68–74, 1991. 

Gfroerer, J.; Penne, M.; Pemberton, M.; and 

Folsom, R. Substance abuse treatment 

need among older adults in 2020: The 

impact of the aging baby-boom cohort. 

Drug and Alcohol Dependence 69(2):127–

135, 2003. 

Glaze, L.E. Probation and parole in the 

United States, 2002. Bureau of Justice 

Statistics Bulletin. Washington, DC: 

Office of Justice Programs, August 2003. 

www.ojp.usdoj.gov/bjs/pub/pdf/ppus02.

pdf [accessed February 11, 2004].

Gloria, A.M., and Peregoy, J.J. Counseling 

Latino alcohol and other substance 

users/abusers: Cultural considerations 

for counselors. Journal of Substance 

Abuse Treatment 13:119–126, 1996. 

Glover, E.D.; Glover, P.N.; and Payne, 

T.J. Treating nicotine dependence. 

American Journal of the Medical Sciences

326(4):183–186, 2003.

Godlaski, T.M.; Leukefeld, C.; and Cloud, 

R. Recovery: With and without self-help. 

Substance Use & Misuse 32(5):621–627, 

1997.

Godley, S.H.; Meyers, R.J.; Smith, J.E.; 

Karvinen, T.; Titus, J.C.; Godley, 

M.D.; Dent, G.; Passetti, L.; and 

Kelberg, P. The Adolescent Community 

Reinforcement Approach for Adolescent 

Cannabis Users. Cannabis Youth 

Treatment Series, Volume 4. DHHS 

Publication No. (SMA) 01–3489. 

Rockville, MD: Center for Substance 

Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 

2001. 

Goldenberg, I., and Goldenberg, H. 

Family Therapy: An Overview, Second 

Edition. Brooks Grove, CA: Brooks/Cole 

Publishing Co., 1985. 

Goodman, D. Arab Americans and American 

Muslims express mental health needs. 

SAMHSA News 10(1):2–3, 2002. 

Gorski, T.T. The CENAPS® model of relapse 

prevention therapy (CMRPT®). In: 

Carroll, K.M., ed. Approaches to Drug 

Abuse Counseling. NIH Publication 

No. 00–4151. Rockville, MD: National 
218 Appendix A

Institute on Drug Abuse, 2000, pp. 23–

38. 

Gorski, T.T., and Kelley, J.M. Counselor’s 

Manual for Relapse Prevention With 

Chemically Dependent Criminal 

Offenders. Technical Assistance 

Publication (TAP) Series 19. DHHS 

Publication No. (SMA) 96–3115. 

Rockville, MD: Center for Substance 

Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 

1996.

Gorski, T.T.; Kelley, J.M.; Havens, L.; and 

Peters, R.H. Relapse Prevention and the 

Substance-Abusing Criminal Offender.

Technical Assistance Publication (TAP) 

Series 8. DHHS Publication No. (SMA) 

95–3071. Rockville, MD: Center for 

Substance Abuse Treatment, Substance 

Abuse and Mental Health Services 

Administration, 1993, reprinted 1995.

Gottheil, E.; Weinstein, S.P.; Sterling, R.C.; 

Lundy, A.; and Serota, R.D. A randomized controlled study of the effectiveness 

of intensive outpatient treatment for 

cocaine dependence. Psychiatric Services

49(6):782–787, 1998. 

Greenfeld, L.A., and Snell, T.L. Women 

offenders. Bureau of Justice Statistics 

Special Report. Washington, DC: Office 

of Justice Programs, December 1999, 

revised October 2000. www.ojp.usdoj.gov/

bjs/abstract/wo.htm [accessed February 

11, 2004]. 

Greenwood, G.L.; White, E.W.; Page-Shafer, 

K.; Bein, E.; Osmond, D.H.; Paul, J.; and 

Stall, R.D. Correlates of heavy substance 

use among young gay and bisexual men: 

The San Francisco Young Men’s Health 

Study. Drug and Alcohol Dependence

61(2):105–112, 2001. 

Gregoire, T.K., and Snively, C.A. The relationship of social support and economic 

self-sufficiency to substance abuse outcomes in a long-term recovery program 

for women. Journal of Drug Education 

31(3):221–237, 2001. 

Grella, C.E.; Polinsky, M.L.; Hser, Y.-I.; and 

Perry, S.M. Characteristics of womenonly and mixed-gender drug abuse treatment programs. Journal of Substance 

Abuse Treatment 17:37–44, 1999. 

Grieco, E.M. The Native Hawaiian and 

other Pacific Islander population: 

2000. Census 2000 Brief. C2KBR/01-14. 

Washington, DC: U.S. Census Bureau, 

2001.

Grosenick, J.K., and Hatmaker, C.M. 

Perceptions of the importance of physical setting in substance abuse treatment. 

Journal of Substance Abuse Treatment 

18:29–39, 2000. 

Gruber, K.; Chutuape, M.A.; and Stitzer, 

M.L. Reinforcement-based intensive outpatient treatment for inner city opiate 

abusers: A short-term evaluation. Drug 

and Alcohol Dependence 57:211–223, 

2000. 

Guardia, J.; Caso, C.; Arias, F.; Gual, A.; 

Sanahuja, J.; Ramirez, M.; Mengual, 

I.; Gonzalvo, B.; Segura, L.; Trujols, J.; 

and Casas, M. A double-blind, placebocontrolled study of naltrexone in the 

treatment of alcohol-dependence disorder: Results from a multicenter trial. 

Alcoholism, Clinical and Experimental 

Research 26(9):1381–1387, 2002.

Guss, J.R., ed. Addictions in the Gay and 

Lesbian Community. New York: Haworth 

Press, 2000. 

Guydish, J.; Sorensen, J.L.; Chan, M.; 

Werdegar, D.; Bostrom, A.; and 

Acampora, A. A randomized trial comparing day and residential drug abuse 

treatment: 18-month outcomes. Journal 

of Consulting and Clinical Psychology

67(3):428–434, 1999. 

Guydish, J.; Werdegar, D.; Sorensen, J.L.; 

Clark, W.; and Acampora, A. Drug abuse 

day treatment: A randomized clinical 
Bibliography 219

trial comparing day and residential treatment programs. Journal of Consulting 

and Clinical Psychology 66(2):280–289, 

1998. 

Hadjicostandi, J., and Cheurprakobkit, S. 

Drugs and substances: Views from a 

Latino community. American Journal of 

Drug and Alcohol Abuse 28(4):693–710, 

2002. 

Hamilton, N.L.; Brantley, L.B.; Tims, F.M.; 

Angelovich, N.; and McDougall, B. 

Family Support Network for Adolescent 

Cannabis Users. Cannabis Youth 

Treatment Series, Volume 3. DHHS 

Publication No. (SMA) 01–3488. 

Rockville, MD: Center for Substance 

Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 

2001. 

Harrison, P.M., and Beck, A.J. Prisoners 

in 2002. Bureau of Justice Statistics 

Bulletin. Washington, DC: Office of 

Justice Programs, July 2003. www.ojp.

usdoj.gov/bjs/pub/pdf/p02.pdf [accessed 

February 11, 2004].

Hasin, D.S.; Trautman, K.D.; Miele, G.M.; 

Samet, S.; Smith, M.; and Endicott, 

J. Psychiatric Research Interview 

for Substance and Mental Disorders 

(PRISM): Reliability for substance abusers. American Journal of Psychiatry

153:1195–1201, 1996.

Health Resources and Services 

Administration. Cultural Competence 

Works: Using Cultural Competence 

To Improve the Quality of Health 

Care for Diverse Populations and Add 

Value to Managed Care Arrangements.

Washington, DC: U.S. Department of 

Health and Human Services, 2001. 

Heather, N.; Luce, A.; Peck, D.; Dunbar, B.; 

and James, I. Development of a treatment version of the Readiness to Change 

Questionnaire. Addiction Research 7:63–

68, 1999. 

Heather, N.; Rollnick, S.; and Bell, A. 

Predictive validity of the Readiness 

to Change Questionnaire. Addiction 

88:1667–1677, 1993.

Higgins, S.T. Some potential contributions 

of reinforcement and consumer-demand 

theory to reducing cocaine use. Addictive 

Behaviors 21(6):803–816, 1996. 

Higgins, S.T. Introduction. In: Higgins, 

S.T., and Silverman, K., eds. Motivating 

Behavior Change Among Illicit-Drug 

Abusers: Research on Contingency 

Management Interventions. Washington, 

DC: American Psychological Association, 

1999, pp. 3–13. 

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; 

Foerg, F.E.; Ogden, D.; and Badger, 

G.J. Outpatient behavioral treatment 

for cocaine dependence: One year 

outcomes. Experimental and Clinical 

Psychopharmacology 3:205–212, 1995.

Higgins, S.T., and Silverman, K., eds. 

Motivating Behavior Change Among 

Illicit-Drug Abusers: Research on 

Contingency Management Interventions.

Washington, DC: American Psychological 

Association, 1999. 

Higgins, S.T.; Wong, C.J.; Badger, G.J.; 

Ogden, D.E.; and Dantona, R.L. 

Contingent reinforcement increases 

cocaine abstinence during outpatient 

treatment and 1 year of follow-up. 

Journal of Consulting and Clinical 

Psychology 68(1):64–72, 2000.

Hodgins, D.C.; el-Guebaly, N.; and 

Addington, J. Treatment of substance 

abusers: Single or mixed gender programs. Addiction 92(7):805–812, 1997.

Hoffman, F. Cultural adaptations of 

Alcoholics Anonymous to serve Hispanic 

populations. International Journal of 

Addiction 29(4):445–460, 1994. 

Hoffman, J.A.; Jones, B.; Caudill, B.D.; Mayo, 

D.W.; and Mack, K.A. The living in balance counseling approach. In: Carroll, 
220 Appendix A

K.M., ed. Approaches to Drug Abuse 

Counseling. NIH Publication No. 00–

4151. Rockville, MD: National Institute 

on Drug Abuse, 2000, pp. 39–60. 

Hoffmann, N.G.; Halikas, J.A.; Mee-Lee, D.; 

and Weedman, R.D. Patient Placement 

Criteria for the Treatment of Psychoactive 

Substance Use Disorders. Chevy Chase, 

MD: American Society of Addiction 

Medicine, 1991. 

Howell, E.M.; Heiser, N.; and Harrington, M. 

A review of recent findings on substance 

abuse treatment for pregnant women. 

Journal of Substance Abuse Treatment

16:195–219, 1999. 

Hser, Y.I.; Polinsky, M.L.; Maglione, M.; and 

Anglin, M.D. Matching clients’ needs 

with drug treatment services. Journal of 

Substance Abuse Treatment 16(4):299–

305, 1999. 

Hubbard, J.R.; Everett, A.S.; and Khan, M.A. 

Alcohol and drug abuse in patients with 

physical disabilities. American Journal of 

Drug Abuse 22(2):215–231, 1996. 

Humphreys, K.; Moos, R.H.; and Cohen, 

G. Social and community resources 

and long-term recovery from treated 

and untreated alcoholism. Journal of 

Alcoholism Studies 58:231–238, 1997. 

Hurt, R.D.; Offord, K.P.; Croghan, I.T.; 

Gomez-Dahl, L.; Kottke, T.E.; Morse, 

M.E.; and Melton, L.J., III. Mortality following inpatient addictions treatment: 

Role of tobacco use in a communitybased cohort. JAMA 275:1097–1103, 

1996. 

Inciardi, J.A. A Corrections-Based Continuum 

of Effective Drug Abuse Treatment: 

Research Preview. Washington, DC: 

National Institute of Justice, U.S. 

Department of Justice, June 1996. 

Institute of Medicine. Bridging the Gap 

Between Practice and Research: 

Forging Partnerships With CommunityBased Drug and Alcohol Treatment.

Washington, DC: National Academy 

Press, 1998. 

Irvin, J.E.; Bowers, C.A.; Dunn, M.E.; and 

Wang, M.C. Efficacy of relapse prevention: A meta-analytic review. Journal 

of Consulting and Clinical Psychology

67:563–570, 1999. 

Jaffe, J.H., and O’Keefe, C. From morphine 

clinics to buprenorphine: Regulating 

opioid agonist treatment of addiction 

in the United States. Drug and Alcohol 

Dependence 70:S3–S11, 2003. 

Jainchill, N. Substance dependency treatment for adolescents: Practice and 

research. Substance Use & Misuse 35(12–

14):2031–2060, 2000. 

Jezewski, M.A., and Sotnik, P. Culture 

Brokering: Providing Culturally 

Competent Rehabilitation Services to 

Foreign-Born Persons. Buffalo, NY: 

Center for International Rehabilitation 

Research Information and Exchange, 

2001. cirrie.buffalo.edu/cbrokering.html 

[accessed February 11, 2004].

Joe, G.W.; Simpson, D.D.; and Broome, K.M. 

Effects of readiness for drug abuse treatment on client retention and assessment 

of process. Addiction 93:1177–1190, 

1998.

Johnson, K.M., and Beale, C.L. The rural 

rebound. Wilson Quarterly 22(2):16–27, 

1998.

Johnson, J.L., and Leff, M. Children of substance abusers: Overview of research 

findings. Pediatrics 103:1085–1099, 

1999. 

Johnson, R.E., and McCagh, J.C. 

Buprenorphine and naloxone for heroin 

dependence. Current Psychiatry Reports 

2:519–526, 2000.

Johnson, R.E.; Strain, E.C.; and Amass, L. 

Buprenorphine: How to use it right. Drug 

and Alcohol Dependence 70:S59–S77, 

2003.
Bibliography 221

Jordan, L.C.; Davidson, W.S.; Herman, S.E.; 

and Boots Miller, B.J. Involvement in 12-

Step programs among persons with dual 

diagnoses. Psychiatric Services 53:894–

896, 2002. 

Joyner, L.M.; Wright, J.D.; and Devine, J.A. 

Reliability and validity of the Addiction 

Severity Index among homeless substance misusers. Substance Use & Misuse

31(6):729–751, 1996. 

Kadden, R.; Carroll, K.M.; Donovan, D.; 

Cooney, N.; Monti, P.; Abrams, D.; Litt, 

M.; and Hester, R., eds. Cognitive–

Behavioral Coping Skills Therapy 

Manual: A Clinical Research Guide for 

Therapists Treating Individuals With 

Alcohol Abuse and Dependence. Project 

MATCH Monograph Series, Volume 3. 

NIH Publication No. 94–3724. Bethesda, 

MD: National Institute on Alcohol Abuse 

and Alcoholism, 1995. 

Kandel, D.B.; Johnson, J.G.; Bird, H.R.; 

Weissman, M.M.; Goodman, S.H.; Lahey, 

B.B.; Regier, D.A.; and Schwab-Stone, 

M.E. Psychiatric comorbidity among 

adolescents with substance use disorders: 

Findings from the MECA study. Journal 

of the American Academy of Child and 

Adolescent Psychiatry 38:693–699, 1999. 

Karageorge, K. Mental Health Status of 

Male and Female Clients Before and 

After Substance Abuse Treatment. NEDS 

Fact Sheet 135. Fairfax, VA: National 

Evaluation Data Services, 2002. 

Katz, E.C.; Gruber, K.; Chutuape, M.A.; and 

Stitzer, M.L. Reinforcement-based outpatient treatment for opiate and cocaine 

abusers. Journal of Substance Abuse 

Treatment 20(1):93–98, January 2001. 

Kavanagh, K., and Kennedy, P.H. Promoting 

Cultural Diversity: Strategies for Health 

Care Professionals. Thousand Oaks, CA: 

Sage Publications, 1992. 

Kelly, J.F.; McKellar, J.D.; and Moos, R. 

Major depression in patients with substance use disorders: Relationship to 12-

Step self-help involvement and substance 

use outcomes. Addiction 98(4):499–508, 

2003. 

Kelly, R.C.; Mieczkowski, T.; and Sweeney, 

S.A. Hair analysis for drugs of abuse. 

Hair color and race differentials or systematic differences in drug preferences? 

Forensic Science International 107(1–

3):63–86, 2000. 

Kessler, R.C.; Nelson, C.B.; McGonagle, K.A.; 

Edlund, M.H.; Frank, R.G.; and Leaf, P.J. 

The epidemiology of co-occurring addictive and mental disorders: Implications 

for prevention and service utilization. 

American Journal of Orthopsychiatry

66(1):17–31, 1996. 

Kirby, K.C.; Amass, L.; and McLellan, A.T. 

Disseminating contingency management 

research to drug abuse treatment practitioners. In: Higgins, S.T., and Silverman, 

K., eds. Motivating Behavior Change 

Among Illicit-Drug Abusers: Research on 

Contingency Management Interventions.

Washington, DC: American Psychological 

Association, 1999a, pp. 327–344. 

Kirby, K.C.; Marlowe, D.B.; Festinger, 

D.S.; Garvey, K.A.; and LaMonaca, V. 

Community reinforcement training for 

family and significant others of drug 

abusers: A unilateral intervention to 

increase treatment entry of drug users. 

Drug and Alcohol Dependence 56:85–96, 

1999b. 

Kirby, K.C.; Marlowe, D.B.; Festinger, D.S.; 

Lamb, R.J.; and Platt, J.J. Schedule of 

voucher delivery influences initiation of 

cocaine abstinence. Journal of Consulting 

and Clinical Psychology 66(5):761–767, 

1998. 

Kohn, C.S.; Tsoh, J.Y.; and Weisner, C.M. 

Changes in smoking status among substance abusers: Baseline characteristics 

and abstinence from alcohol and drugs 

at 12-month follow-up. Drug and Alcohol 

Dependence 69:61–71, 2003. 
222 Appendix A

Korper, S.P., and Council, C.L., eds. 

Substance Use by Older Adults: Estimates 

of Future Impact on the Treatment 

System. Analytic Series A-21. DHHS 

Publication No. (SMA) 03–3763. 

Rockville, MD: Office of Applied Studies, 

Substance Abuse and Mental Health 

Services Administration, 2002. 

Kremer, D.; Malkin, M.J.; and Benshoff, J.J. 

Physical activity programs offered in substance abuse treatment facilities. Journal 

of Substance Abuse Treatment 12:327–

333, 1995. 

Krestan, J.-A., ed. Bridges to Recovery: 

Addiction, Family Therapy, and 

Multicultural Treatment. New York: Free 

Press, 2000. 

