RESIDENTIAL TREATMENT OF SUBSTANCE USE DISORDERS

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1 RESIDENTIAL TREATMENT OF SUBSTANCE USE DISORDERS Core Therapeutic Elements and Their Relationship to Effectiveness Practice Committee Consensus Report April 2013

2 Executive Summary The Affordable Care Act (ACA) requires coverage of substance use disorder (SUD) care, identifying SUD services as one of the law s Essential Health Benefits (EHB). As more discretion has been given by the Department of Health and Human Services (HHS) to states to define the EHB, it will be most important to work at the state level to ensure that individuals with mental illness and substance use disorders receive quality care within a full continuum of evidenced-based care. Addiction is a chronic health condition and can be successfully managed over time like other chronic conditions. Residential treatment is a more intense service within the continuum of care with levels responsive to the conditions of the patient. The described core elements and therapeutic processes presented in this paper, together with the Patient Placement Criteria developed by the American Society of Addiction Medicine (ASAM) are the basis of the following description of residential treatment: Residential Treatment is a normative, pervasive environment supporting a 24 hour-per-day culture and milieu of beliefs and ideology, which value respect for the inherent goodness of the individual, the capacity to change, personal responsibility, and the reliance on the treatment community as a therapeutic agent. Core Elements 1. Structure and stability 2. Safety and separateness 3. Therapeutic conditions and processes Central to the continuing evolution of residential treatment is a commitment to the principles of selfmanagement of a chronic health condition. Within the normative pervasive environment of the residential setting the community is a therapeutic agent where patients are empowered to manage their health. Disease control and outcomes depend on patients using effective self-management. Support includes acknowledging the patients' role in their care, fostering a sense of responsibility for their health, using proven programs that provide emotional support and strategies for living with chronic illness. Providers and patients work collaboratively to define barriers, set priorities, establish goals, create treatment plans, and solve problems. Goals include sustaining abstinence, preparing for triggers, improving personal health and social functioning, and engaging in continuing care. Conclusions 1. The effectiveness of residential treatment is embedded in how the core elements of this safe, separate, secure, and stable environment respond to the needs of individuals with deficits in cognitive, social, interpersonal, emotional, and/or coping skills. 2. These individuals come from environments that are unstable, chaotic, abusive, and/or toxic, and need a regimented, supportive, stable environment to habilitate or rehabilitate. 3. Individuals with more severe dysfunctions exhibit impulsivity, deficient anger management, hostile/violent acting out, and/or resistance/antagonism to limits. They need an environment which manifests respect, capacity to change, and personal responsibility within a communal setting. The communal setting represents a microcosmic representation of the larger society and provides the social context to alter thinking, feelings, and behaviors. 4. Treatment interventions are matched to a person s readiness to change and it is critical that this individualized treatment matching occurs to assure that residential treatment is not under-utilized or over-utilized. 1

