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Model of care practice guidelines
Counselling and Treatment Service
Alcohol and Drug Services
Version / Author/Designation / Date
1.0 / M. Whitney, Clinical Supervisor / 26 September 2011

Contents

Contents

Purpose

Background

Scope

Service Description

Client Characteristics

Principles of Care

Treatment Processes

Framework

Clinical challenges

General treatment process

Service Relationships

Psychotherapeutic Interventions

General considerations

Brief interventions

Cognitive behavioural therapy (CBT)

Motivational enhancement therapy (MET)

Mindfulness based stress reduction (MBSR)

Acceptance and commitment therapy (ACT)

Psychodynamic psychotherapy

Group Programs

Clinical Governance

Definitions

References

Appendices

Appendix A. common standardised screening tools for assessing substance use

Purpose

This document aims to provide clinicians in the Counselling and Treatment Service (CTS) of Alcohol and Drug Services with practical guidelines for providing care to clients of the service. It is intended to be a working document that is open to revision by all staff. It aims to:

  • orient new clinicians to the nature of service delivery in CTS
  • provide a framework for communicating to key stakeholders what services CTS offers and their purposes and benefits, and
  • outline a common starting point for CTS clinicians to develop their clinical practice and share their professional development.

The model of care outlined herein does not aim to dictate how clinicians will deliver alcohol and other drugs counselling and other psychotherapeutic services. Each practitioner is responsible for updating their knowledge by accessing new research as it is published and maintaining currency in their clinical practice. This document instead aims to provide transparency, accountability and a rationale for innovation in service delivery through describing the core principles of CTS business. It is intended to complement other resources relevant to CTS staff, including standard operating procedures for the provision of individual and group based counselling and psychotherapy.

Background

Counselling and other psychotherapeutic, or psychosocial, interventions are often the most common form of alcohol and other drug treatment in Australia. In 2008-09, they accounted for 37% per cent of all requests for substance abuse treatment in Australia (Australian Institute of Health and Welfare, 2010) and 30% of all treatment episodes in the ACT (Australian Institute of Health and Welfare, 2011). The model of care described in this document accords with the intentions of the National Drug Strategy 2010-2015to improve treatment outcomes and promote the use of evidence based and evidence informed practice by clinicians. Accordingly, key references relied upon to validate the clinical efficacy of the psychotherapeutic interventions for alcohol and other drug treatment described here are the NSW Health practice guidelines for drug and alcohol psychosocial interventions (NSW Department of Health, 2008); and the substance abuse treatment guidelines of the American Psychiatric Association (American Psychiatric Association, 2010), the American Academy of Addiction Psychiatry and the American Society of Addiction Medicine (Galanter & Kleber, 2011).

Scope

This document is intended for all clinicians in CTS who provide direct counselling and/or psychotherapy interventions. This includes staff employed as health professionals (psychologists, social workers and counsellors) as well as staff in positions classified as ‘drug and alcohol worker’ (intake officers). It also applies to students from allied health disciplines undertaking clinical placements in CTS.

Service Description

The Counselling and Treatment Service provides central telephone intake assessment services for all programs offered by Alcohol and Drug Services as well as information and referral to other local and interstate alcohol and other drug treatment services. The core business of CTS is the provision ofcounselling and psychotherapy for hazardous or harmful alcohol and other drug use as well as substance intoxication, substance abuse and substance dependence disorders defined by the DSM-IV-TR (American Psychiatric Association, 2000).It also offers treatment for a range of psychosocial problems that either result in or derive from the presenting substance use difficulties. Individual and group psychotherapy programs are offered. The bulk of CTS services are provided in a face-to-face format during standard business hours, but there is brief telephone counselling provided 24 hours a day, 7 days a week for anyone seeking assistance for problems associated with binge drinking. It also offers a secondary needle and syringe program. Health promotion on alcohol and other drug use and treatment is offered on demand to both government and nongovernment organisations and groups.

CTS is afree outpatient government service that offers full–time services at its central office in Civic, Canberra, and part-time services at government health services in the main town centres of Canberra.Outreach services are provided to clients of the youth custodial facility Bimberi Youth Justice Centre as well as prisoners in the Alexander Maconochie Centre.Clients are seen on average once a week, though the intensity and duration of treatment may be increased or decreased depending on the needs of the client and the capacity of the organisation.

All CTS clinicians meet minimum qualifications for providing alcohol and other drug services (Certificate IV in Alcohol and Other Drugs Work). Intake staff are designated drug and alcohol workers who provide assessments and brief telephone counselling interventions. Allied health professionals (e.g., psychologists, social workers and counsellors with postgraduate certification) provide counselling and psychotherapy interventions in addition to assessments and brief interventions. Allied health professional staff are likely to be trained in more than one form of psychotherapy but at a minimum are competent to provide cognitive behaviour therapy (e.g., motivational interviewing, relapse prevention training) for substance use disorders. All staff operate according to ACT Government Health Directorate policies covering their code of conduct, client confidentiality and professional ethics.