Krystal, J.H.; Cramer, J.A.; Krol, W.F.; Kirk, 

G.F.; and Rosenheck, R.A. Naltrexone 

in the treatment of alcohol dependence. 

New England Journal of Medicine

345(24):1734–1739, 2001. 

Kurasaki, K.S.; Okazaki, S.; and Sue, S., 

eds. Asian American Mental Health: 

Assessment Theories and Methods. New 

York: Plenum, 2002. 

Kus, R.J., ed. Addiction and Recovery in Gay 

and Lesbian Persons. New York: Haworth 

Press, 1995.

Laken, M.P., and Ager, J.W. Effects of case 

management on retention in prenatal 

substance abuse treatment. American 

Journal of Drug and Alcohol Abuse

22:439–448, 1996. 

Laken, M.P.; McComish, J.F.; and Ager, J. 

Predictors of prenatal substance use and 

birth weight during outpatient treatment. 

Journal of Substance Abuse Treatment

14:359–366, 1997. 

Langan, N.P., and Pelissier, B.M. Gender 

differences among prisoners in drug 

treatment. Journal of Substance Abuse

13:291–301, 2001. 

LaPlante, M.P.; Kennedy, J.; Kaye, H.S.; 

and Wenger, B.L. Disability and employment. Disability Statistics Abstract. 

Number 11. San Francisco: Disability 

Statistics Center, 1996. dsc.ucsf.edu/pdf/

abstract11.pdf [accessed February 11, 

2004].

Latimer, W.W.; Winters, K.C.; D’Zurilla, T.; 

and Nichols, M. Integrated family and 

cognitive–behavioral therapy for adolescent substance abusers: A stage I efficacy 

study. Drug and Alcohol Dependence

71(3):303–317, 2003.

Laudet, A.; Magura, S.; Furst, R.T.; and 

Kumar, N. Male partners of substanceabusing women in treatment: An exploratory study. American Journal of Drug 

and Alcohol Abuse 25(4):607–627, 1999. 

Laudet, A.; Magura, S.; Vogel, H.; and 

Knight, E. Twelve Month Follow-up on 

Members of a Dual Recovery Self-help 

Program. Poster presented at the 128th 

Annual Meeting of the American Public 

Health Association, Boston, November 

2000a. 

Laudet, A.B.; Magura, S.; Vogel, H.S.; and 

Knight, E. Recovery challenges among 

dually diagnosed individuals. Journal of 

Substance Abuse Treatment 18(4):321–

329, 2000b.

La Veist, T.A.; Diala, C.; and Jarrett, N.C. 

Social status and perceived discrimination: Who experiences discrimination 

in the health care system, how, and 

why? In: Hogue, C.J.R.; Hargraves, M.A.; 

and Collins, K.S., eds. Minority Health 

in America. Baltimore: Johns Hopkins 

University Press, 2000, pp. 194–208. 

Lawental, E.; McLellan, A.T.; Grissom, G.; 

Brill, P.; and O’Brien, C.P. Coerced 

treatment for substance abuse problems 

detected through workplace urine surveillance: Is it effective? Journal of Substance 

Abuse 8(1):115–128, 1996. 

Legal Action Center. Steps to Success: 

Helping Women With Alcohol and Drug 
Bibliography 223

Problems Move From Welfare to Work.

New York: Legal Action Center, 1999. 

Leonhard, C.; Mulvey, K.; Gastfriend, D.R.; 

and Shwartz, M. The Addiction Severity 

Index: A field study of internal consistency and validity. Journal of Substance 

Abuse Treatment 18(2):129–135, 2000.

Liddle, H.A. Theory development in a 

family-based therapy for adolescent 

drug abuse. Journal of Clinical Child 

Psychology 28(4):521–532, 1999. 

Liddle, H.A. Multidimensional Family 

Therapy for Adolescent Cannabis Users.

Cannabis Youth Treatment Series, 

Volume 5. DHHS Publication No. (SMA) 

02–3660. Rockville, MD: Center for 

Substance Abuse Treatment, Substance 

Abuse and Mental Health Services 

Administration, 2002. 

Liddle, H.A.; Dakof, G.A.; Parker, K.; 

Diamond, G.S.; Barrett, K.; and Tejeda, 

M. Multidimensional family therapy for 

adolescent drug abuse: Results of a randomized clinical trial. American Journal 

of Drug and Alcohol Abuse 27(4):651–

688, 2001.

Ling, W.; Charuvastra, C.; Collins, J.F.; Batki, 

S.; Brown, L.S., Jr.; Kintaudi, P.; Wesson, 

D.R.; McNicholas, L.; Tusel, D.J.; 

Malkerneker, U.; Renner, J.A., Jr.; Santos, 

E.; Casadonte, P.; Fye, C.; Stine, S.; 

Wang, R.I.; and Segal, D. Buprenorphine 

maintenance treatment of opiate dependence: A multicenter, randomized clinical trial. Addiction 93(4):475–486, 1998. 

Longabaugh, R.; Wirtz, P.W.; Zweben, A.; 

and Stout, R.L. Network support for 

drinking, Alcoholics Anonymous and 

long-term matching effects. Addiction

93:1313–1333, 1998. 

Loustaunau, M.O., and Sobo, E.J. The 

Cultural Context of Health, Illness, and 

Medicine. Westport, CT: Bergin & Garvey, 

1997.

Macdonald, D.I., and Kaplan, D.J. The role 

of the substance abuse professional. 

In: Graham, A.W.; Schultz, T.K.; MayoSmith, M.F.; Ries, R.K.; and Wilford, 

B.B., eds. Principles of Addiction 

Medicine, Third Edition. Chevy Chase, 

MD: American Society of Addiction 

Medicine, 2003, pp. 987–992. 

Magerl, H., and Schulz, E. Methods of Saliva 

Analysis and the Relationship Between 

Saliva and Blood Concentration. 

Paper presented at 13th International 

Conference on Alcohol, Drugs and 

Traffic Safety, Adelaide, Australia, 

August 13–18, 1995. www.druglibrary.

org/schaffer/Misc/driving/s3p1.htm 

[accessed February 11, 2004]. 

Magura, S.; Laudet, A.B.; Mahmood, D.; 

Rosenblum, A.; Vogel, H.S.; and Knight, 

E.L. Role of self-help processes in achieving abstinence among dually diagnosed 

persons. Addictive Behaviors 28(3):399–

413, 2003. 

Magura, S.; Nwakeze, P.C.; Rosenblum, A.; 

and Joseph, H. Substance misuse and 

related infectious diseases in a soup 

kitchen population. Substance Use & 

Misuse 35(4):551–583, 2000.

Mann, K.; Lehert, P.; and Morgan, M.Y. 

The efficacy of acamprosate in the 

maintenance of abstinence in alcoholdependent individuals: Results of a 

meta-analysis. Alcoholism, Clinical and 

Experimental Research 28(1):51–63, 

2004. 

Marlatt, G.A., and Gordon, J.R., eds. Relapse 

Prevention: Maintenance Strategies in the 

Treatment of Addictive Behaviors. New 

York: Guilford Press, 1985. 

Marlatt, G.A., and Kristeller, J.L. 

Mindfulness and meditation. In: Miller, 

W.M., ed. Integrating Spirituality Into 

Treatment: Resources for Practitioners.

Washington, DC: American Psychological 

Association, 1999. 
224 Appendix A

Marlowe, D.B.; DeMatteo, D.S.; Lamb, R.J.; 

and Festinger, D.S. A sober assessment of 

drug courts. Federal Sentencing Reporter

16(2):153–157, 2003. 

Marlowe, D.B.; Husband, S.D.; Lamb, R.J.; 

Kirby, K.C.; Iguchi, M.Y.; and Platt, 

J.J. Psychiatric comorbidity in cocaine 

dependence. American Journal on 

Addictions 4:70–81, 1995. 

Marlowe, D.B.; Kirby, K.C.; Bonieskie, L.M.; 

Glass, D.J.; Dodds, L.D.; Husband, S.D.; 

Platt, J.J.; and Festinger, D.S. Assessment 

of coercive and noncoercive pressures to 

enter drug abuse treatment. Drug and 

Alcohol Dependence 42(2):77–84, 1996. 

Marsh, J.C.; D’Aunno, T.A.; and Smith, B.D. 

Increasing access and providing social 

services to improve drug abuse treatment for women with children. Addiction

95:1237–1247, 2000. 

Martin, C.S., and Winters, K.C. Diagnosis 

and assessment of alcohol use disorders among adolescents. Alcohol and 

Youth 22:95–105, 1998. www.niaaa.nih.

gov/publications/arh22-2/95-106.pdf 

[accessed March 3, 2004].

Martin, D.J.; Garske, J.P.; and Davis, M.K. 

Relation of the therapeutic alliance with 

outcome and other variables: A metaanalytic review. Journal of Consulting 

and Clinical Psychology 68:438–450, 

2000. 

Martino, S.; Carroll, K.M.; O’Malley, S.S.; 

and Rounsaville, B.J. Motivational interviewing with psychiatrically ill substance 

abusing patients. American Journal on 

Addictions 9(1):88–91, 2000. 

Maruschak, L.M. HIV in prisons, 2000. 

Bureau of Justice Statistics Bulletin. 

Washington, DC: Office of Justice 

Programs, October 2002, revised 

February 2003. www.ojp.usdoj.gov/bjs/

abstract/hivp00.htm [accessed February 

11, 2004].

Matrix Center. The Matrix Model of 

Outpatient Chemical Dependency 

Treatment: Family Education Guidelines 

and Handouts. Los Angeles: The Matrix 

Center, 1989. 

McCaul, M.E.; Svikis, D.S.; and Moore, R.D. 

Predictors of outpatient treatment retention: Patient versus substance use characteristics. Drug and Alcohol Dependence

62(1):9–17, 2001. 

McCrady, B.S. Recent research in twelve step 

programs. In: Graham, A.W.; Schultz, 

T.K.; and Wilford, B.B, eds. Principles 

of Addiction Medicine, Second Edition. 

Chevy Chase, MD: American Society of 

Addiction Medicine, 1998, pp. 707–717. 

McCrady, B.S.; Epstein, E.E.; and Hirsch, 

L.S. Maintaining change after conjoint behavioral alcohol treatment for 

men: Outcomes at 6 months. Addiction 

94(9):1381–1396, 1999. 

McCrady, B.S., and Miller, W.R., eds. 

Research on Alcoholics Anonymous: 

Opportunities and Alternatives. New 

Brunswick, NJ: Rutgers Center of Alcohol 

Studies, 1993. 

McKay, J.R.; Alterman, A.I.; Cacciola, J.S.; 

Rutherford, M.J.; O’Brien, C.P.; and 

Koppenhaver, J. Group counseling versus individualized relapse prevention 

aftercare following intensive outpatient 

treatment for cocaine dependence: 

Initial results. Journal of Consulting and 

Clinical Psychology 65(5):778–788, 1997. 

McKay, J.R.; Alterman, A.I.; and Rutherford, 

M.J. The relationship of alcohol use to 

cocaine relapse in cocaine dependent 

patients in an aftercare study. Journal of 

Studies on Alcohol 60(2):176–180, 1999. 

McKay, J.R.; Lynch, K.G.; Shepard, D.S.; 

and Pettinati, H.M. The effectiveness of 

telephone-based continuing care for alcohol and cocaine dependence: 24-month 

outcomes. Archives of General Psychiatry 

62(2):199–207, 2005.
Bibliography 225

McKinnon, J. The Black population 

in the United States: March 2002. 

Current Population Reports. P20–541. 

Washington, DC: U.S. Census Bureau, 

2003.

McLellan, A.T.; Cacciola, J.; Kushner, H.; 

Peters, R.; Smith, I.; and Pettinati, 

H. The fifth edition of the Addiction 

Severity Index: Cautions, additions and 

normative data. Journal of Substance 

Abuse Treatment 9:461–480, 1992a. 

McLellan, A.T.; Hagan, T.A.; Levine, M.; 

Gould, F.; Meyers, K.; Bencivengo, M.; 

and Durell, J. Supplemental social services improve outcomes in public addiction treatment. Addiction 93:1489–1499, 

1998. 

McLellan, A.T.; Hagan, T.A.; Levine, M.; 

Meyers, K.; Gould, F.; Bencivengo, M.; 

Durell, J.; and Jaffee, J. Does clinical 

case management improve outpatient 

addiction treatment? Drug and Alcohol 

Dependence 55:91–103, 1999. 

McLellan, A.T.; Hagan, T.A.; Meyers, K.; 

Randall, M.; and Durell, J. “Intensive” 

outpatient substance abuse treatment: 

Comparisons with “traditional” outpatient treatment. Journal of Addictive 

Diseases 16(2):57–84, 1997.

McLellan, A.T.; Kushner, H.; and Metzger, 

D. The fifth edition of the Addiction 

Severity Index. Journal of Substance 

Abuse Treatment 9:199–213, 1992b. 

McLellan, A.T.; Lewis, D.C.; O’Brien, C.P.; 

and Kleber, H.D. Drug dependence, a 

chronic medical illness: Implications for 

treatment, insurance, and outcomes evaluation. JAMA 284(13):1689–1695, 2000. 

Mee-Lee, D., and Shulman, G.D. The ASAM 

placement criteria and matching patients 

to treatment. In: Graham, A.W.; Schultz, 

T.K.; Mayo-Smith, M.F.; Ries, R.K.; and 

Wilford, B.B., eds. Principles of Addiction 

Medicine, Third Edition. Chevy Chase, 

MD: American Society of Addiction 

Medicine, 2003, pp. 453–465. 

Mee-Lee, D.; Shulman, G.D.; Callahan, J.F.; 

Fishman, M.; Gastfriend, D.; Hartman, 

R.; and Hunsicker, R.J., eds. Patient 

Placement Criteria for the Treatment 

of Substance-Related Disorders: Second 

Edition-Revised (PPC-2R). Chevy Chase, 

MD: American Society of Addiction 

Medicine, 2001. 

Meezan, W., and O’Keefe, M. Multifamily 

group therapy: Impact on family functioning and child behavior. Families in 

Society 79(1):32–44, 1998. 

Meissen, G.; Powell, T.J.; Wituk, S.A.; 

Girrens, K.; and Arteaga, S. Attitudes of 

AA contact persons toward group participation by persons with a mental illness. 

Psychiatric Services 50(8):1079–1081, 

1999. 

Mendelson, J., and Jones, R.T. Clinical and 

pharmacological evaluation of buprenorphine and naloxone combinations: Why 

the 4:1 ratio for treatment. Drug and 

Alcohol Dependence 70:S29–S37, 2003. 

Mendelson, J.; Jones, R.T.; Welm, S.; Baggott, 

M.; Fernandez, I.; Melby, A.K.; and Nath, 

R.P. Buprenorphine and naloxone combinations: The effects of three dose ratios 

in morphine-stabilized, opiate-dependent 

volunteers. Psychopharmacology 141:37–

46, 1999. 

Mercer, D. Description of an addiction counseling approach. In: Carroll, K.M., ed.

Approaches to Drug Abuse Counseling.

NIH Publication No. 00–4151. Rockville, 

MD: National Institute on Drug Abuse, 

2000, pp. 81–90. 

Mercer, D., and Woody, G.E. An Individual 

Drug Counseling Approach to Treating 

Cocaine Addiction: The Collaborative 

Cocaine Treatment Study Model. Manual 

3: Therapy Manuals for Drug Addiction. 

NIH Publication No. 99–4380. Rockville, 

MD: National Institute on Drug Abuse, 

1999. 

Merikangas, K.R.; Mehta, R.L.; Molnar, B.E.; 

Walters, E.E.; Swendsen, J.D.; Aguilar-
226 Appendix A

Gaziola, S.; Bijl, R.; Borges, G.; CaraveoAnduaga, J.J.; Dewitt, D.J.; Kolody, B.; 

Vega, W.A.; Wittchen, H.-U.; and Kessler, 

R.C. Comorbidity of substance use disorders with mood and anxiety disorders: 

Results of the international consortium 

in psychiatric epidemiology. Addictive 

Behaviors 23:893–907, 1998. 

Metsch, L.R., and McCoy, C.B. Drug treatment experiences: Rural and urban 

comparisons. Substance Use & Misuse 

34(4&5):763–784, 1999. 

Meyers, R.J.; Miller, W.R.; Hill, D.E.; and 

Tonigan, J.S. Community reinforcement 

and family training (CRAFT): Engaging 

unmotivated drug users in treatment. 

Journal of Substance Abuse 10:291–308, 

1998. 

Meyers, R.J.; Miller, W.R.; Smith, J.E.; and 

Tonigan, J.S. A randomized trial of two 

methods for engaging treatment-refusing 

drug users through concerned significant 

others. Journal of Consulting and Clinical 

Psychology 70:1182–1185, 2002. 

Meyers, R.J.; Smith, J.E.; and Lash, D.N. The 

community reinforcement approach. 

Recent Developments in Alcoholism 

16:183–195, 2003. 

Mid-America Addiction Technology Transfer 

Center (MATTC). Psychotherapeutic 

Medications 2003: What Every Counselor 

Should Know. Kansas City, MO: MATTC, 

2000. 134.193.108.18/MATTC/

information/mattcProds.asp [accessed 

February 11, 2004]. 

Mieczkowski, T., and Newel, R. Patterns of 

concordance between hair assays and 

urinalysis for cocaine: Longitudinal analysis of probationers in Pinellas County, 

Florida. In: Harrison, L., and Hughes, 

A., eds. Validity of Self-Reported Drug 

Use: Improving the Accuracy of Survey 

Estimates. NIDA Research Monograph 

167. NTIS Publication No. 97–4147. 

Rockville, MD: National Institute on 

Drug Abuse, 1997, pp. 161–199. 

Mieczkowski, T.; Newel, R.; and Wraight, B. 

Using hair analysis, urinalysis, and selfreports to estimate drug use in a sample 

of detained juveniles. Substance Use & 

Misuse 33(7):1547–1567, 1998. 

Miele, G.M.; Carpenter, K.M.; Cockerham, 

M.S.; Trautman, K.D.; Blaine, J.; and 

Hasin, D.S. Substance Dependence 

Severity Scale (SDSS): Reliability and 

validity of a clinician-administered interview for DSM-IV substance use disorders. 

Drug and Alcohol Dependence 59:63–75, 

2000. 