3 Residential Treatment of Substance Use Disorders Core Therapeutic Elements and Their Relationship to Effectiveness Introduction Alignment with Health Care Reform The Affordable Care Act (ACA) requires coverage of substance use disorder (SUD) care, identifying SUD services as one of the law s Essential Health Benefits (EHB). With the ACA s strong coverage provisions, millions more Americans will have better access to the SUD care and supports they need to become and remain well. Work to define which services are covered in each of the EHB categories continues at the federal level and in the states. As a field we are moving forward to assure full coverage for mental illness and substance use disorders. We have seen, so far, the strong commitment from the federal Department of Health and Human Services (HHS) to make mental health (MH) and SUD care a top priority. As more discretion has been given by HHS to states to define the EHB, it will be most important to work at the state level to ensure that individuals with mental illness and substance use disorders receive quality care within a full continuum of evidenced based care. To support this inclusion there is significant evidence of the effectiveness of residential treatment which is compiled by the report Adult Residential Treatment for Substance Use Disorders: Summary of the Evidence (Reif et al, Institute for Behavioral Health, Brandies, 2010). There is also support of the effectiveness of residential treatment in the extensive seminal research completed in 1974 by Sells and Simpson (Sells and Simpson 1980) and follow- up studies (Simpson and Sells 1982). There also seems to be, in the professional literature, an identification of the core elements of residential treatment that correlate with its effectiveness. However, it is less clear how and why these core elements are effective and why they need to occur for some individuals in the environment of a residential setting. This report will summarize these core elements and some correlation to their possible therapeutic effectiveness. There is still work to do to support the inclusion of residential treatment in the EHB. It is in this context that the Practice Committee was given the charge to compile a consensus report for SAAS on the how and why of residential treatment s effectiveness, which would further support its inclusion as a part of the continuum of care for the treatment of substance use disorders. The intention of this report is to gain a consensus that supports the evidence base of the core set of services and structured activities which have been described in the good and modern adult residential treatment setting (SAMSHA, O Brien 2010). This report also emphasizes that addiction is a chronic health condition which can be successfully managed over time like other chronic health conditions. Residential treatment is a level of more intense care within the continuum of care with 2 the Practice Committee was given the charge to compile a consensus report for SAAS on the how and why of residential treatment s effectiveness, which would further support its inclusion as a part of the continuum of care for the treatment of substance use disorders.

4 levels of intensity responsive to the conditions of the patient. The report will also strongly urge the field to arrive at a consensus in which there is a standardization of the levels of care which balance: the need to individualize care to the needs, strengths, severity of brain dysregulation and resulting functional deficits of the individual, their status within the progression and/or remission of the chronic conditions the matched intensity and frequency of the essential care services and structured activities (the dosage) the required credentials and ratio of staff to the patient population. The confirmation of evidenced based practices of the core services and the balanced standardization of the levels of care are necessary to support a reasoned and consistent payment structure. Definitions and Terminology This report primarily uses the definitions and description of both the ASAM Patient Placement Criteria and the NIDA Principles of Drug Addiction Treatment as sources for defining residential treatment. We limited our focus to ASAM s Level III (non-hospital residential). Level III programs offer organized treatment services that feature a planned regimen of care in a 24 hour residential setting. Treatment services adhere to defined policies, procedures, and clinical protocols. The defining characteristics of all Level III programs is that they serve individuals who, because of their specific functional deficits, need safe and stable living environments in order to develop their recovery skills (ASAM PPC -2R) The National Institute of Drug Abuse (NIDA) Principles of Drug Addiction Treatment defines residential treatment as follows: Short-term residential programs provide 24 hour per day intensive but relatively brief treatment typically based on a modified 12-step approach. Long-term residential treatment provides care 24 hours a day, generally in non-hospital settings. Addiction is viewed in the context of an individual's social and psychological deficits, and treatment focuses on developing personal accountability and responsibility as well as socially productive lives. Treatment is highly structured. with activities designed to help residents examine damaging beliefs, self-concepts, and destructive patterns of behavior and adopt new, more harmonious and constructive ways to interact with others. There is significant confusion about the language used to distinguish between clinical residential treatment and other supportive forms of residential housing which provide an important part of the continuum of care supporting some individuals needs for a stage of their recovery. Some authors have suggested clarifying terminology for clinical residential treatment as non-hospital inpatient services. This report is concerned that this new terminology will only add further confusion with the mix of another term for clinical residential treatment as distinct from a supportive form of housing. Therefore throughout this study we will continue to use the terminology residential treatment of substance use disorders. 3