Client Characteristics

CTS offers services to young people aged 12 to 18 with complex needs through its Youth Drug and Alcohol Program (YDAP) as well as adults aged 18 and over who are resident in the ACT. Services are available for both substance users as well as others affected by the substance use of a loved one.

In 2008-09, two-thirds (63%) of counselling treatment episodes in the ACT[1] were for men;90% of clients seeking counsellingdid so for their own drug use; the median age of clients was 32;the most common principal substance clients sought assistance with was alcohol (56%) followed by cannabis (16%); and the median number of days for a treatment episode was 32 (Australian Institute of Health and Welfare, 2011).

Principles of Care

CTS services are based on the demand and harm reduction principles of the National Drug Strategy 2010-2015. Harm reduction is a realistic and practical approach focussed on reducing the negative effects of a client’s problematic substance use and reinforcing any positive changes the client is able to make. The harm minimisation approach recognises that abstinence may be the only safe goal for clients with significant substance dependence. Reducing demand for, and the harms associated with, substance use is the primary goal of CTS treatment interventions followed by a reduction in, if not cessation in, alcohol and other drug use. Harm reduction approaches include education about the harms of substance abuse; the provision of strategies to reduce the frequency and amount of substances used by clients; and a focus on the negative effects of problematic alcohol and drug use.

CTS interventions also accord with several principles of drug addiction treatment of the National Institute on Drug Abuse (National Institute on Drug Abuse, 2009:2)—namely, that:

  • no single treatment is appropriate for everyone. Treatment interventions need to be matched to an individual’s particular problems in order to allow them to successfully resume their functioning.
  • treatment needs to be readily available. Because clients are ambivalent about entering treatment, they need to be able to take advantage of available services.
  • effective treatment attends to multiple needs of the individual, not just his or her substance abuse. Treatment needs to address substance abuse as well as any associated medical, psychological, social, vocational and legal problems. It also needs to be appropriate to the individual’s age, gender, ethnicity and culture.
  • remaining in treatment for an adequate period of time is critical. Recovery from substance dependence is a long-term process and frequently requires multiple episodes of treatment. The best outcomes occur with longer durations of treatment. Because individuals leave treatment prematurely, programs should include strategies to engage and keep clients in care.
  • an individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. Clients need various combinations of service and treatment components during the course of treatment and recovery.
  • many substance dependent individuals also have other mental health disorders. Clients presenting with substance abuse problems should be assessed for other mental health conditions.

Treatment Processes

Framework

CTS utilises a client-centred,stepped, integrated model of treatment. In offering client centred care, clinicians work collaboratively with clients in such a way that respects their experience, expertise, perceptions and goals. Client centred care appreciates that clients have the right to set their own goals, draw their own conclusions and make their own choices about treatment.

In a stepped care model of counselling and psychotherapy (Bower & Gilbody, 2005; Haaga, 2003), cliniciansbegin with the interventions and treatment methods that are the least intensive or restrictive but most likely to be effective and provide safety and security for the client. After monitoring their effectiveness, in line with the needs of the client, the interventions are then either ‘stepped up’ or ‘stepped down’ in intensity such that more intensive treatments are provided to people who do not benefit from simpler initial treatments. As a general principle, minimal interventions are best restricted to the least severe disorders. The chronic nature of substance dependence, underpinned by a vulnerability to relapse, suggests that maintaining therapeutic contact in a continuing care format over extended periods (e.g., more than 6 months) results in better long-term outcomes (McKay, 2005). Changes in therapeutic intensity during the treatment period can be made in response to changes in symptoms and functioning (e.g., ‘stepping down’ treatment during periods of sustained abstinence or non-problematic use). It is important to note that while both minimal interventions and intensive interventions are effective, they are not equivalent. Moreover, as clients are active participants in treatment decision-making, they need to be offered choice about the intensity of interventions available to them in collaboration with the treating clinician(Bower & Gilbody, 2005).

Stepped care requires clinicians to regularly monitor client progress and outcomes, particularly symptom severity and behaviour. The benefits ofthe approach are that it isself-correcting and uses therapeutic resources (i.e., clinician time and cost) efficiently.Several models have been developed for a range of substances and psychological disorders (Bower & Gilbody, 2005). Less intensive interventions include psychoeducation, brief counselling (1-3 sessions), time-limited group programs and guided self-help approaches while more intensive interventions include a full course of psychotherapy. Interventions can also be ‘stepped up’ by increases in the frequency and duration of sessions, expanding the focus of the intervention to address multiple issues simultaneously (e.g., to address comorbid conditions) and incorporating a range of different strategies at the same time (e.g., pharmacotherapy in addition in psychotherapy) and modalities (e.g., telephone monitoring in addition to face-to-face contact).