Milby, J.B.; Schumacher, J.E.; Raczynski, 

J.M.; Caldwell, E.; Engle, M.; Michael, 

M.; and Carr, J. Sufficient conditions for 

effective treatment of substance abusing homeless persons. Drug and Alcohol 

Dependence 43:39–47, 1996. 

Miller, B.A. Partner violence experiences 

and women’s drug use: Exploring the 

connections. In: Wetherington, C.L., 

and Roman, A.B., eds. Drug Addiction 

Research and the Health of Women. 

Rockville, MD: National Institute on 

Drug Abuse, 1998, pp. 407–416. 

Miller, M.M. Traditional approaches to the 

treatment of addiction. In: Graham, 

A.W.; Schultz, T.K.; and Wilford, B.B, 

eds. Principles of Addiction Medicine, 

Second Edition. Chevy Chase, MD: 

American Society of Addiction Medicine, 

1998, pp. 315–326. 

Miller, N.S.; Ninonuero, F.G.; Klamen, 

D.L.; Hoffmann, N.G.; and Smith, D.E. 

Integration of treatment and posttreatment variables in predicting results of 

abstinence-based outpatient treatment 

after one year. Journal of Psychoactive 

Drugs 29(3):239–248, 1997.

Miller, W.R., and Rollnick, S. Motivational 

Interviewing: Preparing People for 

Change, Second Edition. New York: 

Guilford Press, 2002. 

Miller, W.R., and Sanchez, V.C. Motivating 

young adults for treatment and lifestyle 
Bibliography 227

change. In: Howard, G.S., and Nathan, 

P.E., eds. Alcohol Use and Misuse by 

Young Adults. Notre Dame, IN: University 

of Notre Dame Press, 1994, pp. 55–81. 

Miller, W.R., and Tonigan, J.S. Assessing 

drinkers’ motivation to change: The 

States of Change Readiness and 

Treatment Eagerness Scale (SOCRATES). 

Psychology of Addictive Behaviors

10(2):81–89, 1996. 

Miller, W.R.; Tonigan, J.S.; and Montgomery, 

H.A. Assessment of Client Motivation 

for Change: Preliminary Validation 

of the SOCRATES (Rev.) Instrument.

Albuquerque, NM: University of New 

Mexico, 1990. 

Minkoff, K. An integrated treatment model 

for dual diagnosis of psychosis and 

addiction. Hospital and Community 

Psychiatry 40(10):1031–1036, 1989.

Minkoff, K. Models for addiction treatment 

in psychiatric populations. Psychiatric 

Annals 24(8):412–417, 1994. 

Minkoff, K. Integration of addiction and 

psychiatric services. In: Minkoff, K., and 

Pollack, D., eds. Managed Mental Health 

Care in the Public Sector: A Survival 

Manual. The Netherlands: Harwood 

Academic Publishers, 1997, pp. 233–246. 

Minkoff, K. Dual Diagnosis: An Integrated 

Model for the Treatment of People With 

Co-Occurring Psychiatric and Substance 

Disorders in Managed Care Systems. 

Presentation at Building the Bridge: 

The Integration of Mental Health and 

Substance Abuse Services, Baltimore, 

August 5–7, 2002. 

Moggi, F.; Ouimette, P.C.; Finney, J.W.; and 

Moos, R.H. Effectiveness of treatment 

for substance abuse and dependence for 

dual diagnosis patients: A model of treatment factors associated with one-year 

outcomes. Journal of Studies on Alcohol

60(6):856–866, 1999. 

Mok, D.; Matthews, L.; and Mendoza, J. 

Changing American ethnic minority 

families: Highlights on Asian American, 

African American, and Hispanic/Latino 

Families. The Family Psychologist 

19(3):4–9, 2003.

Moore, D., and Li, L. Prevalence and risk 

factors of illicit drug use by people 

with disabilities. American Journal on 

Addictions 7(2):93–102, 1998. 

Moos, R.; Schaefer, J.; Andrassy, J; and 

Moos, B. Outpatient mental health care, 

self-help groups, and patients’ one-year 

treatment outcomes. Journal of Clinical 

Psychology 57:273–287, 2001. 

Moos, R.H.; Finney, J.W.; Ouimette, P.C.; 

and Suchinsky, R.T. A comparative 

evaluation of substance abuse treatment: 

I. Treatment orientation, amount of care, 

and 1-year outcomes. Alcoholism, Clinical 

and Experimental Research 23(3):529–

536, 1999. 

Moos, R.H., and Moos, B.S. Long-term influence of duration and intensity of treatment on previously untreated individuals 

with alcohol use disorders. Addiction

98:325–337, 2003. 

Morral, A.R.; Iguchi, M.Y.; and Belding, M.A. 

Reducing drug use by encouraging alternative behaviors. In: Higgins, S.T., and 

Silverman, K., eds. Motivating Behavior 

Change Among Illicit-Drug Abusers: 

Research on Contingency Management 

Interventions. Washington, DC: American 

Psychological Association, 1999, pp. 

203–220. 

Mulvey, K.P.; Hubbard, S.; and Hayashi, 

S. A national study of the substance 

abuse treatment workforce. Journal of 

Substance Abuse Treatment 24:51–57, 

2003. 

Mumola, C.J. Substance abuse and treatment, State and Federal prisoners, 

1997. Bureau of Justice Statistics Special 

Report. Washington, DC: Office of Justice 

Programs, January 1999. www.ojp.usdoj.
228 Appendix A

gov/bjs/abstract/satsfp97.htm [accessed 

February 11, 2004]. 

Mumola, C.J. Incarcerated parents and their 

children. Bureau of Justice Statistics 

Special Report. Washington, DC: Office 

of Justice Programs, August 2000. www.

ojp.usdoj.gov/bjs/abstract/iptc.htm 

[accessed February 11, 2004].

Narcotics Anonymous. In Cooperation With 

Therapeutic Communities Worldwide. 

Presentation to the World Federation of 

Therapeutic Communities Conference, 

Cartagena, Colombia, February 1998. 

www.na.org/prespapers/in-cooperation.

htm [accessed April 15, 2004].

Nardi, D. Addiction recovery for low-income 

pregnant and parenting women: A process of becoming. Archives of Psychiatric 

Nursing 12(2):81–89, 1998. 

National Alliance for Hispanic Health. 

Quality Health Services for Hispanics: 

The Cultural Competency Component. 

DHHS Publication No. 99–21. 

Washington, DC: U.S. Department of 

Health and Human Services, 2000. 

National Clearinghouse on Child Abuse and 

Neglect Information. Substance Abuse 

and Child Maltreatment. Washington, 

DC: U.S. Department of Health and 

Human Services, 2003. nccanch.acf.hhs.

gov/pubs/factsheets/subabuse_childmal.

cfm [accessed May 25, 2006].

National Institute of Justice. 1996–1997 

Update: HIV/AIDS, STDs, and TB in 

Correctional Facilities. Washington, DC: 

U.S. Department of Justice, July 1999. 

www.ojp.gov/80/nij/pubs-sum/176344.

htm [accessed February 11, 2004].

National Institute on Alcohol Abuse and 

Alcoholism. Alcohol use among special populations (special issue). Alcohol 

Health & Research World 22(4), 1998. 

National Institute on Drug Abuse (NIDA). 

Assessing Drug Abuse Among Adolescents 

and Adults: Standardized Instruments.

The Clinical Report Series. NIH 

Publication No. 94–3757. Rockville, MD: 

NIDA, 1994. 

National Institute on Drug Abuse (NIDA). 

Principles of Drug Addiction Treatment: A 

Research-Based Guide. NIH Publication 

No. 99–4180. Rockville, MD: NIDA, 

1999, reprinted 2000. 

National Institute on Drug Abuse (NIDA). 

Therapeutic community. NIDA Research 

Report Series. NIH Publication No. 02–

4877. Rockville, MD: NIDA, 2002. 

Naumann, P.; Langford, D.; Torres, S.; 

Campbell, J.; and Glass, N. Women battering in primary care practice. Family 

Practice 16(4):343–352, 1999.

Nebelkopf, E.; Philips, M.; and Native 

American Health Center Staff. Morning 

star rising: Healing in Native American 

communities (special issue). Journal of 

Psychoactive Drugs 35(1), 2003. 

Nowinski, J.; Baker, S.; and Carroll, K.M. 

Twelve Step Facilitation Therapy 

Manual: A Clinical Research Guide 

for Therapists Treating Individuals 

With Alcohol Abuse and Dependence.

NIAAA Project MATCH Monograph 

Series, Volume 1. DHHS Publication 

No. (ADM) 92–1893. Bethesda, MD: 

National Institute on Alcohol Abuse and 

Alcoholism, 1992, reprinted 1994 and 

1999. 

Obert, J.L.; McCann, M.J.; Marinelli-Casey, 

P.; Weiner, A.; Minsky, S.; Brethen, P.; 

and Rawson, R. The matrix model of 

outpatient stimulant abuse treatment: 

History and description. Journal of 

Psychoactive Drugs 32(2):157–164, 2000. 

O’Connor, P.G.; Oliveto, A.H.; Shi, J.M.; 

Triffleman, E.G.; Carroll, K.M.; Kosten, 

T.R.; Rounsaville, B.J.; Pakes, J.A.; and 

Schottenfeld, R.S. A randomized trial of 

buprenorphine maintenance for heroin 

dependence in a primary care clinic for 

substance users versus a methadone 
Bibliography 229

clinic. American Journal of Medicine

105:100–105, 1998. 

O’Farrell, T.J.; Choquette, K.A.; and Cutter, 

H.S.G. Couples relapse prevention sessions after behavioral marital therapy 

for male alcoholics: Outcomes during 

the three years after starting treatment. 

Journal of Studies on Alcohol 59(4):357–

370, 1998. 

O’Farrell, T.J., and Fals-Stewart, W. 

Family-involved alcoholism treatment: 

An update. Recent Developments in 

Alcoholism 15:329–356, 2001. 

O’Farrell, T.J., and Fals-Stewart, W. 

Behavioral couples therapy for alcoholism and drug abuse. Journal of 

Substance Abuse Treatment 18:51–54, 

2002. 

O’Farrell, T.J., and Fals-Stewart, W.A. 

Alcohol abuse. Journal of Marital and 

Family Therapy 29(1):121–146, 2003. 

Office of Applied Studies. Summary of 

Findings From the 2000 National 

Household Survey on Drug Abuse.

NHSDA Series H–13. DHHS Publication 

No. (SMA) 01–3549. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, 2001. www.

samhsa.gov/oas/NHSDA/2kNHSDA/

2kNHSDA.htm [accessed February 11, 

2004].

Office of Applied Studies. Treatment 

Episode Data Set (TEDS): 1992–2000, 

National Admissions to Substance Abuse 

Treatment Services. DASIS Series: S-17, 

DHHS Publication No. (SMA) 02–3727. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

2002. wwwdasis.samhsa.gov/teds00/

TEDS_2k_index.htm [accessed February 

11, 2004].

Office of Applied Studies. The DASIS Report: 

Admissions of Persons With Co-Occurring 

Disorders, 2000. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, April 2003a. 

www.samhsa.gov/oas/2k3/dualTX/

dualTX.htm [accessed February 11, 2004].

Office of Applied Studies. The DASIS Report: 

Characteristics of Homeless Admissions 

to Substance Abuse Treatment, 2000.

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

August 8, 2003b. www.samhsa.gov/

oas/2k3/homelessTX/homelessTX.htm 

[accessed February 11, 2004].

Ogunwole, S.U. The American Indian and 

Alaska Native population: 2000. Census 

2000 Brief. C2KBR/01–15. Washington, 

DC: U.S. Census Bureau, 2002.

O’Malley, S.S.; Jaffe, A.J.; Chang, G.; 

Schottenfeld, R.S.; Meyer, R.E.; and 

Rounsaville, B. Naltrexone and coping 

skills therapy for alcohol dependence: 

A controlled study. Archives of General 

Psychiatry 49(11):881–887, 1992. 

Osgood, N.J.; Wood, H.E.; and Parham, I.A., 

eds. Alcoholism and Aging: An Annotated 

Bibliography and Review. Westport, CT: 

Greenwood, 1995. 

Osher, F.C., and Kofoed, L.L. Treatment of 

patients with psychiatric and psychoactive substance abuse disorders. Hospital 

and Community Psychiatry 40(10):1025–

1030, 1989. 

Oslin, D.W.; Pettinati, H.; and Volpicelli, J.R. 

Older age predicts better adherence and 

drinking outcomes. American Journal of 

Geriatric Psychiatry 10:740–747, 2002. 

Ouimette, P.C.; Kimerling, R.; Shaw, J.; and 

Moos, R.H. Physical and sexual abuse 

among women and men with substance 

use disorders. Alcoholism Treatment 

Quarterly 18(3):7–17, 2000.

Owen, P. Minnesota model: Description 

of a counseling approach. In: Carroll, 

K.M., ed. Approaches to Drug Abuse 

Counseling. NIH Publication No. 00–

4151. Rockville, MD: National Institute 

on Drug Abuse, 2000, pp. 117–125. 
230 Appendix A

Paluska, S.A., and Schwenk, T.L. Physical 

activity and mental health: Current concepts. Sports Medicine 29(3):167–180, 

2000.

Perry, M.J., and Mackun, P.J. Population 

change and distribution: 1990 to 

2000. Census 2000 Brief. C2KBR/01-2. 

Washington, DC: U.S. Census Bureau, 

2001.

Peters, R.H.; Greenbaun, P.E.; Steinberg, 

M.L.; Carter, C.R.; Ortiz, M.M.; Fry, B.C.; 

and Valle, S.K. Effectiveness of screening 

instruments in detecting substance use 

disorders among prisoners. Journal of 

Substance Abuse Treatment 18:349–358, 

2000. 

Petrakis, I.L.; Gonzalez, G.; Rosenheck, 

R.; and Krystal, J.H. Comorbidity of 

Alcoholism and Psychiatric Disorders: 

An Overview. Bethesda, MD: National 

Institute on Alcohol Abuse and 

Alcoholism, November 2002. www.niaaa.

nih.gov/publications/arh26-2/81-89.htm 

[accessed February 11, 2004].

Petry, N.M. A comprehensive guide to the 

application of contingency management 

procedures in standard clinic settings. 

Drug and Alcohol Dependence 58:9–25, 

2000. 

Physicians’ Desk Reference (PDR), 53d 

Edition. Montvale, NJ: Medical 

Economics, 2003.

Pickens, R.W.; Battjes, R.; Svikis, D.S.; and 

Gupman, A.E. Substance use risk factors 

for HIV infection. Psychiatric Clinics of 

North America 16:119–125, 1993.

Preston, K.L.; Silverman, K.; and Cone, E.J. 

Monitoring cocaine use during contingency management interventions. In: 

Higgins, S.T., and Silverman, K., eds. 

Motivating Behavior Change Among 

Illicit Drug Abusers. Washington, DC: 

American Psychological Association, 

1999, pp. 283–308. 

Prochaska, J.O., and DiClemente, C.C. The 

Transtheoretical Approach: Crossing 

Traditional Boundaries of Therapy.

Homewood, IL: Dow Jones and Irwin, 

1984. 

Prochaska, J.O., and DiClemente, C.C. 

Toward a comprehensive model of 

change. In: Miller, W.R., and Heather, 

N., eds. Treating Addictive Behaviors: 

Processes of Change. New York: Plenum 

Press, 1986, pp. 3–27. 

Prochaska, J.O., and DiClemente, C.C. Stages 

of change in the modification of problem 

behavior. In: Hersen, M.; Eisler, R.; and 

Miller, P.M., eds. Progress in Behavior 

Modification. Sycamore, IL: Sycamore 

Publishing, 1992. 

Prochaska, J.O.; Norcross, J.C.; and 

DiClemente, C.C. Changing for Good.

New York: William Morrow, 1994. 

Project MATCH Research Group. Matching 

alcoholism treatments to client heterogeneity: Project MATCH posttreatment 

drinking outcomes. Journal of Studies on 

Alcohol 58:7–29, 1997. 

Project MATCH Research Group. Matching 

alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism, Clinical and 

Experimental Research 22:1300–1311, 

1998. 

Ramirez, R.R., and de la Cruz, G.P. The 

Hispanic population in the United 

States: March 2002. Current Population 

Reports, P20–545. Washington, DC: U.S. 

Census Bureau, 2003. 

Rawson, R.A. Welcome to the ISAP news. 

ISAP News 1(1):1, 2003. www.uclaisap.

org/newsletter/documents/May-2003-

ISAP-News.pdf [accessed February 11, 

2004].

Rawson, R.A.; Huber, A.; Brethen, P.; Obert, 

J.; Gulati, V.; Shoptaw, S.; and Ling, W. 

Status of methamphetamine users 2–5 
Bibliography 231

years after outpatient treatment. Journal 

of Addictive Diseases 21:107–119, 2002. 

Rawson, R.A.; Obert, J.L.; McCann, M.J.; and 

Mann, A.J. Cocaine treatment outcome: 

Cocaine use following inpatient, outpatient, and no treatment. In: Harris, L.S., 

ed. Problems of Drug Dependence, 1985: 

Proceedings of the 47th Annual Scientific 

Meeting, the Committee on Problems of 

Drug Dependence, Inc. NIDA Research 

Monograph 67. Rockville, MD: National 

Institute on Drug Abuse, 1986, pp. 271–

277. 

Reeves, T., and Bennett, C. The Asian and 

Pacific Islander population in the United 

States: March 2002. Current Population 

Reports, P20–540. Washington, DC: U.S. 

Census Bureau, 2003. 

Reoux, J.P., and Miller, K. Routine hospital 

alcohol detoxification practice compared 

to symptom triggered management with 

an objective withdrawal scale (CIWA-Ar). 

American Journal on Addictions 9(2):135–

144, 2000.

Richard, A.J.; Montoya, I.D.; Nelson, R.; and 

Spence, R.T. Effectiveness of adjunct 

therapies in crack cocaine treatment. 

Journal of Substance Abuse Treatment

12(6):401–413, 1995. 

Richmond, R., and Zwar, N. Review of 

bupropion for smoking cessation. Drug 

and Alcohol Review 22:203–220, 2003. 

Ries, R.K.; Russo, J.; Wingerson, D.; 

Snowden, M.; Comtois, K.A.; Srebnik, 

D.; and Roy-Byrne, P. Shorter hospital stays and more rapid improvement 

among patients with schizophrenia and 

substance disorders. Psychiatric Services 

51:210–215, 2000. 

