For the last 20 years, I have been a consultant to various residential treatment centers (RTCs) for clients who experience co-occurring disorders of substance abuse and various psychiatric disorders. I have trained staff on ways to develop integrative treatment programs that are designed to bolster the client’s level of resilience (see www.roadmaptoresilience.org). In this consulting capacity, I have also helped them critically evaluate their programs to determine if they were meeting a “gold-standard” of care. My relatives, friends and colleagues know of my consulting work with these RTCs and they have, on occasion, asked me, “How can I choose a residential treatment center for my loved one or client?” I have written a letter that they can submit to the director of RTCs in order to gather information to make a more informed decision about possible placement.
Imagine what the impact might be if the directors of RTCs had to address each of these questions on a regular basis or post the answers to these questions on their website.
To: Director of Treatment
From: A Concerned Parent (Spouse or Referring Therapist)
I am considering your Treatment Center for my family member. Before I decide on a placement, I would greatly appreciate your providing me with answers to the following questions so I can make an informed decision.
I gather that critical reviews of the treatment research literature indicate that the following factors have been found to be key predictors of outcome for clients with psychiatric and substance abuse disorders. They include:
a) the quality of the therapeutic alliance that is established and maintained between clients and treatment staff;
b) the degree of client engagement and active participation in treatment;
c) the client’s perception of improvement in training;
d) the inclusion of an active aftercare program that involves significant others (family members), supportive non-substance abusing peers and the development of a long-term recovery program;
e) the flexible implementation of a treatment package that incorporates regular feedback from outcome-driven results.
I would like to learn how your treatment center incorporates each of these treatment features, specifically in terms of therapeutic alliance:
(1) How does your treatment program develop and monitor a therapeutic alliance with clients? How does your staff handle possible impasses or strains that may arise over the course of treatment?
(2) What specific client feedback measures about the quality of the therapeutic alliance does your staff regularly employ? For example, what specific helping-alliance scales, client engagement/participation measures do you regularly obtain?
(3) Since continuity of care is so important, please share your staff turnover data and what you have done to address this issue.
(4) Since client engagement and active participation are critical to treatment outcome, what specific engagement strategies does your treatment center employ?
a) Is your staff trained and certified in using motivational interviewing procedures?
b) How does your staff engage clients in collaborative goal-setting and in developing a long-term Recovery Plan? Could you please send me a copy of the resident handbook, goal sheets and recovery plan forms that clients are asked to fill out?
(5) What is your treatment center’s policy for involving family members (significant others) from the outset and keeping them informed throughout treatment? What is your policy toward visiting, phone call consultations, family therapy and the like?
In terms of assessment issues, I would appreciate your answers to the following questions:
(6) How effective has your treatment program been in helping clients become abstinent or at least reducing their substance intake and in developing a better quality of life? Please share what long-term outcome data you have collected (beyond testimonials). How do you go about collecting such follow up data on a regular basis?
(7) How do you intend to obtain long-term data from clients and from significant others? I would appreciate any reports on your treatment efficacy.
(8) I gather that the best assessment data in helping clients is to use ongoing outcome-driven feedback that is given to both clients and therapists in real-time. In this way both clients and therapists can adapt the treatment program in a flexible individualized fashion to reach agreed upon treatment goals. How does your treatment staff obtain such outcome-driven data and employ it in treatment? What specific assessment measures do your therapists employ and how is this information shared with all staff and the clients?
(9) How does your treatment team assess for the presence and history of polysubstance use, comorbid disorders, risk to self and others? How is this information incorporated into an integrated case conceptualization model that informs treatment decision-making?
(10) How does your treatment staff assess for the “rest of the story” namely, the client’s strengths, evidence of resilience, values, interests, talents and how are these traits incorporated into the treatment plan? How does your staff explicitly nurture hope in clients, significant others and staff?
(11) How does your staff employ a lifespan perspective and assess for early victimization and trauma exposure? If such developmental events are identified, how do you incorporate this into the client’s treatment program? What specific trauma-focused interventions do you use and how do you integrate them with the treatment of substance abuse?
In terms of treatment issues I would appreciate answers to the following questions:
(12) What is the weekly treatment schedule? Please indicate how each of these various activities have some evidence-based or empirical support for clients with comorbid disorders? How will engaging in these activities help with long-term recovery? Do you have any evidence for this?
(13) How does your staff provide integrative (as compared to sequential or parallel) treatment approaches for clients with dual diagnosis? Has your treatment team adapted its approach and receive training in any specific evidence-based integrative treatment procedures? If so, which programs?
(14) How do you ensure that your treatment staff communicates regularly and conveys a similar treatment message to clients and significant others?
(15) Most importantly, when your treatment staff trains clients on a variety of intrapersonal and interpersonal coping skills, how do you ensure that the staff has incorporated generalization guidelines designed to improve the likelihood of transfer and maintenance of the treatment effects? In short, what explicitly does your staff do besides “train and hope” for generalization and maintenance of treatment effects?
(16) What specific coping skills does your treatment team teach? How do you decide which skills should be taught and nurtured (tailored) with which clients?
(17) When psychotherapies are provided, either individual, group or family, what specific approaches are used? Is this left up to the individual psychotherapist or is there one general psychotherapy approach at your treatment center? What is the psychotherapeutic approach and how do you evaluate its effectiveness?
(18) Given the high incidence of lapses and relapses, how does your treatment team incorporate relapse prevention training? How do you work with clients to develop and maintain a life of sobriety, a balanced lifestyle and a high quality of life that is drug free?
(19) How are your various treatment interventions culturally and gender sensitive? How do you incorporate the client’s cultural background, rituals and values into treatment? Do you conduct any gender-specific treatment programs? Please describe them.
(20) How do you incorporate spiritually-based interventions, such as 12 Step AA programs into your treatment program? How do you explicitly facilitate such AA programs to increase the likelihood that clients will continue his or her participation, once he or she leaves the treatment center? Are such AA meetings on campus or off campus? How do you monitor the quality of these meetings? What percentage of the week’s activities are devoted to AA meetings?
(21) How do you incorporate psychotropic medications as part of your treatment program? How do you go about educating clients about their medication, systematically assess for possible side-effects and efficacy, and ensure that the client “takes credit” (makes self-attributions) about what the medication has allowed him or her to achieve in terms of their treatment goals. Since I raised the issue of medication, what is your treatment center’s policy about smoking and how do you handle clients who feel addicted to cigarettes?
(22) How does your treatment program conduct an assertive after-care program with follow up regarding recovery programs in the client’s natural environment? What specifically, do you do in the form of follow-up contracts, assessments and ongoing contacts? Moreover, are there any additional charges for such aftercare activities, or is this service included in the initial treatment fees?
(23) How do you explicitly address the needs of your staff at the individual, collegial and organizational levels to avoid burnout and vicarious traumatization? How do you ensure their professional development?
I realize that this is a long list of comprehensive questions, but I am sure you will understand my desire to make the best, most informed decision concerning our loved one. If you were in my shoes, I am certain you would want to thoughtfully address each of these areas of therapeutic alliance, assessment procedures, treatment effectiveness and various features of the treatment program to make an informed decision.
Thank you for your careful consideration of each of these questions, and I look forward to meeting you and discussing a possible placement at your setting.