Figure 1 illustrates the progress of treatment using a stepped care model based on the decision rules for patient placement treatment matching criteria developed by the American Society of Addiction Medicine Clinicians (Gastfriend & Mee-Lee, 2011) as well as the progress of psychosocial treatment interventions developed by NSW Health (NSW Department of Health, 2008). Following a thorough comprehensive assessment, clinicians should discuss with clients who are commencing treatmenttheir entry at any level along the continuum of care. Progress represents movement to the next stage of care. Levels of care are discrete but can be considered benchmarks for measuring treatment response based on initial client need. Clients can skip levels of care as needed. A range of treatment options and advice should be presented as part of an integrated treatment plan.

Figure 1. The sequence for client assessment and matching to level of treatment.

Using this approach, at initial assessment, high risk behaviours that would interfere with the client’s ability to engage in counselling and psychotherapy are identified and referrals are made to relevant specialist treatment providers. For clients who are at imminent risk of suicide, for example, this would be the Crisis and Assessment and Treatment Team of Mental Health ACT while for clients with imminent risk of seizure or severe withdrawal symptoms, it would be the Withdrawal Services unit of Alcohol and Drug Services. For clients whose progress in counselling or psychotherapy would be significantly undermined by social and structural factors in their immediate environment, referral to residential treatment needs to be considered.

If there are no other imminent risks, the assessment for counselling and psychotherapy should identify the client’s history of engagement in any brief or early intervention programs, such as education sessions about the effects of substance use and symptom management. Upon review of the client’s response to engagement at this level, and monitoring of risk factors that could impact on engagement with CTS, consideration can be given to the need for more intense intervention, such as a course of psychotherapy, if there are a residual symptoms and the client’s functioning remains low despite the brief intervention. Time limited, structured psychotherapies with a strong evidence base of effectiveness across a wide range of disorders, such as cognitive behaviour therapy, are recommended at this point. For substance abuse and dependence, relapse prevention strategies aimed at identifying specific relapse triggers, developing a relapse prevention plan and evaluating lapses would be introduced at this point.

Following completion of a course of treatment, the client’s progress should be evaluated. Residual symptoms or specific problems in functioningthat increase the likelihood of the client’s relapse to substance abuse or dependence implicate an extended treatment program. Usually thiswill involve a more targeted form of psychotherapy, such as, for example, mindfulness based stress reduction, trauma therapy or psychodynamic psychotherapy. These interventions would be used to address symptoms related to chronic problems with mood, anxiety, psychosis, trauma,pain, compulsions and characterological difficulties with affect tolerance and regulation, identity, relationships and cognition and memory that are often associated with chronic substance dependence (Khantzian, Halliday, & McAuliffe, 1990). This level of intervention would be subject to ongoing monitoring and assessment such that progress in treatment would lead to discharge and after-care support while therapeutic impasses or deterioration would lead to a review of the delivery of psychotherapy and/or a referral for conjunct treatment (e.g. psychiatric review, crisis interventions etc.). Recommendations for specific approaches are considered in the section entitled ‘Psychotherapeutic Interventions’. In general, regardless of the level of care at which they enter treatment, a client’s progress can be assessed at each stage according to their level of treatment engagement, their recovery and maintenance of functioning and the degree of support in their immediate living environment.

Given that clients presenting for substance abuse psychotherapeutic interventions typically have coexisting psychiatric and physical health difficulties, treatment needs to be provided in an integrated manner. Integrated treatment includes strategies that address both the substance use and coexisting concern at the same time; strategies for dealing with the substance use that take the coexisting condition into account; referral for concurrent treatment; models of treatment that conceptualise substance use in a manner consistent with underlying concerns; and approaches that build resilience for managing coexisting concerns.

Clinical challenges

Reducing client attrition from treatment needs to be a clinician priority. Engagement and retention in treatment are improved by a number of factors. The most commonly referenced is the skill of the clinician in forming a collaborative working relationship, known as the therapeutic alliance, with clients. The importance of this factor is recognised in the universal promotion of motivational interviewing, which is based on the use of specific clinician relational strategies for managing client resistance, ambivalence and discrepancies between client goals and their substance use. Engagement and retention are also enhanced by clinicians taking a thorough treatment history from the client to identify what aspects of past treatment were appealing or led to the client dropping out prematurely from it. Clinicians also need to provide flexible treatment schedules within the limits of their roles to accommodate clients who may be inhibited from pursuing assistance because of work or childcare responsibilities. Consideration should also be given to offering group interventions early in treatment so that treatment ambivalent clients can participate in treatment with identified peers who may offer support and the safety of numbers.

Clinicians can also solidify client commitment to treatment by clarifying treatment processes and goals in collaboration with the client. Clients with substance use disorders often have an impaired ability to form and maintain attachments to others (Flores, 2004). Seeking feedback from the client in the earliest sessions about their experience of the treatment relationshipcan forestall flights from treatment. In this regard, clinicians need skills in monitoring and assessing client reactions to them as therapists so as to be able to respond non-defensively to those clients whose characteristic way of managing relationships is initially dismissive or hostile. Finally, clinicians’ demonstration of dedication to the client by following up on cancelled and unattended appointments can positively affect the client’s attitude and willingness to complete treatment.