Ritsher, J.B.; Moos, R.H.; and Finney, J.W. 

Relationship of treatment orientation 

and continuing care to remission among 

substance abuse patients. Psychiatric 

Services 53(5):595–601, 2002.

Robertson, E.B.; Sloboda, Z.; Boyd, G.M.; 

Beatty, L.; and Kozel, N.J. Rural 

Substance Abuse: State of Knowledge and 

Issues. NIDA Research Monograph 168. 

NIH Publication No. 97–4177. Rockville, 

MD: National Institute on Drug Abuse, 

1997. 

Rosenheck, R.; Harkness, L.; and Johnson, 

B. Intensive community-focused treatment of veterans with dual diagnoses. American Journal of Psychiatry

155(10):1429–1433, 1998. 

Rounsaville, B.J.; Tims, F.M.; Horton, 

A.M.; and Sowder, B.J., eds. Diagnostic 

Source Book on Drug Abuse Research 

and Treatment. DHHS Publication No. 

(ADM) 93–3508. Rockville, MD: National 

Institute on Drug Abuse, 1993. 

Rowe, C.L., and Liddle, H.A. Substance 

abuse. Journal of Marital and Family 

Therapy 29:97–120, 2003. 

Rubin, A.; Stout, R.L.; and Longabaugh, R. 

Gender differences in relapse situations. 

Addiction 91(Suppl):S111–S120, 1996. 

Sampl, S., and Kadden, R. Motivational 

Enhancement Therapy and Cognitive–

Behavioral Therapy for Adolescent 

Cannabis Users: 5 Sessions. Cannabis 

Youth Treatment Series, Volume 1. 

DHHS Publication No. (SMA) 01–3486. 

Rockville, MD: Center for Substance 

Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 

2001. 

Schmidley, D. The foreign-born population in the United States: March 2002.

Current Population Reports, P20–539. 

Washington, DC: U.S. Census Bureau, 

2003. 

Schmitz, J.M.; Henningfield, J.E.; and 

Jarvik, M.E. Pharmacologic therapies for 

nicotine dependence. In: Graham, A.W.; 

Schultz, T.K.; and Wilford, B.B., eds. 

Principles of Addiction Medicine, Second 

Edition. Chevy Chase, MD: American 
232 Appendix A

Society of Addiction Medicine, 1998, pp. 

571–582.

Schmitz, J.M.; Oswald, L.M.; Jacks, S.D.; 

Rustin, T.; Rhoades, H.M.; and 

Grabowski, J. Relapse prevention treatment for cocaine dependence: Group 

versus individual format. Addictive 

Behaviors 22(3):405–418, 1997. 

Schneider, R.; Mittelmeier, C.; and Gadish, 

D. Day versus inpatient treatment for 

cocaine dependence: An experimental 

comparison. Journal of Mental Health 

Administration 23(2):234–245, 1996. 

Schottenfeld, R.S., and Pantalon, M.V. 

Assessment of the patient. In: Galanter, 

M., and Kleber, H.D., eds. The American 

Psychiatric Press Textbook of Substance 

Abuse Treatment, Second Edition. 

Washington, DC: American Psychiatric 

Press, 1999, pp. 109–119. 

Schuckit, M.S. Goals of treatment. In: 

Galanter, M., and Kleber, H.D., eds. The 

American Psychiatric Press Textbook of 

Substance Abuse Treatment. Washington, 

DC: American Psychiatric Press, 1994, 

pp. 3–10. 

Schumacher, J.E.; Milby, J.B.; Caldwell, E.; 

Raczynski, J.; Engle, M.; Michael, M.; and 

Carr, J. Treatment outcome as a function of treatment attendance with homeless persons abusing cocaine. Journal of 

Addictive Diseases 14(4):73–85, 1995. 

Schwartz, M.; Baker, G.; Mulvey, K.P.; and 

Plough, A. Improving publicly funded 

substance abuse treatment: The value of 

case management. American Journal of 

Public Health 87:1659–1664, 1997. 

Scott, J.; Gilvarry, E.; and Farrell, M. 

Managing anxiety and depression in 

alcohol and drug dependence. Addictive 

Behaviors 23(6):919–931, 1998.

Seidner, A.L.; Burling, T.A.; Gaither, D.E.; 

and Thomas, R.G. Substancedependent inpatients who accept smoking treatment. Journal of Substance 

Abuse 8(1):33–44, 1996.

Sheehan, D.V.; Lecrubier, Y.; HarnetSheehan, K.; Amorim, P.; Janavs, J.; 

Weiller, E.; Hergueta, T.; Baker, R.; 

and Dunbar, G. The Mini International 

Neuropsychiatric Interview (M.I.N.I.): 

The development and validation of a 

structured diagnostic psychiatric interview. Journal of Clinical Psychiatry

(Suppl. 20):22–33, 1998. 

Shoptaw, S.; Frosch, D.; Rawson, R.A.; and 

Ling, W. Cocaine abuse counseling as 

HIV prevention. AIDS Education and 

Prevention 9(3):15–24, 1997. 

Shoptaw, S.; Reback, C.J.; Freese, T.E.; 

and Rawson, R.A. Friends Health 

Center: Behavioral Interventions for 

Methamphetamine Abusing Gay and 

Bisexual Men, A Treatment Manual 

Combining Relapse Prevention and 

HIV Risk-Reduction Interventions. Los 

Angeles: Friends Research Institute, Inc., 

1998. 

Shoptaw, S.; Rotheram-Fuller, E.; Yang, X.; 

Frosch, D.; Nahom, D.; Jarvik, M.E.; 

Rawson, R.A.; and Ling, W. Smoking 

cessation in methadone maintenance. 

Addiction 97:1317–1328, 2002. 

Siegal, H.A.; Fisher, J.A.; Rapp, R.C.; 

Kelliher, C.W.; Wagner, J.H.; O’Brien, 

W.F.; and Cole, P.A. Enhancing substance abuse treatment with case management: Its impact on employment. 

Journal of Substance Abuse Treatment

13(2):93–98, 1996. 

Siegal, H.A.; Li, L.; and Rapp, R.C. Case 

management as a therapeutic enhancement: Impact on post-treatment criminality. Journal of Addictive Diseases 21:37–

46, 2002. 

Simpson, T.L., and Miller, W.R. 

Concomitance between childhood 

sexual and physical abuse and substance use problems: A review. Clinical 

Psychological Review 22(1):27–77, 2002. 
Bibliography 233

Sloan, K.L., and Rowe, G. Substance abuse 

and psychiatric illness: Treatment experience. American Journal of Drug and 

Alcohol Abuse 24(4):589–601, 1998. 

Spicer, P.; Beals, J.; Croy, C.D.; Mitchell, 

C.M.; Novins, D.K.; Moore, L.; Manson, 

S.M.; and the American Indian Service 

Utilization, Psychiatric Epidemiology, 

Risk and Protective Factors Project 

Team. The prevalence of DSM-III-R 

alcohol dependence in two American 

Indian populations. Alcoholism, Clinical 

and Experimental Research 27(11):1785–

1797, 2003.

Stanton, M.D., and Shadish, W.R. Outcome, 

attrition, and family—Couples treatment for drug abuse: A meta-analysis 

and review of the controlled, comparative studies. Psychological Bulletin

122(2):170–191, 1997. 

Stasiewicz, P.R., and Stalker, R. A comparison of three “interventions” on pretreatment dropout rates in an outpatient substance abuse clinic. Addictive Behaviors

24(4):579–582, 1999. 

Stewart, E.C., and Bennett, M.J. American 

Cultural Patterns: A Cross-Cultural 

Perspective, Second Edition. Yarmouth, 

ME: Intercultural Press, 1991. 

Substance Abuse and Mental Health 

Services Administration (SAMHSA).

Report to Congress on the Prevention and 

Treatment of Co-Occurring Substance 

Abuse Disorders and Mental Disorders. 

Rockville, MD: SAMHSA, 2002. 

Substance Abuse and Mental Health 

Services Administration (SAMHSA). 

Strategies for Developing Treatment 

Programs for People With Co-Occurring 

Substance Abuse and Mental Disorders. 

SAMHSA Publication No. 3782. 

Rockville, MD: SAMHSA, 2003.

Sue, D.W., and Sue, D. Counseling the 

Culturally Different: Theory and Practice,

Third Edition. New York: John Wiley and 

Sons, 1999. 

Sullivan, J.T.; Sykora, K.; Schneiderman, 

J.; Naranjo, C.A.; and Sellers, E.M. 

Assessment of alcohol withdrawal: The 

revised Clinical Institute Withdrawal 

Instrument for Alcohol Scale (CIWAAr). British Journal of the Addictions

84:1353–1357, 1989.

Szapocznik, J.; Kurtines, W.M.; Foote, F.H.; 

Perez-Vidal, A.; and Hervis, O. Conjoint 

versus one-person family therapy: Some 

evidence for the effectiveness of conducting family therapy through one person. 

Journal of Consulting and Clinical 

Psychology 51:881–889, 1983. 

Szapocznik, J.; Kurtines, W.M.; Foote, F.H.; 

Perez-Vidal, A.; and Hervis, O. Conjoint 

versus one-person family therapy: 

Further evidence for the effectiveness 

of conducting family therapy through 

one person with drug-abusing adolescents. Journal of Consulting and Clinical 

Psychology 54:395–397, 1986. 

Szapocznik, J., and Williams, R.A. Brief strategic family therapy: Twenty-five years 

of interplay among theory, research and 

practice in adolescent behavior problems and drug abuse. Clinical Child and 

Family Psychology Review 3(2):117–134, 

2000. 

Tempesta, E.; Janiri, L.; Bignamini, 

A.; Chabac, S.; and Potgieter, A. 

Acamprosate and relapse prevention in 

the treatment of alcohol dependence: A 

placebo-controlled study. Alcohol and 

Alcoholism 35(2):202–209, 2000.

Tolman, R.M. The development of a measure 

of psychological maltreatment of women 

by their male partners. Violence and 

Victims 4:159–177, 1989. 

Tonigan, J.S. Project MATCH treatment participation and outcome by self-reported 

ethnicity. Alcoholism, Clinical and 

Experimental Research 27(8):1340–1344, 

2003. 

Tonigan, J.S.; Miller, W.R.; and Schermer, 

C. Atheists, agnostics, and Alcoholics 
234 Appendix A

Anonymous. Journal of Studies on 

Alcohol 63:534–541, 2002. 

Tracy, E.M., and Whittaker, J.K. The social 

network map: Assessing social support in 

clinical practice. Families in Society: The 

Journal of Contemporary Human Services

71:461–470, 1990. 

Turner, R.J., and Gil, A.G. Psychiatric substance use disorders in South Florida: 

Racial/ethnic and gender contrasts in a 

young adult cohort. Archives of General 

Psychiatry 59(1):43–50, 2002. 

Tuten, M., and Jones, H.E. A partner’s 

drug-using status impacts women’s drug 

treatment outcome. Drug and Alcohol 

Dependence 70(3):327–330, 2003.

Urban Institute; Burt, M.R.; Aron, L.Y.; 

Douglas, T.; Valente, J.; Lee, E.; and 

Iwen, B. Homelessness: Programs and 

the People They Serve—Findings of the 

National Survey of Homeless Assistance 

Providers and Clients, Technical Report. 

Washington, DC: Interagency Council on 

the Homeless, 1999. www.huduser.org/

publications/homeless/homeless_tech.

html [accessed February 11, 2004].

U.S. Census Bureau. Asian Pacific American 

Heritage Month: May 2003. Facts for 

Features. Washington, DC: U.S. Census 

Bureau, April 17, 2003. www.census.gov/

Press-Release/www/2003/cb03-ff05.html 

[accessed February 11, 2004].

U.S. Department of Health and Human 

Services. Mental Health: A Report of the 

Surgeon General. Rockville, MD: Center 

for Mental Health Services, Substance 

Abuse and Mental Health Services 

Administration, 1999. www.

mentalhealth.org/features/

surgeongeneralreport/home.asp 

[accessed February 11, 2004].

U.S. Department of Health and Human 

Services. Mental Health: Culture, Race, 

and Ethnicity—A Supplement to Mental 

Health: A Report of the Surgeon General.

Rockville, MD: Center for Mental Health 

Services, Substance Abuse and Mental 

Health Services Administration, 2001. 

www.mentalhealth.org/cre/default.asp 

[accessed February 11, 2004]. 

U.S. Government Office of Technology 

Assessment. Technologies for 

Understanding and Preventing Substance 

Abuse and Addiction. Washington, DC: 

U.S. Government Printing Office, 1994.

U.S. House Committee on the Judiciary, 

Subcommittee on Crime. Testimony of 

Bruce C. Fry, J.D., M.P.P., Center for 

Substance Abuse Treatment, Substance 

Abuse and Mental Health Services 

Administration, U.S. Department of 

Health and Human Services. 104th 

Cong., 2d sess., October 2, 2000. www.

house.gov/judiciary/fry1002.htm 

[accessed February 11, 2004]. 

Vaillant, G.E. The Natural History of 

Alcoholism. Cambridge, MA: Harvard 

University Press, 1983. 

Veach, L.J.; Remley, T.P., Jr.; Kippers, S.M.; 

and Sorg, J.D. Retention predictors 

related to intensive outpatient programs 

for substance use disorders. American 

Journal of Drug and Alcohol Abuse

26(3):417–428, 2000.

Vega, W.A.; Gil, A.G.; and Wagner E. 

Cultural adjustment and Hispanic adolescents. In: Vega, W.A., and Gil, A.G., 

eds. Drug Use and Ethnicity in Early 

Adolescence. New York: Plenum, 1998, 

pp. 125–148.

Vega, W.A.; Gil, A.G.; and Zimmerman, 

R.S. Patterns of drug use among CubanAmerican, African-American, and white 

non-Hispanic boys. American Journal of 

Public Health 83(2):257–259, 1993. 

Volpicelli, J.R.; Alterman, A.I.; Hayashida, 

M.; and O’Brien, C.P. Naltrexone in 

the treatment of alcohol dependence. 

Archives of General Psychiatry 49:876–

880, 1992. 
Bibliography 235

Volpicelli, J.R.; Markman, I.; Monterosso, 

J.; Filing, J.; and O’Brien, C.P. 

Psychosocially enhanced treatment for 

cocaine-dependent mothers: Evidence 

of efficacy. Journal of Substance Abuse 

Treatment 18(1):41–49, 2000. 

Washton, A.M. Evolution of intensive outpatient treatment (IOP) as a “legitimate” 

treatment modality. Journal of Addictive 

Diseases 16(2):xxi–xxvii, 1997. 

Washton, A.M. A psychotherapeutic and 

skills-training approach to the treatment of addiction. In: Carroll, K.M., ed. 

Approaches to Drug Abuse Counseling.

NIH Publication No. 00–4151. Rockville, 

MD: National Institute on Drug Abuse, 

2000, pp. 139–148. 

Watkins, K.E.; Burnam, A.; Kung, F.Y.; and 

Paddock, S. A national survey of care 

for persons with co-occurring mental 

and substance use disorders. Psychiatric 

Services 52(8):1062–1068, 2001.

Webb, C.; Scudder, M.; Kaminer, Y.; 

and Kadden, R. The Motivational 

Enhancement Therapy and Cognitive–

Behavioral Therapy Supplement: 7 

Sessions of Cognitive–Behavioral Therapy 

for Adolescent Cannabis Users. Cannabis 

Youth Treatment Series, Volume 2. 

DHHS Publication No. (SMA) 02–3659. 

Rockville, MD: Center for Substance 

Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 

2002. 

Weinberg, N.Z.; Rahdert, E.; Colliver, J.D.; 

and Glantz, M.D. Adolescent substance 

abuse: A review of the past 10 years. 

Journal of the American Academy of 

Child and Adolescent Psychiatry 37:252–

261, 1998. 

Weinstein, S.P.; Gottheil, E.; and Sterling, 

R.C. Randomized comparison of intensive outpatient vs. individual therapy 

for cocaine abusers. Journal of Addictive 

Diseases 16(2):41–56, 1997. 

Weiss, R.D.; Griffin, M.L.; Greenfield, S.F.; 

Najavits, L.M.; Wyner, D.; Soto, J.A.; and 

Hennen, J.A. Group therapy for patients 

with bipolar disorder and substance 

dependence: Results of a pilot study. 

Journal of Clinical Psychiatry 61(5):361–

367, 2000.

Wells, K.; Klap, R.; Koike, A.; and 

Sherbourne, C. Ethnic disparities in 

unmet need for alcoholism, drug abuse, 

and mental health care. American Journal 

of Psychiatry 158:2027–2032, 2001. 

White, J.M.; Winn, K.I.; and Young, W. 

Predictors of attrition from an outpatient chemical dependency program. 

Substance Abuse 19(2):49–59, 1998. 

White, W.L. Slaying the Dragon: The History 

of Addiction Treatment and Recovery 

in America. Bloomington, IL: Chestnut 

Health Systems, 1998. 

Whiteside-Mansell, L. The development 

and evaluation of an alcohol and drug 

prevention and treatment program for 

women and children: The AR-CARES 

Program. Journal of Substance Abuse 

Treatment 16:265–275, 1999. 

Williams, R., and Gorski, T.T. Relapse 

Prevention Counseling for African 

Americans: A Culturally Specific Model.

Independence, MO: Herald, 1997. 

Williams, R., and Gorski, T.T. Relapse 

Prevention Workbook for African 

Americans: Hope and Healing for the 

Black Substance Abuser. Independence, 

MO: Herald, 1999. 

Williams, R.J.; Chang, S.Y.; and Addiction 

Centre Adolescent Research Group. A 

comprehensive and comparative review 

of adolescent substance abuse treatment 

outcome. Clinical Psychology: Science 

and Practice 7:138–166, 2000. 

Willoughby, F.W., and Edens, J.F. Construct 

validity and predictive utility of the stages 

of change scale for alcoholics. Journal of 

Substance Abuse 8:275–291, 1996. 
236 Appendix A

Winters, F.; Fals-Stewart, W.; O’Farrell, 

T.J.; Birchler, G.R.; and Kelley, M.L. 

Behavioral couple therapy for female 

substance-abusing patients: Effects on 

substance abuse and relationship adjustment. Journal of Consulting and Clinical 

Psychology 70:344–355, 2002. 

