Hello everyone and welcome back. In our past sections we been talking about screening and assessment issues and issues related to screening and assessment. In this section we begin talking about client placement so let's begin by going to slide two.

As you can see in slide two we have gone through this kind of process. We have screened the client. We have assessed the client. And now what we have to do is place the client in some kind of treatment program that is appropriate for what they have. The ranges we had in relation to determining where we should put the client ranged from basically no treatment all the way to hospitalization in an ICU.

Let's talk about things we used to do in the past, and as we can see in slide three, the model was very simple. Basically, the client was placed on what the counselor determined was good for the client. That is, there was no reasoning or no scientific process for placement in treatment or in any kind of treatment. Basically all clients went through the same kind of treatment regardless of the type of problem they had. It was assumed symptoms when one was discussing alcoholism that everyone walking through the door of the treatment center was an alcoholic.

The classic model as seen in slide four was very simple. You begin with treatment for sixty to ninety days. From there you went to intensive outpatient where you were given groups two or more times a week, individual sessions at least once per week and of course you had to go to either AA or NA depending upon what the problem was, and you had to do that at least one time a week but more often it was three to four times per week. After this treatment was concluded the person then went into outpatient treatment where they continued going to AA, they continued having group once per week or individual once a week and then when they were done with all of this and they were basically done with the treatment they then continued to go to AA for the rest of their life or until they did not need AA anymore.

The problem with all this as you can see in slide five, was the cost. It was very expensive for an individual to be placed for sixty to ninety days in inpatient treatment. Also, the treatment outcome data for these centers was not very good. Basically, it had the same success rate to that of spontaneous remission. Furthermore, other models that did not use inpatient treatment had similar outcomes as the clients that did have inpatient treatment. So you had people in outpatient versus inpatient and basically they got the same results. Finally, a lot of clients did not even need inpatient treatment at all and consequently dropped out. As a result of this, government agencies found they could not afford the cost.

As we can see in slide six, managed care steps in. Managed care begins to have an impact. It requires agencies to become much more efficient. And whether you like managed care or not it has done that. It also required agencies to document the treatment process which many had not done before. And of course in the combination of all of this it caused all sorts of uproar in the treatment field.

The result of all this as we see in slide seven, was that treatment agencies were required to become accountable to the government agencies and ultimately to the tax payer. Managed care not only had an impact on government agencies but it also had a huge impact across the entire health care system. It even occurred when the clients were within the criminal justice system. So ultimately we found that we needed to have alternative types of treatment and that we knew that some clients needed certain types of treatment while other clients needed different types of treatment.

Ultimately, as part of all of this the American Society of Addiction Medicine, as we see in slide eight, developed a manual to help place clients in treatment. This was ultimately called the Patient Placement Criteria for the Treatment of Substance-Related Disorders and is currently in its second edition. The ASAM as it is commonly called basically uses diagnostic information found in the DSM and from assessment information to place clients in particular types of treatment. So what you are doing is getting information from the diagnosis of the DSM and you are getting information from the assessment process of which the client has gone through and then it places the client in treatment based on a crosswalk.

This crosswalk as seen in slide nine has two dimensions. It has a vertical dimension which basically looks at things such as biomedical conditions and complications, emotional or cognitive complications, readiness for change, etc. It also has the other part of the crosswalk, a "levels of care." This crosswalk runs horizontal and ranges all the way from early intervention through level four which is a medically managed intensive inpatient care facility. As a consequence there are many, many levels in between.

The result of this as we see in slide eleven, is that based on the client’s symptoms; the client is place in some kind of appropriate treatment agency. The same information is also given to a gatekeeper who may work in an insurance company, government agency, or even in the local community. The gatekeeper then makes the final decision about where this client should be placed. Now, that forces a couple of things to occur. First of all, it forces the evaluator to justify why a particular type of treatment is needed. It further forces individuals at the treatment site to continually reevaluate the client and determine if the treatment is appropriate for the particular individual. Now, of course there are checks and balances in place. If the gatekeeper decides that the client does not need as heavy a level of treatment the assessor can then come back and discuss with the gatekeeper their rationale for why the individual needs to be in there and from that a compromise is often made. The combination of both of these processes makes for a cleaner and clearer treatment placement. You can now back up what is going on and why the client was placed in a particular type of treatment. Both to the accounting agencies, the client, and to the evaluator that did it in the first place.

Now once a client is in treatment as we can see in slide twelve, there is an ongoing evaluation. This might result in the client being moved from ICU where they were initially experiencing hallucinations and seizures to a less intensive inpatient medical treatment. So, ultimately, as your treatment progresses additional evaluations and assessments are going to be conducted. This often occurs every thirty days or it may occur more often depending upon the process.

So what are some general conclusions regarding the ASAM? Well as we can see on slide thirteen; it is a major improvement over the way we used to do things. Where the counselor kind of did things as they saw fit. It also requires counselors to justify why they are placing a particular client in a particular treatment and justify their decisions with data. "I believe they should have "X" treatment does not cut it anymore. Basically, the old days are gone. It also requires the counselors to be very competent in the assessment process. And, that counselors reevaluate their clients on a periodic basis. Both of these have been major, major improvements within this issue.

Now there is another aspect of client placement that may also occur and that is in relation to Drug Court. As we see in slide fourteen, Drug Court is an alternative to treatment placement. This usually involves an individual who has committed some drug related crime or is involved in the criminal justice system. It requires the client to be involved within the probation and parole system, working with some kind of treatment agency, participating in a variety of different groups, and a variety of other aspects as well.

These individuals within Drug Court, as we see in slide fifteen, often are required to provide random urinalysis testing. Further, Drug Court ties the client into other treatment agencies where the client can be placed based on what the client needs to have. In essence, the client does not get lost in the cracks. And as a consequence, Drug Court has had major impacts in reducing recidivism for criminal related activity which is very good for all of us.

Overall, Drug Court is a different treatment model from the traditional treatment models that we commonly have. It also is having very good results. Consequently, it is causing all sorts of problems and controversy for a variety of certification boards.

So, we have screened them, we have assessed them, and we have placed them in some kind of alternative treatment. Now what? Well, as we can see in slide seventeen the assessment does not stop. Basically, we need to have ongoing assessment while the client is going through treatment. Usually this occurs at thirty day intervals. The question asked is very simple. Is the client improving, remaining the same, or increasing their use? If they are remaining the same or increasing their use, how then do you treat the particular client?

In the past, if the client was not improving, we basically considered the client to be experiencing was "resistance". As you see in slide eighteen the classic statement was that the client was "undergoing resistance" to the treatment. Basically, what the answer to that is that the client is not doing what I want them to do. And, of course, it is obviously their fault.

Today, however, that has changed. As we see in slide nineteen, what counselors do today is reevaluate the treatment plan. What is working? What is not working? What changes do we need to make? This requires a different treatment approach or changing the assumptions of the particular model approach that one may be doing.

The bottom line in all of this is, as we see in slide twenty, treatment agencies are now being held accountable for the client outcomes are. If your agency is not very successful you are not going to be receiving third party or government payments. That is going to have even greater importance in the future.

So, in conclusion, basically what we have found through this entire section is that clients enter a process. They enter from screening all the way through placement. If the process is going to be successful and well done, clients should be able to complete a treatment program successfully.

Well that concludes this section, in our next section we are going to be talking about family issues that are involved with treatment and within addictions. So, until then have yourself a great day and we look forward to talking with you soon.

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