5 Scope of Consensus Report and Method of Study The committee completed a limited survey of the literature to identify the core elements of residential treatment which seem to correlate to its effectiveness. In our survey the core elements are foundational to a residential treatment environment. They are foundational in the sense that they are the necessary and sufficient conditions of the residential environment, which are responsive to the needs and functional deficits identified in the ASAM Patient Placement Criteria for residential levels of care for both adults and adolescents. They are also the necessary and sufficient conditions for the various therapeutic processes and outcomes to occur. Those foundational core elements are: Safety and Separateness, Structure and Stability. The next section summarizes the characteristics of the core elements and the therapeutic process that occur with the environment that these core elements support. Core Elements Structure and stability are supported by an environment which includes the following major characteristics: Daily regimen of scheduled and structured activities: Group therapy Reflective time Individual therapy Community meetings Didactics Recreational/physical activities Meals Defined policies, procedures and clinical protocols Specified roles for staff, residents, and family members Predictable times to practice recovery and coping skills Safety and separateness are supported by an environment which provides: Safety from: Alcohol and other drugs Dominant drug culture Drug places Chaos Safety to: Practice recovery and coping skills Controlled experiential community environment separate from larger society and from the drug using culture to which many patients belong Microcosmic representation of a larger society providing a social and interactive context to alter thinking, feelings, and behaviors 4

6 Therapeutic conditions and processes that occur within the residential environment that seem to correlate to its effectiveness include: Structures and regimens that support a recovery environment and related behaviors and skills Sufficient stability to prevent and minimize relapse Treatment and community structure to practice and integrate recovery and coping skills Community and treatment settings built upon residents imitative tendencies to learn through reciprocal role modeling by both peers and staff An environment built upon the social nature of persons Encouragement of progress which is dependent on reciprocal interaction in a safe and separate community setting A separate community as a means of personal, and in some cases spiritual, transformation which requires a shift from the self-centeredness of one s personal identity, which is characterized by addiction thinking, feeling, and behaving, to letting go to a power greater than oneself Healing not in isolation, but in communion with others Residential treatment is intended to be individualized though varied levels of care and intensity to the functional deficits identified in the ASAM Patient Placement Criteria. The core elements and therapeutic processes described above are responsive to the functional deficits for patients who meet the ASAM Level III placement criteria. These deficits cumulatively support the need for a safe and separate environment which has structure, stability and a degree of predictability. Throughout a review of these functional deficits are clear indications of the need for a separate environment, stronger and consistent structure to support the application and practice of recovery skills. While all levels of treatment do respond to the dysregulation of brain systems caused by addiction to psychoactive substances, the characteristic of this dysregulation, and 5 In the residential treatment environment an individual s functional cognitive deficits require treatment that is primarily slower paced, more concrete and repetitive in nature. resulting functional deficits, is more intense and continual in individuals who need a separate environment to develop and practice their recovery skills. Therefore, in the residential treatment environment an individual s functional cognitive deficits require treatment that is primarily slower paced, more concrete and repetitive in nature. The daily regimens, the structured patterns of activities, are intended to restore cognitive functioning and build behavioral patterns within a community. In addition to cognitive functional deficits this safe and stable environment with the community as a therapeutic agent is also responsive to emotional, social, and interpersonal deficits identified in these criteria. Some of these deficits are the results of trauma which require competencies of trauma informed care in both individual and focused group interventions. Structured group activities and communal living provide the opportunity for learning and practicing new skills in all these areas of significant dysfunction. Social learning within the normative environment occurs through modeling new skills and the practicing of new skills which is responsive to the individual s chaotic environment and often isolated self-centeredness.

7 ASAM Patient Placement Criteria: Level Functional deficits and needs include: Problems in the application of recovery skills Lack of connectivity to the world of work, education, and family life Person in pre-contemplation who is living in an environment too toxic to permit treatment in an outpatient basis Need a supportive environment for receiving discovery rather than recovery services. Level III.3 Functional deficits and needs include: Person for whom the effects of substance use disorders is so significant that he/she results in a level of impairment for which outpatient services are not feasible or effective Functional deficits are primarily cognitive and can be temporary or permanent which require treatment at a slower pace, more concrete and repetitive until cognitive impairment subsides Responsive to a person with such severe deficits in interpersonal and coping skills that treatment focuses more on habilitation rather than rehabilitation Level III.5 Functional deficits and needs include: Person with significant social and psychological problems who can benefit from the treatment community as a therapeutic agent Functional deficits: chaotic, often abusive, non supportive interpersonal relationships More serious or lengthy criminal history Limited or significantly sporadic work and educational history Treatment interventions are matched to a person s readiness to change: For some it is discovery For some it may focus on maintaining abstinence and preventing relapse For some it is preventing a return to antisocial behavior For some it is developing a sense of personal responsibility and positive character change For some it is habilitative For some it is rehabilitative Anti-social value systems characterized by: Impulsivity, deficient anger management skills Hostile or violent acting out Resistance and antagonism to limits or problems with authority Hyperactivity and distractibility (ASAM PPC-2R). (2001) The above core elements and therapeutic processes lead the committee to the following description of residential treatment: Residential Treatment is a normative, pervasive environment supporting a 24 hour-per-day culture and milieu of beliefs and ideology, which value respect for the inherent goodness of the individual, the capacity to change, personal responsibility, and the reliance on the treatment community as a therapeutic agent. 6