Winzelberg, A., and Humphreys, K. Should 

patients’ religiosity influence clinicians’ 

referral to 12-step self-help groups? 

Evidence from a study of 3,018 male 

substance abuse patients. Journal of 

Consulting Psychology 67:790–794, 1999. 

Wiseman, E.J.; Henderson, K.L; and Briggs, 

M.J. Individualized treatment for outpatients withdrawing from alcohol. Journal 

of Clinical Psychiatry 59(6):289–293, 

1998.

Woody, G.E.; Donnell, D.; Seage, G.R.; 

Metzger, D.; Marmor, M.; Koblin, B.A.; 

Buchbinder, S.; Gross, M.; Stone, B.; and 

Judson, F.N. Non-injection substance use 

correlates with risky sex among men having sex with men: Data from HIVNET. 

Drug and Alcohol Dependence 53(3):197–

205, 1999. 

World Health Organization (WHO). 

International Classification of Diseases, 

10th Edition (ICD-10) Classification 

of Mental and Behavioral Disorders: 

Clinical Descriptions and Diagnostic 

Guidelines. Geneva, Switzerland: WHO, 

1992.

World Health Organization (WHO). 

Composite International Diagnostic 

Interview (CIDI). Core Version 2.1. 

Geneva, Switzerland: WHO, 1997. 

Zerger, S. Substance Abuse Treatment: What 

Works for Homeless People? A Review of 

the Literature. Nashville, TN: National 

Health Care for the Homeless Council, 

2002.

Ziedonis, D.M., and D’Avanzo, K. 

Schizophrenia and substance abuse. In: 

Kranzler, H.R., and Rounsaville, B.J., 

eds. Dual Diagnosis and Treatment. New 

York: Marcel Dekker, 1998, pp. 427–465. 

Zilberman, M.L.; Tavares, H.; Blume, S.B.; 

and el-Guebaly, N. Substance use disorders: Sex differences and psychiatric 

comorbidities. Canadian Journal of 

Psychiatry 48(1):5–13, 2003. 

Zullino, D.F.; Besson, J.; Favrat, B.; Krenz, 

S.; Zimmerman, G.; Schnyder, C.; and 

Borgeat, F. Acceptance of an intended 

smoking ban in an alcohol dependence 

clinic. European Psychiatry 18(5):255–

257, 2003.
237

Urine testing is the best developed and most commonly used monitoring technique in substance abuse treatment programs. This 

appendix describes procedures for implementing this service and 

other methods for detecting clients’ substance use. The Substance 

Abuse and Mental Health Services Administration (SAMHSA) has a 

number of documents about drug testing available in the Workplace 

Resources section of its Web site, www.samhsa.gov.

Testing Schedule

Urine specimens are collected

As part of the intake process to confirm a newly admitted client’s 

substance use history

As a routine part of therapy

To identify an intoxicated client or confirm abstinence

Each intensive outpatient treatment (IOT) program should consider 

establishing a schedule for urine testing that takes into account 

Federal and State requirements (e.g., for methadone programs) and 

balances the therapeutic needs of the population being served with 

costs to the program or payer. Clients generally need more frequent 

monitoring during the initial stages of treatment when they are trying to achieve abstinence but still may be using substances. Routine 

specimen collection after admission should take place in conjunction 

with regular clinic visits.

Under ideal conditions, the consensus panel believes that collection should occur not less than once a week or more frequently than 

every 3 days in the first weeks of treatment. It is important that the 

scheduled frequency of urine collection match the usual detection 

window for the primary drug. Too long an interval between urine 

tests can lead to unreliable results because most of the target drug 

and its metabolites will have been excreted. On the other hand, if the 

interval between tests is too short, a single incidence of drug use may 

•

•

•

Appendix B—

Urine Collection and 

Testing Procedures and 

Alternative Methods for 

Monitoring Drug Use
238 Appendix B

be detected twice in separate urine samples. 

Multiple positive urine test results produced 

by a single ingestion (carryover positives) can 

be discouraging for the client and misleading for the clinician (Preston et al. 1999).

Once clients are stabilized in treatment, 

they require less intensive monitoring of 

abstinence. At this point, most programs 

reduce the frequency of scheduled tests and 

randomize the collection times. Even with a 

decreased and randomized testing schedule, 

specimen collection should be scheduled on 

clinic days following weekends, holidays, or 

paychecks—the times when clients are most 

tempted to use.

During IOT, monthly testing is standard 

in most programs. Random testing can be 

achieved by 

Asking clients to produce specimens only 

on random days

Requiring that all clients provide a specimen on every visit but analyzing only a 

randomly selected sample

Collection Procedures 

and Policies

Urine sample collection procedures need to 

strike a balance between trusting clients and 

ensuring that specimens are not contaminated or falsified. Some programs insist that 

a staff member of the same sex accompany a 

client into the bathroom to observe urine collection. Others find that monitoring through 

an open door and having clients leave packages and coats outside are sufficient. A sink 

that is separate from the toilet area also discourages attempts to dilute samples (Bureau 

of Justice Assistance 1999). Many programs 

use temperature strips to make certain that 

urine specimens are produced on site and 

are body temperature. Tests of creatinine 

or specific gravity can determine whether a 

sample has been diluted with water or the 

client is consuming excessive fluids to lower 

the concentration of drugs below detectable 

levels (Preston et al. 1999). 

•

•

Information about how to beat the drug testing system is widely available. Web sites 

advertise inexpensive products that can be 

added to urine specimens to absorb toxins as 

well as herbal remedies for consumption for 

a few hours before testing to cleanse the 

urine. Concentrated, “clean” specimens can 

be purchased for mixing with warm water at 

the test site. A variety of low-cost, self-testing 

kits also are available to preview likely 

results from more formal testing procedures.

As part of their orientation to the IOT program, clients need to be informed about 

the urine collection and testing procedures. Clients also should be advised that 

informed consent is necessary for release 

of toxicology results to anyone other than 

staff (see chapter 7 of TIP 46, Substance 

Abuse: Administrative Issues in Outpatient 

Treatment [CSAT 2006f]). Most IOT programs do not comply with workplace 

standards for testing or maintain an adequate chain-of-custody for specimens that 

would meet court challenges. If employers, 

representatives of the criminal justice system, or children’s protection agencies feel 

that such reporting is necessary, they can be 

advised to conduct their own testing or to 

accept other clinical evidence of client progress in treatment.

Clients should report any substance use 

to their counselor before a urine sample is 

submitted so that the substance use can be 

addressed therapeutically. It may be helpful to remind clients that the clinic conducts 

drug monitoring to support their recovery. 

Because there may be some likelihood of 

cross-reactivity and false positive results 

on screening tests, clients need to keep 

counselors informed about any prescribed 

medications or over-the-counter (OTC) drugs 

they have used.

Appropriate attention needs to be given to 

handling and storing collected specimens. 

Collection bottles that are sent to an offsite 

laboratory should be clean and tamperproof. 

Waterproof labels attached to the bottles 
Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 239

should note either the client’s name or 

identification number and be checked for 

accuracy by the client and the counselor or 

technician. Collected specimens need to be 

kept cool—or refrigerated—until transmitted 

to the laboratory and should be stored in a 

protected or locked room for security. Clients 

and staff members who touch the urine 

collection bottles need to be reminded to 

wash their hands thoroughly. Rubber gloves 

should be worn by technicians who perform 

onsite analyses.

Selection of Drug 

Batteries and Testing 

Techniques

Programs need to test for a standard battery of drugs, which may include such drug 

groups as amphetamines, barbiturates, 

benzodiazepines, cannabinoids, cocaine, 

methadone, methaqualone, opioids, phencyclidine (PCP), propoxphene, or euphorics 

(Ecstasy). In programs where the majority 

of clients use only a few types of substances, 

the standard battery can be small, and only 

selected individual clients need be tested 

for other specified substances. Programs 

should add substances to the routine battery, 

temporarily or permanently, if patterns of 

substance use change in the target population or in the community. It is helpful to 

stay up to date about local drug use patterns identified by the nearest Community 

Epidemiology Work Group (www.nida.nih.

gov/CEWG/CEWGHome.html) or the Single 

State Authority. For example, oxycodone 

(OxyContin®) has become a serious drug of 

abuse in particular locales. Fads come and 

go for abuse of a wide variety of substances 

(e.g., Ecstasy, PCP, pentazocine [Talwin®], 

propoxyphene [Darvon®]).

Detection Limits for the 

Substances Being Tested

The length of time during which different 

licit and illicit substances or their metabolites can be detected in urine samples 

depends on many interacting factors, 

including

Chemical properties (e.g., half-life) of the 

selected drugs

Metabolism rates and excretion routes

Amount, administration route, frequency, 

and chronicity of the dose consumed 

Sensitivity and specificity of the assay 

Individual variations in clients’ physical 

health, exercise, diet, weight, gender, and 

fluid intake that affect excretion rates

Most substances of abuse can be detected for 

approximately 2 to 4 days (see exhibit B-1). 

However, the higher the dose taken and the 

more frequently the substance has been used 

over an extended time, the more likely that 

it will be detected. Although substances are 

excreted at various rates, they accumulate in 

the body with continued use. Whereas a single use of cocaine may be detectable in urine 

for only a day or less, continued daily use is 

likely to be detectable for 2 to 3 days following its discontinuation (Preston et al. 1999). 

Chronic use of such drugs as marijuana, 

PCP, and benzodiazepines may be detectable 

for up to 30 days, whereas alcohol remains in 

the system for 24 hours or less. Realistically, 

it may be difficult to detect illicit substances 

in most clients who stop all use for several 

days before a drug screen. An accurate profile of a client’s substance use over more 

than a few days requires both urine test 

results and a good retrospective history.

Selecting an Appropriate 

Testing Technique

A program should consider a variety of factors in selecting a method and source for 

drug testing. None of the methods are inexpensive, with costs ranging from less than $5 

to more than $100 per assay for a particular 

drug. Turnaround time in receiving results 

is another important determinant. Whereas 

onsite methods can provide results in a matter of minutes, more accurate and expensive 

commercial laboratory analyses may take 

•

•

•

•

•
240 Appendix B

several days or longer. Reliability is a major 

consideration. However, substance abuse 

treatment programs that are using results 

for clinical purposes do not require the same 

accuracy (i.e., workplace standards) as agencies that make important, one-time decisions 

Exhibit B-1

Urine Toxicology Detection Periods for Different Substances

Substance Typical Urine Detection Period

Amphetamine or methamphetamine 2–4 days

Barbiturates 

 Short-acting—Secobarbital

 Long-acting—Pentobarbital

Phenobarbital 

1–2 days

2–4 days

10–20 days

Benzodiazepines

 Therapeutic dose

 Chronic dosing

3–7 days

Up to 30 days

Cocaine 1–3 days 

Cannabinoids 

 Casual use

 Daily use 

 Chronic use

1–3 days

5–10 days

Up to 30 days 

Ethanol (alcohol) 12–24 hours

Opioids (e.g., codeine, morphine) 1–3 days

Methadone 2–4 days 

Propoxyphene 6–48 hours 

Ecstasy/euphorics 1–5 days 

PCP

 Acute use

 Chronic use

2–7 days

Up to 30 days

Copyright © 1999 by the American Psychological Association. Adapted with permission. No further reproduction 

or distribution is permitted without the written permission of the American Psychological Association (Preston et 

al. 1999, p. 286).
Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 241

about such issues as employment, safety, 

eligibility for sports competitions, or probation or parole violations. Some cities and 

States have assumed responsibility for selecting a single vendor for providers under their 

jurisdiction to use and choosing a standard 

battery of drugs to be tested. Providers may 

wish to create a buying collective to negotiate 

the best discounts from a local drug-testing 

laboratory.

Two categories of urine tests are available:

Screening tests. These detect only the presumptive presence or absence of a class of 

drugs in the urine specimen, return results 

rapidly, are relatively inexpensive ($1 to 

$5 per assay), can be set to detect low concentrations of drugs (have high sensitivity), 

and are relatively simple to perform. But 

these screening tests—the ones most frequently used by substance abuse treatment 

programs—do not distinguish specific drug 

metabolites (only groups), provide only 

qualitative results (yes or no), and may 

mistake other chemically similar medications, OTC preparations, or substances for 

the target drug class (Preston et al. 1999). 

This potential for cross-reactivity is of more 

concern in detecting amphetamines, benzodiazepines, and opioids than cocaine or 

marijuana. More specifically, the following 

cross-reactive results may occur:

Some cough suppressors in OTC 

preparations may be reported as a 

positive result for opioids.

Phenylpropanolamine or ephedrine in 

cold remedies can cause false positives 

for amphetamines.

Ibuprofen and other anti-inflammatories 

may be interpreted as positives for 

marijuana on the enzyme-multiplied 

immunoassay technique (EMIT) test.

Amitriptyline (an antidepressant) can be 

mistaken for opioids.

Some antibiotics may cause false 

positives for cocaine.

Diazepam has been mistaken for PCP. 

•

–

–

–

–

–

–

Confirmatory tests. These provide more 

definitive information about the quantitative concentrations (nanograms/milliliter) 

of specific drugs or their metabolites in 

urine specimens and are more accurate 

than drug screens (have higher specificity and sensitivity). They are much more 

expensive (up to $100 per assay), technically complex, labor intensive, and time 

consuming—often taking days to complete. 

If the results of a drug test will be used as 

a basis for actions taken against an individual (e.g., in a justice system context), 

positive findings should be followed by a 

confirmatory test of equal or greater sensitivity and better specificity (Bureau of 

Justice Assistance 1999). Although results 

from these quantitative tests can be more 

useful than a simple positive or negative 

for monitoring intermediate changes in 

drug consumption patterns, the concentration in urine might be the same for a small 

amount of a drug administered recently as 

for a large amount of the drug consumed 

several days ago. In addition, concentrations can be affected by fluid consumption 

levels and may be misleading (Preston et 

al. 1999).

The Meaning of Test Results

Urine test results can be inaccurate. 

Counselors should keep this fact in mind 

when discussing findings with a client. 

Asking the client whether results are accurate and, if so, when and how much of a 

particular substance was used can be the 

beginning of a therapeutic discussion that 

includes the circumstances surrounding substance use and the client’s triggers.

In interpreting test results, clinicians should 

know the following:

Positive results show a presumptive or confirmed presence of targeted substances at a 

detectable level. Positive results also mean 

that the amount of the substance detected 

is above the cutoff point for labeling a 

specimen positive. (SAMHSA has 

•

•
242 Appendix B

established Federal guidelines for cutoff levels; see workplace.samhsa.gov/

DrugTesting/RegGuidance/UrineConcen.

htm.) Findings cannot determine when, 

how much, or how a drug was administered or the degree of impairment the drug 

produced (Bureau of Justice Assistance 

1999).

Negative results do not guarantee that the 

individual did not consume the substances 

tested. Despite a client’s use of the targeted substance, results could be negative 

because (1) most evidence may have been 

excreted or metabolized before testing took 

place, (2) the specimen may have been 

diluted or switched, (3) the client may have 

consumed an excessive amount of fluids 

to dilute the urine, or (4) the test may not 

have been sufficiently sensitive (Bureau of 

Justice Assistance 1999).

False-positive results that mistakenly find 

the presence of a substance can result from 

laboratory errors (e.g., outdated reagents 

and labeling mistakes), specimen tampering, or cross-reactivity of an immunoassay 

test with a substance of similar chemical 

structure.

Urine-Testing 

Techniques

Most screening tests are immunoassays that 

take advantage of antigen-antibody interactions—using enzymes, radioisotopes, or 

fluorescent compounds—and compare the 

specimen with a calibrated quantity of the 

substance being tested (Bureau of Justice 

Assistance 1999). 

EMIT test is the least expensive, most widely 

used, and simplest test to conduct. It often 

is used on site at a cost of about $5 per 

screen. It also has the poorest performance 

record, returning up to 30 percent false 

positives. Although EMIT can be used to 

test for a wide variety of drugs and alcohol, some sources report that as many as 

300 OTC preparations cause false-positive 

readings.

•

•

•

Fluorescent polarization immunoassay 

TDxTM is highly sensitive and highly specific.

Radioimmunoassay (RIA) is a more sensitive test than the EMIT and is used extensively by the military.

Kinetic interaction of microparticles in 

solution is a screening test used with most 

substances.

Thin-layer chromatography (TLC) involves 

the addition of a solvent to the specimen 

that causes the target drugs and metabolites to move up a porous strip, leaving colored spots at different distances that can 

be compared with known standards. The 

results are reported as positive or negative, without any quantitative information, 

and require skill to interpret. Because TLC 

returns many false positives, it is no longer 

used widely.

Confirmatory urine testing methods include

Gas liquid chromatography 

High performance liquid chromatography 

Gas chromatography/mass spectrometry 

(GC/MS) (the gold standard for drug detection, but costly at $25 to $100 a test)

Alternative Testing 

Methods

Several other body products are gaining 

prominence in the search for simpler, less 

expensive, noninvasive, and more accurate 

techniques for detecting the recent and current use of substances. Exhibit B-2 compares 

the effectiveness of urine, breath, saliva, 

sweat, blood, and hair testing methodologies 

for detecting drugs.

