14- 118 C.M.R. ch. 2, § L
Statement of purpose
This document sets forth a common framework within which Community-based Service Providers of DEEP approved substance abuse services can evaluate, treat and recommend completion of treatment of persons suspended for operating under the influence. It presents criteria for classifying clients according to their degree of progression and recommends appropriate treatment requirements. Consistent use of this framework should result in a uniform approach to the DEEP evaluation, referral and treatment process.
DEEP clients include both offenders who are addicted and those who are not. The needs of both groups are different. Also, although addicted persons share the characteristics of loss of control, they differ in the degree to which they have progressed and may also have different needs.
DEEP affirms that addiction is a disease that requires abstinence from alcohol and other drugs. DEEP also recognizes that the current DSM manual provides the accepted standard for diagnosis of behavioral disorders but is not intended to diagnose addiction as a disease. Thus, the DEEP guidelines have been revised to be consistent with the both DSM standards and the Prevention Research Institute Phases of use, which reconciles the concepts of Dependence and Addiction. In these guidelines, Phase Two and Three refers to clients who may qualify for the DSM IV diagnosis of "Abuse" or of "Dependence Without Physiological Dependence," but are not yet addicted. Phase Four refers to clients who are addicted to alcohol or other drugs. People in Phase Four usually qualify for DSM IV Diagnosis of "Dependence with Physiological Dependence."
We need to acknowledge the presence of Phase One, although individuals who display drinking choices identified as Phase One will very likely not be involved in services unless they progress into Phase Two. Phase One is characterized by consistent low-risk drinking choices. That is to say that individuals will either abstain or drink 0 to 2 drinks if daily and no more than 0 to 3 if less than daily, depending on their guidelines, and never more than one drink per hour. Individuals in Phase One do not use other drugs to get high since this leads to impairment and any impairment is high-risk. Unless a pattern of high- risk choices develops that would put the individual in Phase Two, it is appropriate for individuals to continue to enjoy alcohol in low-risk quantities for the rest of their lives.
A number of physical, psychological and social experiences characterize each group. The number, severity and frequency of negative consequences increase as the individual progresses.
The client's needs and thus the appropriate treatment response differ according to the client's stage in the progression. That is, a treatment approach that might be effective with an abuser may be completely ineffective with a person who is physically dependent. Conversely, treatment options thatmight be appropriate for a physically dependent person might be too intensive and restrictive for a person who is not addicted.
Clinical experience and knowledge of published studies generated the categories mentioned above. Clients' needs are defined and matched to those general types of treatment most suited to meeting those needs. This establishes a guideline for the practitioner's use during the initial client clinical substance abuse evaluation. It also provides DEEP with a reference point for assessing evaluations.
Obviously, eliciting sufficient information about multiple areas of an individual's life is not always easy, especially when the individual may be consciously or unconsciously denying or minimizing the extent of the individual's involvement with substances. It is critical to supplement information obtained from the substance abuser with information obtained from significant others. Thus the true extent of the person's involvement with substances may only emerge after a series of interviews. This information may then be used to clarify the client's degree of involvement with substances.
This formula for classifying every client describes general patterns of behavior that are usually associated with a given degree of progression into addiction. It provides a set of reference points for gauging a client's degree of harmful involvement with substances. Based on these reference points, a suitable intensity and modality of treatment may be recommended.
DEEP recommends that each client complete the DEEP educational program plus additional evaluation/treatment, if required. All clients respond differently to treatment and may have different treatment needs. Some clients may respond readily to recommended treatment. If the client completes treatment prior to the recommended threshold, the reason for recommending early completion must be justified on forms provided by DEEP. Other clients may not respond to treatment for a significant period of time, resulting in the continued need for treatment beyond the recommended number of clinical hours and time lines. When the clinician decides there is a need for continued treatment that may go beyond thresholds established by the Completion of Treatment Guidelines, the clinician is required by regulation to request and obtain an extension of treatment from DEEP.
The rest of this document is given over to delineating the typical problems and behaviors experienced by individuals in each of the identified groups. Associated with each phase is the treatment approach recommended by the Driver Education and Evaluation Programs (DEEP) as having the highest probability of successful outcome, without being overly restrictive. The guidelines represent the recommended number of clinical hours within a time period and the modality of treatment for significant client improvement in each phase.