8 Conclusions 5. The effectiveness of residential treatment for both adults and adolescents is embedded in how the very characteristics of core elements of this safe, separate, secure, and stable environment respond to the needs of individuals with significant functional deficits in their cognitive, social and interpersonal, and emotional functioning and coping functions. The functional deficits are identified by ASAM Patient Placement Criteria. 6. These individuals more often come from environments that are unstable, chaotic, abusive and toxic, and therefore they need a regimented, supportive, stable environment in which to learn and practice through interventions that habilitate or rehabilitate. 7. Individuals with more severe dysfunctions often exhibit impulsivity, deficient anger management, hostile and violent acting out, and resistance and antagonism to limits. These individuals need a normative, pervasive environment which manifests respect, the capacity to change and personal responsibility within a communal setting. It is this communal setting that represents a microcosmic representation of the larger society that provides the social context to alter thinking, feelings, and behaviors. 8. Treatment interventions are matched to a person s readiness to change and it is critical that this individualized treatment matching occurs to assure that residential treatment is not underutilized or over utilized. This is consistent with The Six Aims of High-Quality Health Care from the Institute of Medicine: Safe - avoiding injuries to patients from the care that is intended to help them. Effective - providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively). Patient-centered - providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Timely - reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficient - avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable - providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. IOM, 2001:5 6. The duration of care is dependent on the individual progress and any of the following needs of the patient: For some it is discovery For some it may focus on maintaining abstinence and preventing relapse For some it is preventing a return to antisocial behavior For some it is developing a sense of personal responsibility and positive character change For some it is habilitative For some it is rehabilitative 7

9 Central to the continuing evolution of residential treatment will be a commitment in practice to the principles of selfmanagement of a chronic health condition. Within the normative pervasive environment of the residential setting the treatment community becomes a therapeutic agent through which patients are empowered and prepared to manage their health and health care. As such, treatment must: Emphasize the patient's central role in managing their health Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up Organize internal and community resources to provide ongoing self-management support to patients All patients with chronic illness make decisions and engage in behaviors that affect their health (self-management). Disease control and outcomes depend to a significant degree on the effectiveness of self-management. Effective self-management support means more than telling patients what to do. It means acknowledging the patients' central role in their care, one that fosters a sense of responsibility for their own health. It includes the use of proven programs that provide basic information, emotional support, and strategies for living with chronic illness. Self-management support can't begin and end with a class. Using a collaborative approach, providers and patients work together to define problems, set priorities, establish goals, create treatment plans and solve problems along the way. The therapeutic goals are to sustain abstinence, understand and prepare for triggers, improve personal health, improve social functioning, and as needed engage in continuing care as needed in outpatient treatment, recovery housing, recovery management and support services. NIDA in its Principles of Drug Addiction Treatment clearly states the need for integration of care for persons with substance use conditions. In 2006 the Institute of Medicine (IOM) published the third report of the Quality Chasm Series, Improving the Quality of Health Care for Mental and Substance Abuse Conditions (National Academies Press 2006). In this report they strongly recommend the integration of care for mental and substance use problems with other general co-occurring health care conditions and illnesses. The IOM report s recommendation for the coordination and integration of care is foundational to understanding and improving the quality of health care. Mental and substance use problems rarely occur in isolation Mental, substance use and general health problems and illnesses are frequently intertwined Coordination of all these types of health care is essential to improved health outcomes, especially for chronic illnesses (IOM 2007) 8 Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual's drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual's age, gender, ethnicity, and culture. NIDA 2009 Principles of Drug Addiction Treatment: A Research Based Guide