Breath-Testing Techniques

Because alcohol is metabolized rapidly at 

an average rate of 15 to 25 milligrams per 

hour—and the detection period is hours, not 

days—drinking usually is not monitored by 

urine or blood tests. Instead, clinicians frequently rely on other observations of current 

use (e.g., an odor of alcohol, slurred speech) 

•

•

•

•

•

•

•
Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 243

Exhibit B-2

Effectiveness of Drug Detection

Methods That Use Different Biological Products

Body 

Product

Drug 

Detection 

Time

Major 

Advantages

Major 

Limitations Primary Use

Urine 2–4 days Mature technique; 

established cutoffs 

for detecting many 

drugs of abuse

Detects only 

recent use; needs 

costly confirmation to be accurate 

Monitors recent 

drug use in many 

populations 

Breath 

(alcohol) 

12–24 

hours 

Easy to use; readily available and 

well-established 

method 

Short detection 

time 

Confirms 

observed 

intoxication or 

impairment

Saliva 12–24 

hours 

Easy to obtain 

samples; good 

correlation with 

blood levels for 

some substances 

Very short detection time; new 

method; oral cavity is contaminated 

easily

Links positive 

drug test to behavioral impairment 

and intoxication 

Sweat 1–4 weeks Cumulative measure; relatively 

tamper-proof collection method

High potential for 

contamination; 

new technique

Detects recent and 

less recent drug 

use

Blood 12–24 

hours 

Accurate results; 

established 

method 

Invasive method; 

expensive; detects 

only current use 

or intoxication

Detects drug 

effects on 

crashes, medical 

emergencies

Hair 4–6 

months 

Measures longterm drug use; 

readily available 

samples; accurate 

results

New technique; 

costly and timeconsuming; no 

dose-response 

relation 

established 

Confirms drug 

use in past 4 to 

6 months; prevalence studies

Copyright © 1999 by the American Psychological Association. Adapted with permission. No further reproduction 

or distribution is permitted without the written permission of the American Psychological Association (Preston et 

al. 1999, p. 299).
244 Appendix B

or an easily administered BreathalyzerTM test 

to confirm alcohol intoxication or drinking 

within the past several hours. Blood alcohol 

concentrations—measured in milligrams (mg) 

of alcohol per deciliter (dl) of blood—usually 

are expressed as a percentage (i.e., 100 mg/

dl equals 100 mg percent or 0.1 percent) and 

correspond closely with measures of alcohol on the breath. One drink increases the 

breath alcohol level (BAL) by approximately 

0.025 percent.

For most men, some impairment is observable at 0.05 percent BAL, and driving ability 

is appreciably affected at 0.07 percent. A 

woman weighing 150 pounds would reach a 

BAL of 0.1 percent if she consumed approximately four drinks in an hour (compared 

with six drinks in an hour for a 200-pound 

man), although individuals’ metabolism 

of alcohol varies considerably according to 

gender, age, simultaneous ingestion of food, 

and physical condition, as well as weight and 

consumption rate. BALs between 0.10 percent and 0.20 percent without obvious signs 

of intoxication usually indicate tolerance for 

alcohol and regular, heavy drinking characteristic of dependence (CSAT 1997a).

Normally, with little or no tolerance for 

alcohol, the following impairment levels are 

observed:

0.40 percent = lethal 

0.30 percent = unconscious

0.20 percent = decreased consciousness 

0.10 percent = intoxication

0.07 percent = impaired driving ability

0.05 percent = detectable effect

In addition to Breathalyzer tests, several 

other simple-to-use but accurate techniques 

now exist for determining either a client’s 

BAL or his or her approximate blood alcohol 

concentration. One is a relatively inexpensive, portable, and disposable unit the size 

of a cigarette containing crystals that turn 

a particular color—from yellow to blue—to 

signify a blood alcohol concentration of 0.02 

percent, 0.08 percent, or 0.10 percent within 

•

•

•

•

•

•

30 seconds after someone blows into the unit 

for 10 seconds.

Saliva

For alcohol, saliva is correlated closely with 

blood concentrations 2 hours after consumption. However, routes of drug administration 

that contaminate the oral cavity can change 

the pH levels of saliva. These changes can 

distort correlations of other drugs found 

in saliva with blood plasma levels (Magerl 

and Schulz 1995; Preston et al. 1999). One 

advantage of saliva testing is the ready availability of saliva specimens and the packaging 

for onsite testing. However, the short time 

window for detecting substances limits the 

effectiveness of this method to ascertaining 

only recent drug use (e.g., for accident investigations and for pilots or other employees 

about to engage in safety-sensitive activities). 

Most substances disappear from both blood 

and saliva within 12 to 24 hours of use; cannabinoids may be detectable for only 4 to 10 

hours after marijuana is smoked. The U.S. 

Food and Drug Administration (FDA) recently approved limited use of RIA-based saliva 

tests. Kits that detect tetrahydrocannabinol 

(the active component of marijuana), opioids, 

and cocaine are available for about $30. 

Sweat

Although a number of licit and illicit substances can be detected in perspiration 

(probably diffused from blood), perspiration 

is difficult to collect for monitoring purposes. 

Manufacturers have introduced a “sweat 

patch” with a tamper-proof adhesive that is 

worn for about a week. It has been used successfully to detect amphetamines, cocaine, 

ethanol, methadone, methamphetamine, 

morphine, nicotine, and PCP. The drugs 

are absorbed gradually into the pad, which 

must be applied carefully on clean skin and 

removed carefully for analysis. Although no 

rapid methods for analysis are available, 

and the pads must be mailed to laboratories, 

the FDA has approved their use for detecting 
Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 245

cocaine, amphetamines, and opioids. The 

pads are used primarily to monitor offenders 

on parole or probation.

Hair

Hair analysis can be used for detecting illicit 

substance use in the workplace and for drug 

treatment screening. The exact mechanism 

by which drug metabolites are absorbed 

into hair follicles remains unclear. Trace 

amounts of metabolites in the bloodstream 

enter hair follicles; these metabolites then 

are trapped in the core of each hair strand. 

It seems to take about a week after substance 

use for hair follicles to absorb drug residues. 

Because hair grows at a rate of about 1⁄2-inch 

per month, a 2-inch strand retains the record 

of a person’s substance use over approximately the past 4 months—a much longer 

historical record than can be found through 

urine testing (Mieczkowski et al. 1998). 

The advantages of this technique are

The presence of larger concentrations of 

the substance use than in urine samples

The ease of specimen collection; hair usually is taken from the scalp, but any body 

hair can be used

The difficulties in falsification or tampering and the simplicity of storage and 

shipping

•

•

•

Certain objections to this technique have 

not been resolved. Few laboratories conduct 

the analyses. Questions exist about potential 

environmental contamination of hair, the 

relationship of dose to the concentrations of 

the substance in hair, and whether biophysical attributes affect outcome. However, a 

large random study of hair analysis found 

little evidence of any bias in assay results 

associated with hair color, race, or ethnicity 

(Kelly et al. 2000). Because hair grows slowly 

and recent drug use cannot be detected 

reliably, the methodology has limited application for routine monitoring of treatment 

compliance. It could be useful for corroborating an intake drug history and conducting 

prevalence research (Preston et al. 1999). 

Hair testing involves dissolving about 50 

strands of hair in solvents and testing the 

liquefied sample with GC/MS. The technique 

appears to be highly reliable for detecting 

cocaine and crack, opioids (heroin), methamphetamines, PCP, and synthetic substances 

such as methylenedioxyamphetamine and 

3-4 methylenedioxymethamphetamine or 

Ecstasy. It may be less reliable for detecting 

marijuana (Mieczkowski and Newel 1997).

247

Appendix C—

Resource Panel

James Callahan, D.P.A.

Executive Vice President & CEO

American Society of Addiction Medicine

Chevy Chase, Maryland

Caroline Cooper

Associate Director

Justice Programs Office

School of Public Affairs

American University

Washington, D.C. 

Jennifer Edwards

Assistant to the Director

Corrections Program Office

U.S. Department of Justice

Washington, D.C. 

Jerry Flanzer, D.S.W., LCSW, CAC

Social Science Analyst

Division of Clinical and Services Research

National Institute on Drug Abuse

National Institutes of Health

Bethesda, Maryland

Brenda Harding

Public Health Advisor

Division of State and Community 

Assistance

Center for Substance Abuse Treatment

Rockville, Maryland

Gil Hill

Director, Office of Substance Abuse

American Psychological Association

Washington, D.C. 

Thomas F. Hilton, Ph.D.

Program Official for Organization and 

Management Sciences Research

Services Research Branch

Division of Clinical and Services Research

National Institute on Drug Abuse

National Institutes of Health

Bethesda, Maryland

Elizabeth (Beth) A. Peyton

President

Peyton Consulting

Newark, New Jersey

Barbara Ray

Public Health Analyst

Substance Abuse and Mental Health 

Services Administration

Rockville, Maryland

Barbara Roberts, Ph.D.

Senior Policy Analyst

Office of Demand Reduction

Office of National Drug Control Policy

Executive Office of the President

Washington, D.C.
248

Mickey Smith

Public Health Advisor

Division of State and Community 

Assistance 

Center for Substance Abuse Treatment

Rockville, Maryland

Richard T. Suchinsky, M.D.

Associate Chief for Addictive Disorders 

and Psychiatric Rehabilitation

Mental Health and Behavioral 

Sciences Services

Department of Veterans Affairs

Washington, D.C. 

Appendix C
249

Appendix D—

Cultural Competency 

and Diversity Network 

Participants

Faye Belgrave, Ph.D.

Professor of Psychology

Virginia Commonwealth University

Richmond, Virginia

Thomas P. Beresford, M.D.

Professor of Psychiatry

University of Colorado Health Sciences 

Department of Veterans Affairs Medical 

Center 

Denver, Colorado

Deion Cash

Executive Director

Community Treatment and Correction 

Center, Inc.

Canton, Ohio

Marty Estrada

Case Manager

General Relief Team

East County Intake and Eligibility Center

Ventura, California

Michael T. Flaherty, Ph.D.

Executive Director

Institute for Research Education and 

Training in Addictions

Pittsburgh, Pennsylvania

Robin C. Halprin, Ph.D.

Licensed Psychologist

D.C. Department of Health/CSA

Washington, D.C.

Martin Hernandez

Administrative Assistant

Ventura County Board of Supervisors, 

Third District

Ventura, California

Alixe McNeil

Assistant Vice President

National Council on the Aging

Washington, D.C.

Rhoda Olkin, Ph.D.

Professor of Psychology

California School of Professional 

Psychology

Alameda, California

David W. Oslin, M.D.

Assistant Professor

Geriatric Psychiatry

University of Pennsylvania

Philadelphia, Pennsylvania

Lawrence Schonfeld, Ph.D.

Professor, Department of Aging and 

Mental Health

Louis de la Parte Florida Mental Health 

Institute

University of South Florida

Tampa, Florida
250

Antony P. Stephen, Ph.D., LCSW, RAS

Executive Director

Mental Health & Behavioral Sciences

New Jersey Asian American Association for 

Human Services, Inc.

Elizabeth, New Jersey

Ann Yabusaki, Ph.D.

Substance Abuse Director

Coalition for a Drug-Free Hawaii

Kaneohoe, Hawaii

Appendix D
251

Appendix E—

Field Reviewers

Lonnetta Albright

Director

Great Lakes Addiction Technology 

Transfer Center

University of Illinois

Chicago, Illinois

Thomas S. Baker, D.M., LPC

Senior Consultant 

Employee Assistance

Johnson & Johnson Corporate Headquarters

New Brunswick, New Jersey

Toni Barrett, M.A., CAP

Senior Vice President of Programs

Stewart-Marchman Center

Daytona Beach, Florida

Faye Belgrave, Ph.D.

Professor of Psychology

Virginia Commonwealth University

Richmond, Virginia

Thomas P. Beresford, M.D.

Professor of Psychiatry

University of Colorado Health Sciences Center

Department of Veterans Affairs Medical Center

Denver, Colorado

Allan J. Cohen, M.A., MFT

Director of Research and Development

Aegis Medical Systems, Inc.

Canoga Park, California

Stephanie Covington, Ph.D.

Consultant

La Jolla, California

Michael Cunningham, Ph.D., CDP

Clinical Supervisor

Triumph Treatment Services

Yakima, Washington 

Dennis C. Daley, Ph.D.

Chief, Addiction Medicine Service

Associate Professor of Psychiatry

Western Psychiatric Institute and Clinic

Pittsburgh, Pennsylvania

Philip Diaz, M.S.W.

Chief Executive Office

Gateway Community Services

Jacksonville, Florida

John Edwards, Ph.D.

Family Therapy Trainer/Consultant

Durham, North Carolina

Marty Estrada

Case Manager

General Relief Team

East County Intake and Eligibility Center

Ventura, California

Marvin E. Fangman, M.A., LMSW, ACADC

Program Manager

First Step: Mercy Recovery Center

Mercy Medical Center

Des Moines, Iowa
252

Dorothy J. Farr, LSW, LADC

Clinical Director

Bucks County Drug and Alcohol Commission

Warminster, Pennsylvania

Michael T. Flaherty, Ph.D.

Executive Director

Institute for Research, Education and 

Training in Addictions

Pittsburgh, Pennsylvania

Cyrus V. Galyon, CAP

Clinical Manager, Non-Residential Services

Center for Drug-Free Living, Inc.

Orlando, Florida

Stephen J. Gumbley, M.A., ACDP II, LCDP

Project Director

Discovery House/Smart Management

Providence, Rhode Island

Diane E. Hague, M.S.S.W., LCSW, CADC 

Director

Jefferson Alcohol and Drug Abuse Center

Louisville, Kentucky

James A. Hall, Ph.D., LISW

Associate Professor of Pediatrics

Roy J. and Lucille A. Carver College of 

Medicine

University of Iowa

Iowa City, Iowa

Robin C. Halprin, Ph.D.

Licensed Psychologist

D.C. Department of Mental Health/CSA

Washington, D.C.

Martin Hernandez

Administrative Assistant

Ventura County Board of Supervisors, 

Third District

Ventura, California

Anne M. Herron, M.S., CRC, CASAC

Director, Treatment Programming

NYS Office of Alcoholism and Substance 

Abuse Services

Albany, New York

Sheryl D. Hunter, M.D.

Massachusetts Mental Health Center

Boston, Massachusetts

Dick Jacobs, M.S., LMFT, CAP

Chief Operating Officer

Center for Drug-Free Living, Inc.

Orlando, Florida

Margaret M. Kotz, D.O.

Addiction Psychiatrist

Cleveland Clinic

Cleveland, Ohio

Roland C. Lamb

Manager, Provider Network Administration

Community Behavioral Health of 

Philadelphia’s Behavioral Health System

Philadelphia, Pennsylvania

Kimberly A. Lucas, M.S., CADC

Treatment Specialist

Delaware Division of Substance Abuse and 

Mental Health

New Castle, Delaware

Thomas E. Lucking, M.A., Ed.S.

Consultant

Kalamazoo, Michigan

Pierluigi Mancini, Ph.D., NCAC II

Executive Director

Clinic for Education, Treatment and 

Prevention of Addiction, Inc.

(Hispanic Program)

Atlanta, Georgia

Michael J. McCann, M.A.

Associate Director

Matrix Institute on Addictions

Los Angeles, California

James R. McKay, Ph.D.

Scientific Director

Treatment Research Institute

Philadelphia, Pennsylvania

Appendix E
253

Cecilia McNamara, Ph.D.

Health Science Administrator

Behavioral Treatment Development Branch

National Institute on Drug Abuse

National Institutes of Health

Bethesda, Maryland 

Alixe McNeil

Assistant Vice President

National Council on the Aging

Washington, D.C.

Terence McSherry, M.P.H., M.H.A.

President and Chief Executive Officer

Northeast Treatment Center

Philadelphia, Pennsylvania

Delinda Mercer, Ph.D.

Treatment Research Center

University of Pennsylvania

Philadelphia, Pennsylvania

Ethan Nebelkopf, Ph.D.

Director

Family and Child Guidance Clinic

Native American Health Center

Oakland, California

Rhoda Olkin, Ph.D.

Professor of Psychology

California School of Professional 

Psychology

Alameda, California

David W. Oslin, M.D.

Assistant Professor of Geriatric Psychiatry

University of Pennsylvania

Philadelphia, Pennsylvania

Deborah J. Owens, M.S., LPC, CACD, CEAP

Senior Consultant

Employee Assistance Programs

Fort Washington, Pennsylvania

Lawrence Schonfeld, Ph.D.

Professor of Aging and Mental Health

Louis de la Parte Florida Mental Health 

Institute

University of South Florida

Tampa, Florida

Harvey A. Siegal, Ph.D.

Professor and Director

Center for Interventions, Treatment, and 

Addictions Research

Wright State University School of Medicine

Dayton, Ohio

Thomas M. Slaven, Ph.D., LPC

Consulting Associate

Duke University Medical Center

Durham, North Carolina

David Smith, M.D.

Founder and Medical Director

Haight-Ashbury Free Clinics

Medical Director

California Alcohol and Drug Programs

San Francisco, California

Antony P. Stephen, Ph.D., LCSW, RAS

Executive Director

Mental Health & Behavioral Studies

New Jersey Asian American Association for 

Human Services, Inc.

Elizabeth, New Jersey

Mary Ann Chutuape Stephens, Ph.D.

Health Scientist Administrator

Center for the Clinical Trials Network

National Institute on Drug Abuse

National Institutes of Health

Bethesda, Maryland

Erik Stone, M.S., CAC III

Director of Compliance and Quality 

Improvement

Signal Behavioral Health Network

Denver, Colorado

Kathy J. Stone, M.B.A., LMSW

Associate Executive Director

Magellan Behavioral Care of Iowa

West Des Moines, Iowa

Philip Toal, Ed.D., LMHC

Clinical Manager, Non-Residential Services

Center for Drug-Free Living, Inc.

Orlando, Florida

Field Reviewers
254

Tim Williams, M.S.W., LCSW

Adult Services Director

Orange, Person and Chatham Area 

Programs

Carrboro, North Carolina

Ann Yabusaki, Ph.D.

