Mindfulness-based cognitive therapy techniques
Summary
Learn how to evaluate addiction treatment programs and determine the appropriate level of care for clients with substance use disorders.
Understand how substance use disorder therapy fits into the broader continuum of care, including outpatient, residential, and inpatient treatment options.
Explore how ASAM Criteria can help therapists assess client needs, make referrals, and identify when specialized treatment may be necessary.
Discover evidence-based strategies for supporting recovery, maintaining sobriety, and responding to relapse with an adaptable treatment approach.
As a therapist, it can be tricky to identify high-quality addiction treatment programs for clients.
Substance use disorder therapy options are now wide-ranging compared to 12-step or rehab options a decade ago. This article briefly explores what levels of care are appropriate for clients with substance use disorders, when to refer out, how to handle relapse, and tips to maintain sobriety.
Substance use disorders occur on a spectrum from mild to severe. Not everyone with a substance use disorder requires inpatient treatment. Some people with mild or moderate SUD may choose to attend an intensive outpatient program and attend weekly therapy, or they may not be ready to address their substance use.
Given the shame that surrounds SUD, which acts as a significant barrier to recovery, it can be tricky to know the extent of a client’s relationship with substances and when to refer to a specialized program. This is where the ASAM criteria can be helpful.
ASAM levels of care for addiction treatment
The ASAM criteria provide a unified language for defining the continuum of addiction treatment programs and the different levels of care available for clients with substance use disorders.
You’ll find the criteria define standards for placement, provide guidelines for continued services, and outline critical information for transferring clients with co-occurring conditions.
ASAM criteria defines four levels of addiction treatment:
Level 1 outpatient: This level includes medically managed outpatient treatment (1.7), outpatient therapy (1.5), and long-term remission monitoring (1.0).
Level 2 IOP/HIOP: This level describes intensive outpatient (2.1), high-intensity outpatient (2.5), and medically managed intensive outpatient (2.7).
Level 3 residential: This level includes clinically managed low-intensity residential treatment (3.1), clinically managed high-intensity residential (3.5), and medically managed residential (3.7).
Level 4 inpatient: This level is designated for medically managed inpatient treatment (4.0).
Understanding these levels of care can help therapists determine when outpatient substance use disorder therapy may be appropriate and when a higher level of treatment may be necessary.
When should therapists refer out?
ASAM provides a free assessment guide outlining six dimensions of care with detailed questions and assessment criteria. These guidelines can help therapists make informed referral decisions and determine whether a client’s needs can be addressed through substance use disorder therapy or require more intensive support.
The assessment cannot replace a thorough biopsychosocial assessment, but it can help quickly determine the need for emergent referrals and the level of care required. The guidelines state that if a patient meets criteria for any subdimension of dimensions one to three, the assessment can stop there, as they may need residential treatment.
While it's not possible to detail the entire assessment guide, we have listed the core dimensions to consider in your assessment. These include:
Dimension 1: Intoxication, withdrawal, and addiction medications: This dimension assesses the level of intoxication, risk of withdrawal, and need for medical detoxification and monitoring.
Dimension 2: Biomedical conditions: Assesses any physical illnesses that may need to be addressed or may impact treatment.
Dimension 3: Psychiatric and cognitive conditions: Assesses mental health conditions, suicidality, cognitive impairment, and any conditions that may impact treatment.
Dimension 4: Substance use-related risks: Assesses risk of returning to use, risk factors, triggers, and the ability to cope with cravings and stress.
Dimension 5: Recovery environment interactions: This section assesses the client’s ability to function in their environment and the supportiveness of that environment.
Dimension 6: Person-centered considerations: These assess the client's willingness to attend treatment, identify concerns, and ask about the client's specific needs and the level of care they would like to receive.
You can access the full assessment guide on the American Society of Addiction Medicine website, or you may find our shorter assessment form helpful.
How to maintain sobriety
Achieving recovery starts with effective treatment, including evidence-based substance use disorder therapy and relapse prevention planning. The Recovery Research Institute has identified eleven indicators of quality addiction treatment programs, which include:
Assessment and treatment matching: Conducting a valid screening with a comprehensive biopsychosocial assessment should include an evaluation of the available recovery resources and support (recovery capital), their functioning, and their readiness to change.
Comprehensive and integrated treatment: Any addiction treatment program should address the whole patient and co-occurring mental and physical health conditions to improve the likelihood of long-term recovery.
Continuing care: Ongoing recovery support, including social, peer-based, and healthcare support, is a key component of sustainable recovery.
Dignified and respectful environment: Treatment facilities to provide quality care and a comfortable environment, just like treatment for other medical conditions.
Significant other/family involvement: Involving supportive family and partners increases the chances of recovery. Programs that incorporate training to improve relationships and communication skills can also help to strengthen recovery and the family unit.
Strategies to engage and retain clients in treatment: With a 50% dropout rate in the first month, engaging clients is crucial, using client-centered, empathetic, and counseling approaches. Motivational incentives have also been successful in sustaining recovery.
Evidence-based practice: Programs designed using evidence-based best practices lead to better outcomes, such as the use of medication-assisted treatment for opioid use disorder.
Qualified treatment professionals: A professionally qualified multi-disciplinary team, with adequate supervision, can address the whole person as part of their treatment to improve functioning and psychological well-being.
Culturally competent and personalized approaches: There is no one-size-fits-all approach to addiction treatment. Programs should meet individuals' needs, including those from minority communities.
Ongoing performance measurement: Addiction treatment programs should be evaluated using valid, reliable, and standardized instruments during treatment to assess effectiveness and document patient progress.
External accreditation: Accreditation from a nationally recognized monitoring agency, such as the Joint Commission or the Accreditation Commission for Rehabilitation Facilities, requires minimum levels of evidence-based care.
How to handle relapse
Just like any other chronic condition, substance use disorder may involve relapse (now called returning to use). According to the National Institute on Drug Abuse, rates of returning to use are around 40 to 60%.
Relapse does not mean that the addiction treatment program has failed. However, it does highlight a need for adapting the treatment approach, which may mean increased support and resources. A robust relapse prevention plan, including triggers, coping strategies, and supports, can help.
Sources
American Society of Addiction Medicine. (n.d.). About the ASAM Criteria.
American Society of Addiction Medicine. (2024). The ASAM Criteria, fourth edition level of care assessment guide, adults.
Centers for Disease Control and Prevention. (2024). Treatment of substance use disorders.
National Institute on Drug Abuse. (2020). Treatment and recovery.
Recovery Research Institute. (n.d.). Guide: 11 indicators of quality addiction treatment.
Substance Abuse and Mental Health Services Administration. (2006). Chapter 3. Intensive outpatient treatment and the continuum of care. Center for Substance Abuse Treatment.
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