10 None of the findings of this report are new. They do however strongly support why residential treatment is effective for those who have more severe functional deficits and require a safe and secure environment in which to learn and practice recovery skills. There is strong evidence that treatment within this level of care can be individualized to the needs, strengths, social supports systems and recovery progress of the patient. Appendix Bibliography ASAM Placement Criteria and Matching Patients to Treatment. (2010) David Mee-Lee, MD and Gerald D. Shulman MA, MAC, FACATA(ASAM, Principles of Addiction Medicine, Chapter 27). DeLeon, G., Recent Research Into Therapeutic Communities,, Principles of Addiction Medicine, 3 rd edition, (2003), Chevy Chase, Maryland: American Society of Addiction Medicine. Drug and Alcohol Service Providers Organization of Pennsylvania, Legal Brief: Inpatient Non-Hospital Addiction Treatment and the Affordable Care Act, Heller, G. December Garnick, D.W., Horgan, C., Acevedo, A., McCorry, F., and Weis-ner, C. Performance Measures for Substance Use Disorders What Research is Needed? Addiction Science and Clinical Prac-tice. (2012). Published online at Institute of Medicine (2006), Improving the Quality of Health Care for Mental and Substance-Use Condition: Quality Chasm Series. Washington DC: National Academy Press. Kurth, D.J., Therapeutic Communities, Features of a Modern Therapeutic Community, Principles of Addiction Medicine, 3 rd edition, (2003), Chevy Chase, Maryland: American Society of Addiction Medicine. McLellan A.T., McKay, J.R. (2009). Evidenced Based Clinical Practices Within and Across Continuum of Addiction Treatment (ASAM Principles of Addiction Medicine, Chapter 25). Mee-Lee D, Shulman, G.D., Fishaman, M, et al., ASAM Patient Placement criteria for the Treatment of Substance Use Disorders, 2 nd Edition-revised (ASAM PPC-2R). (2001) Chevy Chase Maryland: American Society of Addiction Medicine. NIDA: Principles of Effective Treatment, NIH Pub Number: Published: October 1999, Revised: December O Brien, W.B., Perfas, F.B., The Therapeutic Community, Lowinson, J. H., Ruiz, P., Millman, R. B., and Langrod, J. C. (Eds.). (2004). Substance Abuse: A comprehensive textbook. Baltimore, MD: Lippincott Williams & Wilkins. 9

11 Reif, S., Horgan, C.M., Quinnn, A.E., Granick, D.W., Hodgkin, D. Adult Residential Treatment for Substance Use Disorders: Summary of the Evidence, (2010) Brandeis University. S. B. Sells & D. D. Simpson (Eds.). (1976). The Effectiveness of Drug Abuse Treatment: Vols Cambridge, MA: Ballinger. S. B. Sells & D. D. Simpson, The Case for Drug Abuse Treatment Effectiveness, Based on the DARP Research Program, British journal of Addiction 75 (1980) SAMSHA, Models of Adult Residential Substance use Disorder Treatment, 2010 (Paper prepared as summary of Adult Residential Treatment Expert Panel Convened in August 2010). SAMSHA. O Brien J (Draft 2010): Description of a Good and Modern Addiction and Mental Health Service System which can be accessed at the following website: Simpson, D.D., Sells, S.B., Effectiveness of Treatment for Drug Abuse: An Overview of the DARP Research Program, Advances in Alcohol and substance Abuse, (1982). Willenbring MD. (2009) Spectrum of Alcohol Use Disorders Continuum of Care (ASAM, Principles of Addiction Medicine, Chapter 23). Committee Members Michael Reagan, Chair, Chief External Relations Officer, Cherry Street Health Services, MI Susan Blacksher, MSW, MCA, Executive Director CA Association of Addiction Recovery Resources Charles Bush, Program Manager, Clearview Recovery Center, MS Cinda Cash, former Executive Director, Connecticut Women's Consortium, Inc. John Coppola, MSW, Executive Director, NY Association of Alcoholism and Substance Abuse Providers, Inc. John Daigle, Consultant, FL Dick Dillon, CEO, Innovaision, LLC, MO Sheila North, M.A., M.F.T., Executive Director, DePaul Treatment Centers, OR Constance Peters, MSPA, VP for Addiction Services, Association for Behavioral Health MA Art Schut, CEO, Arapahoe House Inc., CO Bill Stauffer, LSW, CADC, Executive Director, PRO-A, PA For more information on this report or other SAAS documents: Go to the SAAS website Contact Becky Vaughn, CEO at or