Substance Abuse Director

Coalition for a Drug-Free Hawaii

Kaneohe, Hawaii

Appendix E
255

Index

12-Step facilitation, 138–139

strengths and challenges of, 139

12-Step groups. See mutual-help groups

24-hour crisis coverage, 40, 41

A

abstinence

family life, 105–106

monitoring, 12

acamprosate, 36

Addiction Severity Index, 11, 64, 74, 85

supplements to six assessment domains, 88–91

Addiction Technology Transfer Centers, 2

adjunctive therapies, 45

admission process, 9, 59–60

components of, 67

adolescents, 171

Asian Americans and Pacific Islanders, 191

behavioral contract, 173

case management, 174

characteristics and behaviors of, 176

family involvement, 172–173

group treatment, 174

Hispanics/Latinos, 185

HIV, 192

ADS. See Alcohol Dependence Scale

adult education, 44

African Americans, 190

resources, 199

Alcohol Abstinence Self-Efficacy Scale, 135

Alcohol Dependence Scale, 64

Alcohol Effects Questionnaire, 135

Alcohol-Specific Role Play Test, 135

ambulatory detoxification, 34–35, 56

American Society of Addiction Medicine

continuum of care levels, 17

Patient Placement Criteria, 68, 69

Americans with Disabilities Act, 60, 193

anger, 123, 126. See also violence

approaches to treatment

12-Step facilitation, 138–139

cognitive-behavioral approach, 140–141

community reinforcement and contingency 

management, 148–152

Matrix model, 146–148

motivational approaches, 141–142

therapeutic community approach, 142–145

ASI. See Addiction Severity Index

Asian Americans and Pacific Islanders, 191–192

resources, 200–201

assessment, biopsychosocial, 73–74

attrition of clients, 59

B

barriers to treatment

addressing, 73

assessing, 64–66

engaging family members in treatment, 98

language, 185

mistrust of authority, 184

people with psychiatric disorders, 162

physical, 60

religious orientation, 187

women, 159, 186

biopsychosocial assessment, 73–74

boundary issues, 132–134

buprenorphine, 14, 36

C

CAGE questionnaire, 64

case management, 38–40

adolescents, 174

clients who are homeless, 194

psychiatric disorders, 166

Because the entire volume is about clinical issues in intensive outpatient treatment (IOT), the use of 

these terms as entry points has been minimized in this index. Commonly known acronyms are listed 

as main headings. Page references for information contained in exhibits appear in italics.
256 Index

qualifications and role of managers, 38

research outcomes and findings, 40

services, 39

child care, 45

barrier to treatment, 73, 159

child-focused therapy, 101

chronic medical conditions

screening for at intake, 65

substance abuse, 12

CIDI. See Composite International 

Diagnostic Interview

Circumstances, Motivation, Readiness, and 

Suitability Scales–Revised, 70

CIWA–Ar scale. See Clinical Institute 

Withdrawal Assessment–Alcohol, Revised 

scale

client issues

attrition, 59

boundary issues, 132–134

counselor-client trust, 10

disruptiveness, 123

education, 14

employment-related challenges, 130–132

quiet, withdrawn clients, 123–124

retention, 10–11, 115–117

socializing, 133

under the influence in group, 127–128

Clinical Institute Withdrawal Assessment–

Alcohol, Revised scale, 35, 64, 71–72

Clinical Trials Network, National Institute 

on Drug Abuse, 2

CMRS. See Circumstances, Motivation, 

Readiness, and Suitability Scales–Revised

cognitive-behavioral approach, 140–141

strengths and challenges of, 141

community reinforcement and contingency 

management approaches, 148–152

research outcomes and findings, 151–152

strengths and challenges of, 151

training, 97

community support, 40–41

goals of, 24, 26

key aspects of, 41

compatible models of care, 20–21

Composite International Diagnostic 

Interview, 85

confidentiality, 61, 63, 72, 96, 128–130

contingency management, 9–10, 148–152

continuing care, 2

definition, 3

people with psychiatric disorders, 170

continuing community care, 24, 40–41

goals of, 25

intensity and duration of, 26

plan for, 76

continuum of care, 17–18

ASAM levels of care, 17

assisting the client through, 18–19

IOT programs, 18

core services of IOT, 27–44, 28

counselor-client trust, 10

couples therapy, 101

cross-training, 170–171

cultural competence, 61

African Americans, 190

Asian Americans and Pacific Islanders, 

191–192

clinical issues, 184, 188–189

clinician issues, 180–181

disability, clients with, 192–193

foreign-born clients, 184

Hispanics/Latinos, 189–190

HIV/AIDS, 192

homeless populations, 194–195

lesbian, gay, and bisexual clients, 192

Native Americans, 190–191

older adults, 195

religious orientation, 187

resources, 197–204

rural populations, 193

staff issues, 185–186

treatment services, 181–182

women, 186–187

worldview differences, 182–183

D

definitions

continuing care, 3

family, 94

intensive outpatient treatment, 3

detoxification

ambulatory, 34–35, 56

providing, 70–72

withdrawal symptoms for four drug classes, 

71

Diagnostic Interview Schedule, 85

DIS. See Diagnostic Interview Schedule
Index 257

disability

clients with, 60, 192–193

resources, 202–203

screening for, 66

disruptive clients, 123

domestic violence, 125–126, 161. See also

violence

barrier to family engagement, 98

dropouts, multiple, 119

drug dealers at facility, 125

DSM-IV criteria for substance dependence 

and substance abuse, 87

duration of treatment, 19

E

education

adult, 44

client, 14

eligibility for IOT, determining, 68

employment

-related challenges, 130–132

services, 42–44

enhanced IOT services, 28, 44–46

enhancing motivation to treatment, 9–10

entry to treatment

ease of, 9

women, 159

evidence-based approaches, 15

F

family involvement in substance abuse treatment, 14–15, 94–95, 170

abstinence, 105–106

adolescents, 172–173

definition of family, 94

engaging the family in treatment, 95–97

estrangement, 103

Family Intervention Program, 174

genogram, 107–108

resources, 112–113

response to relapse, 104

sabotage by family members, 105

sample treatment calendar, 99

social network, 109–110, 111

substance use by family members, 119–

120

family services

clinical issues, 102

education groups, 98–99

expectations about treatment outcomes, 

103

goals of, 95

multifamily groups, 100

mutual-help groups, 102

retreats, 101–102

sample treatment calendar, 99

therapy groups, 100–101

foreign-born clients, 184

funding, of community reinforcement and 

contingency management approaches, 150

G

gang members at facility, 125

genogram, 94, 107–108

gifts from clients to staff, 132–133

goals

family services, 95

IOT, 19

outpatient treatment, 23

stage 1 treatment, 20, 21

stage 2 treatment, 20, 22

stage 3 treatment, 24, 25

stage 4 treatment, 24, 26

graduation from treatment program, 121

group counseling and therapy, 27

adolescents, 174

client under the influence, 127–128

developing cohesion, 120–121

difficult clients, 122–124

family therapy groups, 100–101

key aspects of, 30–32

multifamily groups, 100

psychiatric disorders, 168–169

types of groups, 28–29, 29–30

H

Health Insurance Portability and 

Accountability Act (HIPAA), 72

Hispanics/Latinos, 189–190

resources, 198–199

history form, 84

HIV/AIDS, 128–129, 192

resources, 201

homeless populations, 194–195

housing programs, 44

resources, 203–204
258 Index

I

individual

counseling, 32

family therapy, 101

infectious diseases, 37

initial response procedures, 61

inpatient treatment, versus intensive outpatient treatment, 8

instruments, 85–86

Addiction Severity Index (ASI), 11, 64, 74, 

85

Alcohol Abstinence Self-Efficacy Scale, 135

Alcohol Dependence Scale (ADS), 64, 85

Alcohol Effects Questionnaire, 135

Alcohol-Specific Role Play Test, 135

assessing relapse potential, 135–136

CAGE questionnaire, 64

Circumstances, Motivation, Readiness, and 

Suitability Scales–Revised (CMRS), 70

Clinical Institute Withdrawal Assessment–

Alcohol, Revised scale, 35, 64, 71–72

Composite International Diagnostic 

Interview (CIDI), 85

Diagnostic Interview Schedule (DIS), 85

MINI International Neuropsychiatric 

Interview, 85

Mini-Mental State Examination (MMSE), 

66

Offender Profile Index, 64

Psychiatric Research Interview for 

Substance and Mental Disorders 

(PRISM), 85

Readiness Ruler, 70

Readiness to Change Questionnaire–

Treatment Version, 70

Short Michigan Alcoholism Screening Test 

(S-MAST), 64

Simple Screening Instrument, 64

Situational Confidence Questionnaire, 136

Stages of Change Readiness and 

Treatment Eagerness Scale, 70

Structured Clinical Interview for Diagnosis 

of DSM-IV, Version 2, Substance Abuse 

Disorders module (SCID), 64

Structured Clinical Interview for DSM-IV 

Axis I Disorders, 86

Substance Abuse Screening Instrument 

(SASI), 64

Substance Dependence Severity Scale, 86

Texas Christian University Drug Screen 

(TCUDS), 64, 86

University of Rhode Island Change 

Assessment Scale (URICA), 70

intake interviews, 61–62

effective techniques, 63

including family members, 96

intensive outpatient treatment

case illustrations, 46–55

core features and services, 4–5

culturally competent services, 181

definition, 3, 19, 31

engaging the client, 60–61

functions of, 18

goals of, 19

versus inpatient treatment, 8

the justice system, 155

versus outpatient treatment, 23

intoxication, symptoms at intake, 65

J

justice system

clinical issues, 157

communication between systems, 156

female offenders, 154

memorandum of understanding, 156–157

population in, 152–154

staff issues, 157

stigma, 154

L

LAAM, 36

lesbian, gay, and bisexual clients, 192

resources, 201–202

M

matching treatment services to client needs, 

11

Matrix model, 146–148

research outcomes and findings, 148

strengths and challenges of, 147

medical treatment, 42

medication management, 13–14, 32–34

memorandum of understanding, 156–157

methadone, 36

Mini-Mental State Examination, 66

Minnesota Model. See 12-Step facilitation

MMSE. See Mini-Mental State Examination
Index 259

models, 39, 66

Community Reinforcement Plus Vouchers 

Approach: Treating Cocaine Addiction

(NIDA treatment model), 149

compatible models of care, 20–21

monitoring

abstinence, 12

alcohol and drug use, 38

motivational approaches, 9–10, 68, 141–142

case sample, 77

screening instruments to assess, 70

strengths and challenges of, 143

working with uncommitted clients, 122

mutual-help groups, 12–13, 41–42, 138–139. 