Salient Characteristics/Symptoms
The most important distinguishing characteristic of this phase is frequent engagement in high-risk alcohol and/or drug use in spite of repeated negative consequences. Persons in this group are focused on the short term and artificial benefits substance use appears to bring them. Typically, use is fostered by social pressure or by internal needs. The person may have turned to substance use to dull feelings of pain and insecurity, or may simply be using for fun. They may use chemicals as substitutes for other forms of satisfaction. People in this group will qualify for a DSM IV Abuse diagnosis, but not a DSM IV Dependence diagnosis.
Interventions in this stage typically do not require intensive treatment approaches. Generally, individuals may require motivational enhancement and increased skills inorder to better withstand peer pressure, and to inject more intrinsic satisfaction into their lives. These persons should also receive objective information on the effects of substance abuse and the long-term risks of continuing their pattern of use. Some individuals may have co-occurring issues that may require intensive treatment, possibly including referral to specialized programs.
The recommended treatment interventions can usually be accomplished in 6 - 8 outpatient clinical hours spread over a 60-day period.
6 - 8 clinical hours over a 60-day period
The most important distinguishing characteristic of this group is severe psychological dependence upon the use of substances. It is likely that he/she has not exhibited classic loss of control over consumption of substances. The person may have begun to make psychological or lifestyle adjustments to minimize the appearance of substance use, and to ensure continued access to substances. Physical, economic and social problems have begun to worsen and new problems may have arisen. Generally the person is still employed and within an intact family/relationship. The involvement of significant others is an important component of the treatment process.
A minimum of 10 - 12 clinical hours over a 90-day period is recommended. Usually, successful treatment can be accomplished in an outpatient setting. Severe situational problems may justify residential services. As in all subsequent stages, the clinicianshould forge a link between the person and appropriate self-help group or other systems of support. An aftercare program is usually necessary to ensure continued maintenance of sobriety.
10 - 12 clinical hours over a 90-day period
The most important distinguishing characteristic of this group is loss of control over use. This means that once the person begins using, the compulsion to continue using is so strong that usual efforts to control use will be ineffective and the person will not be able to consistently stop when desired. Individuals in this stage are still maintaining some elements of a "normal" affiliation with society. However, their substance abuse has become a primary component of their life and affects every area of it. Substance abuse has become almost a prerequisite for feeling "normal." Problems in all areas of living are likely to be more numerous and more severe than in earlier stages.
It is possible that individuals in this phasemay require detoxification prior to participating in counseling. Given the severity of their problems, a longer and more intensive period of treatment is required. Persons with a relatively intact and supportive home environment may only require outpatient services consisting of at least 14 - 18 clinical hours over a 120-day period. Persons living in a non-supportive environment, or with physical problems requiring some supervision, or with more severe psychological or social problems may require residential treatment. Aftercare programs geared to the person's needs are strongly recommended.
14 - 18 clinical hours over a 120-day period
or
or
and
a minimum of one (1) contact hour per week over a period of not less than thirty (30) days.
The most important distinguishing characteristic of this group is that withdrawal symptoms are evident when use is interrupted. Psychological dependence is also advanced and this person's entire life typically revolves around substance use and abuse. The person displays continual use of substances and many chronic physical symptoms of such use. Psychologically, his/her cognitive and emotional states are dulled and confused by substance use. The person may have lost the defensiveness and rationalization of substance abuse found in earlier phases and relationships have been seriously disrupted.
Treatment in this stage almost always requires detoxification due to the patterns of substance abuse. This should be followed by a Residential Rehabilitation Program when possible and an Intensive Outpatient when a Residential Rehabilitation Program is not available. If the person has experienced many treatment contacts and requires more extensive treatment, halfway house treatment is recommended.
If the person has not had prior treatment experience and has some family or social supports, halfway house treatment may not be necessary.
Aftercare is also recommended for persons in phase four.
Recommended Duration and Frequency of Treatment
Residential Rehabilitation
and/or
halfway house with DEEP outpatient counseling completion
or
a minimum of one (1) contact hour per week over a period of not less than thirty (30) days.
Individuals in this phase are not likely to have much opportunity to drive since their social and financial position is commonly so severely disrupted. They display continuous abuse of substances with accompanying life threatening physical deterioration. They are totally disengaged from society and their social world is restricted to fellow final stage abusers and the commercial and social systems that serve them. Given the extreme deterioration of these individuals their treatment plans should be individually reviewed by DEEP staff with the clinician.
14- 118 C.M.R. ch. 2, § L