12 Core Therapeutic Elements of Residential Treatment of Substance Use Disorders Residential Treatment is a normative pervasive environment supporting a 24 hour-per-day culture and milieu of beliefs and ideology which values respect for the inherent goodness of the individual, the capacity to change, personal responsibility and the reliance on the treatment community as a therapeutic agent. The following four core elements are identified in the literature and correlated with its effectiveness although is less clear how and why they are effective. Varied Levels of Care and Intensity Responsive to Persons with the Following Needs and Functional Deficits (ASAM Patient Placement Criteria) Level Functional deficits and needs include: - Problems in the application of recovery skills -Lack of connectivity to the world od work, education, family life - Person in "pre-contemplation" who are living in an environment "too toxic" to permit treatment in an outpatient basis Level Functional deficits and needs include: - Person for whom the effects of substance use disorders are so significant that they result in a level of impairment for which outpatient services are not feasible or effective - Functional deficits are primarily cognitive and can be temporary or permanent which require treatment at a slower pace, more concrete and repetitive until cognitive impairment subsides - Responsive to person with such severe deficits in interpersonal and coping skills that treatment focuses more on "habilitation " rather than "rehabilitation" Level Functional deficits and needs include: - Responsive to needs of persons with significant social and psychological problems who can benefit from the treatment community as a therapeutic agent - Functional deficits : chaotic, often abusive, non-supportive interpersonal relationships - More serious or lengthy criminal history - Limited or significantly sporadic work and educational history -Treatment interventions are matched to person's readiness to change : For some it is "discovery" For some it may focus on maintaining abstinence and preventing relapse For some preventing a return to antisocial behavior For some it is developing a sense of personal responsibility and positive character change For some it is "habilitative" For some it is "rehabilitative" -Anti-social value systems characterized by: Impulsivity, deficient anger management skills Hostile or violent acting out, Resistance and antagonism to limits, problems with authority Hyperactivity and distractibility Structure and Stability Daily regimen of scheduled activities: Meals Community meetings Didactics Recreational/physical Reflective time Group therapy Individual therapy Defined policies procedures and clinical protocols Specified roles for staff, residents and family Predictable times to practice recovery and coping skills Safety and Separateness Safety from: Alcohol and other drugs Dominate drug culture Drug places Chaos Safety to: Practice recovery and coping skills Controlled experiential community environment separate from larger society Microcosmic representation of larger society providing a social context to alter thinking, feelings, behaviors Therapeutic Processes and Outcomes -Structured recovery environment -Provides sufficient stability to prevent and minimize relapse -Provide treatment and community structure to practice and integrate recovery and coping skills -Community and treatment settings build upon residents imitative tendencies to learn through role modeling -Build upon the social nature of persons (Social Learning, Social control, Stress and Coping, Theories) -Development is dependent on reciprocal interaction in a safe and separate community setting. -The use of a separate community as a means of personal and spiritual transformation requires a shift from the self-centeredness of the personal identity, which characterizes addiction thinking, feeling and behaving to "letting go" to a power greater than oneself -The resident finds healing not isolation but in communion with others 11

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