See also continuing community care

alternatives to, 42, 43

families, 102

psychiatric disorders, 169

versus substance abuse treatment, 3–4

N

naltrexone, 14, 36

Native Americans, 190–191

resources, 199–200

nicotine cessation treatment, 45

O

Offender Profile Index, 64

older adults, 195

resources, 204

Omnibus Transportation Employee Testing 

Act of 1991, 131

ongoing care, 11–12

orientation to program, 72

outpatient treatment

goals of, 23

versus intensive outpatient treatment, 23

transition to, 20

P

parenting issues, 90, 158, 187

parent skill training, 45–46

Patient Placement Criteria, ASAM, 68

six dimensions of, 69

pharmacotherapy, 13–14, 32–37, 166

pregnancy, 158, 161

principles of intensive outpatient treatment, 7

principle 1: make treatment readily available, 8

principle 2: ease entry, 9

principle 3: build on existing motivation, 

9–10

principle 4: enhance therapeutic alliance, 

10

principle 5: make retention a priority, 

10–11

principle 6: assess and address individual 

treatment needs, 11

principle 7: provide ongoing care, 11–12

principle 8: monitor abstinence, 12

principle 9: use mutual-help and other 

community-based supports, 12–13

principle 10: use medications if indicated, 

13–14

principle 11: educate about substance use 

disorders, recovery, and relapse, 14

principle 12: engage families, employers, 

and significant others, 14–15

principle 13: incorporate evidence-based 

approaches, 15

principle 14: improve program administration, 15–16

PRISM. See Psychiatric Research Interview 

for Substance and Mental Disorders

privacy. See confidentiality

program administration, 15–16

psychiatric disorders, 90

ABC model for psychiatric screening, 66

barriers to treatment, 162

clinical issues, 164

establishing a therapeutic relationship, 

167–168

group treatment, 168–169

the justice system, 154

medications to treat, 13–14

mutual-help groups, 169

people with psychiatric disorders, 165

symptoms at intake, 65

theoretical background, 162–163

working with clients who have, 122–123

Psychiatric Research Interview for Substance 

and Mental Disorders, 85

psychoeducational counseling, 32

topics addressed in, 33–34

psychotherapy, 42
260 Index

publications

A.A. Member—Medications and Other 

Drugs, 169

Alcoholics Anonymous (the “Big Book”), 42

Assessing Alcohol Problems: A Guide for 

Clinicians and Researchers, 64

Assessing Drug Abuse Among Adolescents 

and Adults: Standardized Instruments, 64

Bridging the Gap Between Practice and 

Research (Institute of Medicine report), 2

Confidentiality of Alcohol and Drug Abuse 

Patient Records Regulation and the 

HIPAA Privacy Rule, The, 63

Counselor’s Manual for Relapse Prevention 

With Chemically Dependent Criminal 

Offenders (TAP 19), 118

Diagnostic Source Book on Drug Abuse 

Research and Treatment, 64

Gender-Responsive Strategies: Research, 

Practice, and Guiding Principles for 

Women Offenders, 154

It Works: How and Why, 42

Living Sober, 42

Matrix Intensive Outpatient Treatment for 

People With Stimulant Use Disorders, 148

Mental Health: Culture, Race, and 

Ethnicity (Surgeon General report), 180

Narcotics Anonymous, 42

Principles of Drug Addiction Treatment: A 

Research-Based Guide (National Institute 

on Drug Abuse), 5, 7, 11

Psychotherapeutic Medications 2003: What 

Every Counselor Should Know, 166

Relapse Prevention and the SubstanceAbusing Criminal Offender (TAP 8), 118

Strategies for Developing Treatment 

Programs for People With Co-Occurring 

Substance Abuse and Mental Disorders

(SAMHSA), 171

Therapeutic Community Curriculum (CSAT 

manual), 145

Twelve Steps and Twelve Traditions, 42

Woman’s Way Through the Twelve Steps, A, 

161

Q

quiet, withdrawn clients, 123–124

R

readily available treatment, 8

readiness for change, assessing, 68

Readiness Ruler, 70

Readiness to Change Questionnaire–

Treatment Version, 70

recreational activities, 44, 91

relapse, 14, 36

family response, 104

instruments, 135–136

versus lapse, 117

prevention quiz, 118

prevention strategies, 117–118, 170

religious orientation, 187. See also spirituality

research outcomes and findings

12-Step approaches, 139–140

case management, 40

cognitive-behavioral therapy, 140–141

community reinforcement and contingency 

management approach, 151

Matrix model, 148

motivational approaches, 142

therapeutic community approach, 145

respect for clients, 61

retention, 10–11, 115–117

round-the-clock crisis coverage, 40, 41

rural populations, 193

resources, 203

S

safety, 125–128, 126. See also violence

SASI. See Substance Abuse Screening 

Instrument

SCID. See Structured Clinical Interview for 

Diagnosis of DSM-IV, Version 2, Substance 

Abuse Disorders module

screening

ABC model for psychiatric screening, 66

brief instruments that assess motivational 

stage, 70

chronic medical conditions, 65

collecting information, 62–64

psychiatric disorders, 164–165

sexuality, 90–91

Short Michigan Alcoholism Screening Test, 

64

Simple Screening Instrument, 64

Situational Confidence Questionnaire, 136
Index 261

S-MAST. See Short Michigan Alcoholism 

Screening Test

socializing, 133

social network, 94–95, 109–110

social network grid, 111

spirituality, 91

staff issues

adolescents, 175

community reinforcement and contingency 

management approaches, 150

counselor-client trust, 10

counselors with dual roles, 134

cross-training, 170–171

cultural competence, 185–186

familiarity with 12-Step culture, 139

familiarity with cognitive-behavioral therapy, 140

female clients, 161–162

the justice system, 157

the Matrix model, 147

motivational approaches, 142

therapeutic community approaches, 144

Stages of Change Readiness and Treatment 

Eagerness Scale, 70

stepdown treatment, 23–24

stigma, in the justice system, 154

Structured Clinical Interview for Diagnosis 

of DSM-IV, Version 2, Substance Abuse 

Disorders module, 64

Structured Clinical Interview for DSM-IV 

Axis I Disorders, 86

substance abuse, as a chronic illness, 12

Substance Abuse Screening Instrument, 64

Substance Dependence Severity Scale, 86

suicidality, screening for at intake, 67

summary report of assessment findings, 

74–75

T

TCUDS. See Texas Christian University Drug 

Screen

Temporary Assistance for Needy Families, 

77

Texas Christian University Drug Screen, 64, 

86

therapeutic alliance, 10

therapeutic community approach, 142–145

research outcomes and findings, 145

strengths and challenges of, 145

TIPs cited

Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of 

Opioid Addiction (TIP 40), 36

Comprehensive Case Management for 

Substance Abuse Treatment (TIP 27), 40, 

166

Continuity of Offender Treatment for 

Substance Use Disorders From Institution 

to Community (TIP 30), 155

Detoxification and Substance Abuse 

Treatment (TIP 45), 35, 72

Enhancing Motivation for Change in 

Substance Abuse Treatment (TIP 35), 62, 

118, 141, 142, 168

Guide to Substance Abuse Services for 

Primary Care Clinicians, A (TIP 24), 35

Improving Cultural Competence in 

Substance Abuse Treatment (forthcoming), 61, 181

Integrating Substance Abuse Treatment 

and Vocational Services (TIP 38), 44

Intensive Outpatient Treatment for Alcohol 

and Other Drug Abuse (TIP 8), 1

Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs

(TIP 43), 37, 67

Naltrexone and Alcoholism Treatment (TIP 

28), 36

Screening and Assessing Adolescents for 

Substance Use Disorders (TIP 31), 67, 

171

Screening for Infectious Diseases Among 

Substance Abusers (TIP 6), 37

Simple Screening Instruments for Outreach 

for Alcohol and Other Drug Abuse and 

Infectious Diseases (TIP 11), 64

Substance Abuse: Administrative Issues in 

Outpatient Treatment (TIP 46), 1, 16, 32, 

61, 74, 166, 181, 188

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (forthcoming), 

157

Substance Abuse Treatment and Domestic 

Violence (TIP 25), 67, 89, 126, 157, 161

Substance Abuse Treatment and Family 

Therapy (TIP 39), 30, 93, 172
262 Index

Substance Abuse Treatment for Adults in 

the Criminal Justice System (TIP 44), 127, 

157

Substance Abuse Treatment for Persons 

With Child Abuse and Neglect Issues (TIP 

36), 90, 158

Substance Abuse Treatment for Persons 

With Co-Occurring Disorders (TIP 42), 37, 

42, 123, 165, 167

Substance Abuse Treatment for Persons 

With HIV/AIDS (TIP 37), 37, 129

Substance Abuse Treatment: Group 

Therapy (TIP 41), 29, 120

Substance Use Disorder Treatment for 

People With Physical and Cognitive 

Disabilities (TIP 29), 66, 167

Treatment for Stimulant Use Disorders, 

(TIP 33), 14, 118

Treatment of Adolescents With Substance 

Use Disorders (TIP 32), 171

Tuberculosis Epidemic: Legal and Ethical 

Issues for Alcohol and Other Drug Abuse 

Treatment Providers, The (TIP 18), 37

transition

outpatient treatment, 20

planning, 23

transportation services, 44

treatment

duration of, 19

entry to, 9, 159

graduation from, 121

intensity of, 19

interventions, 15

matching to client needs, 11

medical, 42

plan, 75–83

settings, 19

stages of, 20

well-known person, 129–130

trust between counselor and client, 10

U

University of Rhode Island Change 

Assessment Scale, 70

URICA. See University of Rhode Island 

Change Assessment Scale

urine drug tests, 12

V

violence, 126

domestic, 67, 89, 98, 125–126, 161

screening for at intake, 67

treating violent clients, 127

women, 158

vocational training, 42–44

W

Web sites cited

Adult Children Anonymous, 102

Adult Children of Alcoholics, 102

Al-Anon/Alateen, 13, 99

Alcohol Abstinence Self-Efficacy Scale, 135

Alcoholics Anonymous, 13, 42, 170

American Family Physician, 35

assessment instruments, 70

Center for Substance Abuse Prevention 

Workplace Resource Center, 131

Center for Substance Abuse Treatment, 

138

children and families, 46

Clinical Institute Withdrawal Assessment–

Alcohol, Revised scale, 72

Cocaine Anonymous, 42

Detoxification Clinical Practice Guidelines, 35

domestic violence assessment, 89

Double Trouble in Recovery, 169

Dual Recovery Anonymous, 169

Families Anonymous, 99

Fortune Society, 43

General Services Offices of Alcoholics 

Anonymous, 42

Hazelden Foundation, 137

Hispanic Health Council, 43

Institute on Black Chemical Abuse, 43

Jewish Alcoholics, Chemically Dependent 

Persons and Significant Others, 187

Medication Assisted Treatment, 37

Mini-Mental State Examination, 66

Nar-Anon, 13, 99

Narcotics Anonymous, 13, 42

National Black Alcoholism and Addictions 

Council, 43

National Clearinghouse for Alcohol and 

Drug Information, 138

National Head Start Association, 46

National Institute on Alcohol Abuse and 

Alcoholism, 135, 137
Index 263

Office of Juvenile Justice and Delinquency 

Prevention, 46

Patient Placement Criteria, ASAM, 68

Principles of Addiction Medicine, 35

Rational Recovery, 13

resources for family-based services, 112–

113

Save Our Selves, 43

Secular Organizations for Sobriety, 43

Self-Management and Recovery Training, 43

Smart Recovery, 13

Women for Sobriety, 13, 43

withdrawal

symptoms at intake, 65

symptoms for four drug classes, 71

women, 157–158

barriers to treatment, 159

clinical issues, 159–161

culturally competent services, 186–187

domestic violence, 158, 161

entry to treatment, 159

the justice system, 154

pregnancy, 158, 161

Y

young adults, 175–177

265

TIP 1 State Methadone Treatment Guidelines—Replaced by 

TIP 43

TIP 2* Pregnant, Substance-Using Women—BKD107 

 Quick Guide for Clinicians QGCT02

 KAP Keys for Clinicians KAPT02

TIP 3 Screening and Assessment of Alcohol- and Other 

Drug-Abusing Adolescents—Replaced by TIP 31 

TIP 4 Guidelines for the Treatment of Alcohol- and Other 

Drug-Abusing Adolescents—Replaced by TIP 32 

TIP 5 Improving Treatment for Drug-Exposed Infants—

BKD110

TIP 6 Screening for Infectious Diseases Among Substance 

Abusers—BKD131

 Quick Guide for Clinicians QGCT06

 KAP Keys for Clinicians KAPT06

TIP 7 Screening and Assessment for Alcohol and Other 

Drug Abuse Among Adults in the Criminal Justice 

System—Replaced by TIP 44 

TIP 8 Intensive Outpatient Treatment for Alcohol and 

Other Drug Abuse—Replaced by TIPs 46 and 47

TIP 9 Assessment and Treatment of Patients With 

Coexisting Mental Illness and Alcohol and Other 

Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of Cocaine-Abusing 

Methadone-Maintained Patients—Replaced by TIP 43

TIP 11 Simple Screening Instruments for Outreach for 

Alcohol and Other Drug Abuse and Infectious 

Diseases—BKD143

 Quick Guide for Clinicians QGCT11

 KAP Keys for Clinicians KAPT11

TIP 12 Combining Substance Abuse Treatment With 

Intermediate Sanctions for Adults in the Criminal 

Justice System—Replaced by TIP 44

TIP 13 Role and Current Status of Patient Placement 

Criteria in the Treatment of Substance Use 

Disorders—BKD161

 Quick Guide for Clinicians QGCT13

 Quick Guide for Administrators QGAT13

 KAP Keys for Clinicians KAPT13

TIP 14 Developing State Outcomes Monitoring Systems for 

Alcohol and Other Drug Abuse Treatment—BKD162 

TIP 15 Treatment for HIV-Infected Alcohol and Other Drug 

Abusers—Replaced by TIP 37

TIP 16 Alcohol and Other Drug Screening of Hospitalized 

Trauma Patients—BKD164

 Quick Guide for Clinicians QGCT16

 KAP Keys for Clinicians KAPT16

TIP 17 Planning for Alcohol and Other Drug Abuse 

Treatment for Adults in the Criminal Justice 

System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and Ethical 

Issues for Alcohol and Other Drug Abuse Treatment 

Providers—BKD173

 Quick Guide for Clinicians QGCT18

 KAP Keys for Clinicians KAPT18

TIP 19 Detoxification From Alcohol and Other Drugs—

Replaced by TIP 45 

TIP 20 Matching Treatment to Patient Needs in Opioid 

Substitution Therapy—Replaced by TIP 43 

TIP 21 Combining Alcohol and Other Drug Abuse 

Treatment With Diversion for Juveniles in the 

Justice System—BKD169

 Quick Guide for Clinicians and Administrators QGCA21

TIP 22 LAAM in the Treatment of Opiate Addiction—

Replaced by TIP43

TIP 23 Treatment Drug Courts: Integrating Substance Abuse 

Treatment With Legal Case Processing—BKD205

 Quick Guide for Administrators QGAT23

TIP 24 A Guide to Substance Abuse Services for Primary 

Care Clinicians—BKD234

 Quick Guide for Clinicians QGCT24

 KAP Keys for Clinicians KAPT24

TIP 25 Substance Abuse Treatment and Domestic 

Violence—BKD239

 Linking Substance Abuse Treatment and Domestic 

Violence Services: A Guide for Treatment Providers 

MS668

 Linking Substance Abuse Treatment and Domestic 

Violence Services: A Guide for Administrators MS667

 Quick Guide for Clinicians QGCT25

 KAP Keys for Clinicians KAPT25

CSAT TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians,

researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art 

treatment practices. TIPs are developed under CSAT’s Knowledge Application Program to improve the treatment capabilities of 

the Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is 

divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page 

numbers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and 

summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept 

within a treatment provider’s reach and consulted frequently. The Keys allow the busy clinician or program administrator to 

locate information easily and to use this information to enhance treatment services.

*Under revision
266

TIP 26 Substance Abuse Among Older Adults—BKD250 

 Substance Abuse Among Older Adults: A Guide for 

Treatment Providers MS669

 Substance Abuse Among Older Adults: A Guide for 

Social Service Providers MS670

 Substance Abuse Among Older Adults: Physician’s 

Guide MS671

 Good Mental Health is Ageless PHD881 (English), 

PHD881S (Spanish)

 Aging, Medicines and Alcohol PHD882 (English), 

PHD882S (Spanish)

 Quick Guide for Clinicians QGCT26

 KAP Keys for Clinicians KAPT26

TIP 27 Comprehensive Case Management for Substance 

Abuse Treatment—BKD251

 Case Management for Substance Abuse Treatment: A 

Guide for Treatment Providers MS673

 Case Management for Substance Abuse Treatment: A 

Guide for Administrators MS672

 Quick Guide for Clinicians QGCT27

 Quick Guide for Administrators QGAT27

TIP 28 Naltrexone and Alcoholism Treatment—BKD268

 Naltrexone and Alcoholism Treatment: Physician’s 

Guide MS674

 Quick Guide for Clinicians QGCT28

 KAP Keys for Clinicians KAPT28

TIP 29 Substance Use Disorder Treatment for People With 

Physical and Cognitive Disabilities—BKD288 

 Quick Guide for Clinicians QGCT29

 Quick Guide for Administrators QGAT29

 KAP Keys for Clinicians KAPT29

TIP 30 Continuity of Offender Treatment for Substance Use 

Disorders From Institution to Community—BKD304

 Quick Guide for Clinicians QGCT30

 KAP Keys for Clinicians KAPT30

TIP 31 Screening and Assessing Adolescents for Substance 

Use Disorders—BKD306

 See companion products for TIP 32. 

TIP 32 Treatment of Adolescents With Substance Use 

Disorders—BKD307

 Quick Guide for Clinicians QGC312

 KAP Keys for Clinicians KAP312

TIP 33 Treatment for Stimulant Use Disorders—BKD289

 Quick Guide for Clinicians QGCT33

 KAP Keys for Clinicians KAPT33

TIP 34 Brief Interventions and Brief Therapies for 

Substance Abuse—BKD341

 Quick Guide for Clinicians QGCT34

 KAP Keys for Clinicians KAPT34

TIP 35 Enhancing Motivation for Change in Substance 

Abuse Treatment—BKD342

 Quick Guide for Clinicians QGCT35

 KAP Keys for Clinicians KAPT35

Faces of Change PHD1103

 TIP 36 Substance Abuse Treatment for Persons With Child 

Abuse and Neglect Issues—BKD343

 Quick Guide for Clinicians QGCT36

 KAP Keys for Clinicians KAPT36

 Helping Yourself Heal: A Recovering Woman’s 

Guide—PHD981 (English), PHD981S (Spanish)

 Helping Yourself Heal: A Recovering Man’s 

Guide—PHD1059 (English), PHD1059S (Spanish) 

TIP 37 Substance Abuse Treatment for Persons With HIV/

AIDS—BKD359

 HIV/AIDS: Is Your Client at Risk? MS965

 Drugs, Alcohol and HIV/AIDS: A Consumer Guide 

PHD1126 (English), PHD1134 (Spanish)

 Quick Guide for Clinicians MS678

 KAP Keys for Clinicians KAPT37

TIP 38 Integrating Substance Abuse Treatment and 

Vocational Services—BKD381

 Quick Guide for Clinicians QGCT38

 Quick Guide for Administrators QGAT38

 KAP Keys for Clinicians KAPT38

TIP 39 Substance Abuse Treatment and Family Therapy—

BKD504

 Quick Guide for Clinicians QGCT39

 Quick Guide for Administrators QGAT39

TIP 40 Clinical Guidelines for the Use of Buprenorphine in 

the Treatment of Opioid Addiction—BKD500

 Quick Guide for Physicians QGPT40

 KAP Keys for Physicians KAPT40 

TIP 41 Substance Abuse Treatment: Group Therapy—

BKD507

 Quick Guide for Clinicians QGCT41

TIP 42 Substance Abuse Treatment for Persons With CoOccurring Disorders—BKD515

 Quick Guide for Clinicians QGCT42

 Quick Guide for Administrators QGAT42

 KAP Keys for Clinicians KAPT42

TIP 43 Medication-Assisted Treatment for Opioid Addiction 

in Opioid Treatment Programs—BKD524

 Quick Guide for Clinicians QGCT43

 KAP Keys for Clinicians KAPT43

TIP 44 Substance Abuse Treatment for Adults in the 

Criminal Justice System—BKD526

 Quick Guide for Clinicians QGCT44

 KAP Keys for Clinicians KAPT44 

TIP 45 Detoxification and Substance Abuse Treatment—

BKD541

TIP 46 Substance Abuse: Administrative Issues in Outpatient 

Treatment—BKD545

 Quick Guide for Administrators QGAT46

TIP 47 Substance Abuse: Clinical Issues in Intensive 

Outpatient Treatment—BKD551
Treatment Improvement Protocols (TIPs) from the Substance Abuse and Mental Health Services 

Administration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT)

Place the quantity (up to 5) next to the publications you would like to receive and print your mailing address below.

 ___ TIP 2* BKD107 

 ___ QG† for Clinicians QGCT02 

 ___ KK† for Clinicians KAPT02 

 ___ TIP 5 BKD110 

 ___ TIP 6 BKD131 

 ___ QG for Clinicians QGCT06 

 ___ KK for Clinicians KAPT06 

 ___ TIP 11 BKD143 

 ___ QG for Clinicians QGCT11 

 ___ KK for Clinicians KAPT11 

 ___ TIP 13 BKD161 

 ___ QG for Clinicians QGCT13 

 ___ QG for Administrators QGAT13 

 ___ KK for Clinicians KAPT13 

 ___ TIP 14 BKD162 

 ___ TIP 16 BKD164 

 ___ QG for Clinicians QGCT16 

 ___ KK for Clinicians KAPT16 

 ___ TIP 18 BKD173 

 ___ QG for Clinicians QGCT18 

 ___ KK for Clinicians KAPT18 

 ___ TIP 21 BKD169 

 ___ QG for Clinicians & Administrators

QGCA21 

 ___ TIP 23 BKD205 

 ___ QG for Administrators QGAT23 

 ___ TIP 24 BKD234 

 ___ QG for Clinicians QGCT24 

 ___ KK for Clinicians KAPT24 

 ___ TIP 25 BKD239 

 ___ Guide for Treatment Providers MS668

 ___ Guide for Administrators MS667 

 ___ QG for Clinicians QGCT25 

 ___ KK for Clinicians KAPT25 

 ___ TIP 26 BKD250 

 ___ Guide for Treatment Providers MS669 

 ___ Guide for Social Service Providers MS670 

 ___ Physician’s Guide MS671

 ___ Good Mental Health PHD881

 ___ Good Mental Health PHD881S 

(Spanish) 

 ___ Aging, Medicine PHD882

 ___ Aging, Medicine PHD882S (Spanish)

 ___ QG for Clinicians QGCT26 

 ___ KK for Clinicians KAPT26 

 ___ TIP 27 BKD251 

 ___ Guide for Treatment Providers MS673

 ___ Guide for Administrators MS672 

 ___ QG for Clinicians QGCT27 

 ___ QG for Administrators QGAT27 

 ___ TIP 28 BKD268 

 ___ Physician’s Guide MS674 

 ___ QG for Clinicians QGCT28 

 ___ KK for Clinicians KAPT28 

 ___ TIP 29 BKD288 

 ___ QG for Clinicians QGCT29 

 ___ QG for Administrators QGAT29 

 ___ KK for Clinicians KAPT29 

 ___ TIP 30 BKD304 

 ___ QG for Clinicians QGCT30 

 ___ KK for Clinicians KAPT30 

 ___ TIP 31 BKD306

(see products under TIP 32) 

 ___ TIP 32 BKD307 

 ___ QG for Clinicians QGC312 

 ___ KK for Clinicians KAP312 

 ___ TIP 33 BKD289 

 ___ QG for Clinicians QGCT33 

 ___ KK for Clinicians KAPT33 

 ___ TIP 34 BKD341 

 ___ QG for Clinicians QGCT34 

 ___ KK for Clinicians KAPT34 

 ___ TIP 35 BKD342 

 ___ QG for Clinicians QGCT35 

 ___ KK for Clinicians KAPT35

 ___ Faces PHD1103 

 ___ TIP 36 BKD343 

 ___ QG for Clinicians QGCT36 

 ___ KK for Clinicians KAPT36 

 ___ Brochure for Women (English)

PHD981 

 ___ Brochure for Women (Spanish)

PHD981S 

 ___ Brochure for Men (English)

PHD1059

 ___ Brochure for Men (Spanish)

PHD1059S

 ___ TIP 37 BKD359 

 ___ Your Client At Risk MS965

 ___ Drugs, Alcohol & HIV/AIDS PHD1126

 ___ Drogas, Alcohol y el VIH/SIDA PHD1134

 ___ QG for Clinicians QGCT37

 ___ KK for Clinicians KAPT37 

 ___ TIP 38 BKD381 

 ___ QG for Clinicians QGCT38 

 ___ QG for Administrators QGAT38 

 ___ KK for Clinicians KAPT38 

 ___ TIP 39 BKD504

 ___ QG for Clinicians QGCT39

 ___ QG for Administrators QGAT39

 ___ TIP 40 BKD500

 ___ QG for Physicians QGPT40

 ___ KK for Physicians KAPT40

 ___ TIP 41 BKD507

 ___ QG for Clinicians QGCT41 

 ___ TIP 42 BKD515 

 ___ QG for Clinicians QGCT42

 ___ QG for Administrators QGAT42

 ___ KK for Clinicians KAPT42

 ___ TIP 43 BKD524

 ___ QG for Clinicians QGCT43

 ___ KK for Clinicians KAPT43

 ___ TIP 44 BKD526

 ___ QG for Clinicians QGCT44

 ___ KK for Clinicians KAPT44

 ___ TIP 45 BKD541

 ___ TIP 46 BKD545

 ___ TIP 47 BKD551

Name:

Address:

City, State, Zip:

Phone and e-mail: 

You can either mail this form or fax it to (240) 221-4292. Publications also can be ordered by calling SAMHSA’s NCADI at 

(800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.

TIPs can also be accessed on line at www.kap.samhsa.gov.

*Under revision

†QG = Quick Guide; KK = KAP Keys
SAMHSA’s National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345

Rockville, MD 20847-2345

STAMP

FOLD

FOLD

This TIP, Substance Abuse: Clinical Issues in Intensive Outpatient 

Treatment, addresses the practical needs of treatment providers 

as they design and implement intensive outpatient treatment 

programs. The TIP provides specific information on the principles of intensive outpatient treatment; services and treatment 

models; modifications for distinct population groups; culturally 

competent treatment; screening and patient placement criteria; 

counseling methods and techniques, including involvement of 

families; and the continuum of care. The TIP also covers such 

important issues as how to improve early retention, provide the 

appropriate length and intensity of services, provide the most 

promising mix of wrap-around services for positive client outcomes, and arrange ongoing care in the community.

Quick Guide for Clinicians

KAP Keys for Clinicians

Collateral Products

Based on TIP 47

Substance Abuse:

Clinical Issues in Intensive 

Outpatient Treatment

DHHS Publication No. (SMA) 06-4182

NCADI Publication No. BKD551

Printed 2006

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment