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ATP - Assessment & Treatment Planning

Learn To Effectively Screen, Stabilize, Assess, & Motivate
Clients Suffering From  Addiction And Related
Personality And Mental Disorders

Treatment & Research
Criteria for Substance Dependence Diagnosis (8-14-01)

Here is a quick reference to the major diagnostic criteria for substance dependence disorders:  
(1) Diagnostic & Statistical Manual III-R (DSM-III-R);  
(2) Diagnostic & Statistical Manual IV (DSM-IV); 
(3) International Classification of Disease 10 (ICD-10).

ATP - Assessment & Treatment Planning

Table Of Contents - ATP Process

Major Focus Of ATP

ATP Summary

ATP Goals

ATP Step 1:  Screening, Intake, and Stabilization

ATP Step 2:  Presenting Problem Analysis

ATP Step 3:  Life and Addiction History

ATP Step 4:  Recovery and Relapse History

ATP Step 5:  Assessment Profile

ATP Step 6:  Final Problem List

ATP Step 7: Diagnostic Presentation

ATP Step 8:  Initial Treatment Plan

ATP Step 9:  Comprehensive Treatment Plan

ATP Endorsements

ATP References & Bibliography  <Go To ATP Bibliography>

 

 

Major Focus Of ATP
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Recognizing addiction and coexisting mental and personality disorders, stabilizing the client, & implementing an appropriate treatment plan.

This component presents general guidelines for:  

1.    Completing a screening evaluation and comprehensive assessment for       addiction and coexisting  personality and mental disorders

2.    Developing a brief strategic treatment plan based upon the outcomes of the assessment.  Master  treatment plans are included that can be customized to meet the individualized needs of clients

Summary of the ATP  Process  
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Clients undergo a comprehensive screening interview to determine their appropriateness for treatment and then complete stabilization to assure that they are abstinent from alcohol and drugs, free of acute withdrawal symptoms, and mentally, emotionally, and behaviorally stable enough to complete the treatment process.  

Goals of Assessment & Treatment Planning (ATP)     
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The goal of ATP is to complete a comprehensive biopsychosocial screening and assessment that results in:

(1)       Symptom Profile:  ATP is designed to create an organized Biopsychosocial profile of symptoms that are related to substance use disorders, mental disorders, personality disorders, and situational life problems.  Each symptom will include a standardized rating of symptom severity.

(2)       Problem List:  ATP results in a prioritized problem list that links each identified problem to the presenting problems, its onset and development in the life addiction and mental health history, and the disorder(s) that the problem is related to.

(3)       Target Problem:  ATP identifies the target treatment problem which is the most important problem that needs to be the primary or central focus of the initial treatment plan.

(4)       Initial Treatment Plan:  ATP develops an initial treatment plan consisting of a personalized problem title, a personalized problem description, an outcome goal, and an action plan (a series of linked clinical interventions designed to accomplish the goal)

The ATP Clinical Process

ATP Step 1:  Screening, Intake, and Stabilization  
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This is a brief evaluation that has the goal of placing the client in:

·        the proper type of treatment (based upon current level of motivation, knowledge of foundational recovery skills, and immediate relapse risk).  The type of treatment is determined by nature and severity of the primary target problem on the treatment plan, the goals, and the activities of the action plan. 

·        the proper level of care (based upon the client’s level of physical, psychological, behavioral, and social stability).  The level of care determined by the client’s current level of stability and an assessment of the amount of environmental support and supervision he or she receives while completing the activities on the treatment plan.

ATP Step 2:  Presenting Problem Analysis  
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When clients are able to rationally think and talk about the problems that caused them to seek treatment, the presenting problems are reviewed an analyzed.  This analysis of the presenting problems involves the following steps: 

(1)       Developing the initial list of presenting problems and writing a that list using bullet statements

(2)       Analyzing the client's level of biopsychosocial stabilization.  (If the client is unstable due to intoxication, withdrawal, or post acute withdrawal (substance induced organic mental disorders) they are referred for detoxification and stabilization before an indepth assessment is completed)

(3)       Clarifying each problem by writing a title and a description sentence describing the problem in more detail; 

(4)       Rating the severity of subjective pain and objective dysfunction that each problem causes for the client using a 10 point rating scale (0 = no pain or dysfunction; 10 = Sever pain and dysfunction). 

(5)       Clarifying the relationship between each presenting problem and the use of alcohol and drugs. 

(6)       Clarifying the relationship between each presenting problem and any known mental health problems (i.e. mental or personality disorders)

(7)       Projecting the logical consequences of each problem if the client continues to use alcohol and drugs; 

(8)       Grouping the problems into related clusters to see how the symptoms are related to one another and to determine if there is one or more core or central issues that are causing secondary problems.

(9)       Prioritizing the problems in order of importance (Is this a core or central problem that will result in the spontaneous resolution of other problems when resolved?) and severity (how seriously is this problem interfering with the client’s current ability to function.

ATP Step 3:  Life and Addiction History:  
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The life and addiction has three primary goals: 

(1)       to identify and clarify the sequence of life events that have brought them to their current position in life; and

(2)       to identify the pattern of alcohol and drug use during each major phase of their life history; and

(3)       to identify what the client believed that alcohol and drugs could do for them that they could not do for themselves without it.

ATP Step 4:  Recovery and Relapse History     
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The recovery and relapse history is designed to identify and clarify each episode of recovery and each episode of relapse.  The primary goal of the recovery and relapse history is to organize a time line of critical events in the recovery process and to analyze the key decision points that caused clients to initiate a new period of recovery or decompensate into a new period of either substance use or disabling symptoms of a mental health disorder.  This is done by completing two processes:  Analyzing the decision points that started each episode of recovery and analyzing the decision points that led to each episode of relapse. 

The decision points of recovery are analyzed by identifying the problems that prompted the person to start each episode of recovery, clarifying what they wanted recovery to do for them, and exploring what happened in each episode of recovery that set them up to go back to relapse.  The decision points of recovery are analyzed by using two key focusing questions:  What did you what recovery to do for you that you couldn’t do for yourself while using alcohol and drugs?  Did recovery give you what you wanted? 

The decision points of relapse are analyzed by identifying the problems experienced during recovery that prompted the person to start using alcohol or drugs, clarifying what they wanted alcohol or drug use to do for them, and exploring what happened in during relapse episode that made them want to get back into recovery.  The recovery and relapse history is also designed to analyze each relapse episode to determine what they wanted alcohol and drugs to do for them that recovery wasn’t doing and whether or not the relapse gave them what they wanted.  The decision points of relapse are analyzed by using two key focusing questions:  What did you what alcohol or other drugs to do for you that you couldn’t do for yourself while abstinent?  Did you get what you wanted from using alcohol or other drugs? 

ATP Step 5:  Assessment Profile     
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The assessment profile is organized summary of the significant results of the assessment.  This normally consists of the following:

·        Profile of Disorders:  The profile of disorders is a listing of all of the coexisting disorders that were identified during the assessment.  The disorders are organized as Substance Use Disorders (specified by drugs of choice), Mental Disordered, Personality Disorders, and severe situational problems requiring counseling (DSM V-codes).  It is important the profile of disorders have a brief no-nonsense explanation of each disorder and a simple plain-English title for the disorder. 

·        Symptom Profile:  The symptom profile is a comprehensive list of the specific symptoms of substance use disorders and coexisting mental and personality disorders.  A symptom is described as an area of dysfunction related to the identified disorders.  The symptom profile is developed by working with clients to complete symptom checklists for substance use disorders and the common coexisting mental disorders, personality disorders, and lifestyle problems.  A biopsychosocial assessment grid is used to identify the relationship between biological, psychological, and social symptom clusters.  When the symptoms of all disorders are identified and organized together, two types of symptoms can be identified:  (1) Holistic Symptoms:  The common symptoms that relate across all identified disorders; and (2) Disorder-specific Symptoms:  Symptoms that are associated with only one disorder and are not shared by the other disorders.

·        Personality Profile:  The personality profile describes the essential characteristics of the clients habitual way of relating to self, others, and the world. 

·        Life Style Profile:  The lifestyle profile describes the common habitual structures of the client’s normal way of living and identified the lifestyle components that are centered around and support addiction and coexisting disorders and those that support sobriety, responsibility, and normal functioning.

An assessment the global personality and life style patterns that contribute to relapse is identified by completing a comprehensive self assessment of the life, addiction, and relapse history;

ATP Step 6:  Final Problem List     
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The final problem list is developed by clarifying the important problems which the client must address in order to develop a stable and meaningful lifestyle of sobriety and responsibility.  In a well written final problem list each problem has a title (a word or phrase that summarizes the meaning of the problem) and a description ( a single sentence that describes the dynamics of the problem). 

A well written problem list is prioritized in three ways:

·        by problem severity (how much does it interfere with normal acts of daily living?)

·        by problem significance (is it a central or core problem that will result in the spontaneous remission of other secondary problems if resolved?), and

·        by developmental problem solving (In what order do the problems need to be addressed?)

The first problem on the problem list needs to be the Target Treatment Problem.  The target treatment problem is the central or core problem that is selected to be the primary focus of the current treatment plan.  One of the primary goals of the Final Problem list is to organizer the problems is such a way so that it is clear that the first problem on the prioritized problem list (i.e. the target treatment problem) needs to be the first problem that becomes the central focus in treatment.

ATP Step 7:  Diagnostic Presentation     
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The goal of the diagnostic presentation is to give both the client and family members with an overwhelming and undeniable argument that the client is suffering from the diagnosed disorders, that recovery is possible, and that a comprehensive treatment plan needs to bring implemented that addresses the chronic and persistent symptoms of these disorders.  The diagnostic presentation describes in no-nonsense language exactly what is wrong, what the painful problems are the client and significant others are experiencing, and then explains that recovery is possible and that these problems can be either resolved or effectively managed in ways that significantly reduces pain and dysfunction. 

The process of preparing for a diagnostic presentation involves:  (1) organizing the identified disorders and symptoms in a way that shows that logical connections to the clients Motivational Crisis and shows how all problems and symptoms relate to one another to create the motivational crisis;  (2) Listing the prioritized problems in column one of a four column form with the other three columns being left blank to list the relationship of each problem to alcohol and other drug use (in column #2), to identified mental health disorders (in column #3), and projecting the logical consequences of refusing to address that problem in treatment (in column #4).  The client is then asked to review the contents of all four columns and is asked to make a decision about what they want to do.  A black and white choice is given:  either (1) enter a treatment process to solve the problems, or (2) refuse treatment and continue struggling to cope with the problems without help and risk the logical consequences of the problems getting worse.

ATP Step 8:  Initial Treatment Plan     
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The diagnostic presentation sets the stage for the development of the Initial Treatment Plan which involves development an abstinence contract, a schedule of treatment activities, and an initial structured recovery program that will support the client during initial treatment.  The initial treatment is designed to resolve the Motivational Crisis, provide Biopsychosocial Stabilization, get the client involved in a setting and systematic process in which they can develop a comprehensive treatment plan.  This normally involves:

·        ATP Step 8-1:  The Abstinence Contract:  The abstinence contract is an agreement to abstain from alcohol and other mood altering substances for the duration of treatment and to abstain from behaviors that exacerbate the symptoms of coexisting mental or personality disorders.  The abstinence contract results from the process.

·        ATP Step 8-2:  Schedule of Treatment Activities:  The therapist recommends an initial schedule of treatment activities that includes a level of care recommendation (inpatient vs. outpatient), an intensity of care recommendation (how frequently sessions are scheduled), and the modality of care recommendation (either individual therapy, group therapy, psycho educational programs, supervised participation in self-help programs such as Alcoholics Anonymous, or a combination of two or more).

·        ATP Step 8-3:  Structured Recovery Program:  An initial structured recovery program is developed by collaboratively identifying the recovery activities and other acts of daily living that are required to support initial abstinence, mental status stability, and lifestyle stability during the period of active treatment.  The structured recovery program is an important tool for monitoring a client’s motivation for treatment and identifying relapse warning signs. 

ATP Step 9:  Comprehensive Treatment Plan     
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A comprehensive treatment plan is then developed to manage the most disabling symptoms.  This is done by matching to the clients current needs in recovery to realistic goals and easy to follow action steps.  This is done as a collaborative process by securing a voluntary commitment to complete the action steps of that treatment plan.

The treatment plan is a written document that identifies the target problem (the problem that will be the central focus of the current treatment efforts), the goal (the outcome that needs to be achieved to resolve the target problem, and an action plan (the specific steps that will be taken to resolve the problem and achieve the stated goal, an outcome evaluation that measures the level of completion of step of the action plan and the over all level of achievement of the stated goal. 

A comprehensive treatment plan has the following components.

·        ATP Step 9-1: The Target Problem:  The target problem is the central or core issue that will become the central focus of treatment.  The problem statement is written in a format that includes a title (a word or short phrase that captures the key characteristic of the problem) and a description (A sentence or short paragraph that describes the problem.

In working for the goal of recovery from a chronic lifestyle related illness or disorder there are typically four standard problems that are dealt with sequentially as a person moves through a developmental recovery process.  These are: 

·                   Standard Problem #1:  Denial and Resistance:  The client is exhibiting strong denial of substance abuse and strong resistance to following a standard program of recovery in spite of clear evidence from the assessment that they are suffering from a substance use disorder; 

·                    Standard Problem #2:  Immediate High Risk of Relapse:  The client is facing a number of high risk situations which present an immediate risk of relapse and does not have the confidence or the necessary recovery skills or coping strategies to either responsibly avoid and responsible deal with the situation without relapsing; 

·                    Standard Problem # 3: Lack of Foundational Recovery Skills:  The client recognizes and accepts that they are suffering from a substance use disorder but lacks an accurate understanding of substance use disorders and the process of recovery, and the available recovery tools and supportive services; 

·                    Standard Problem #4:  Personality and Lifestyle Problems:  The client currently has a stable recovery but is exhibiting a number of core personality and lifestyle problems that increase the risk of relapse by creating a state of chronic low grade stress and problems that interferes with their recovery program and with their ability to comfortably adapt to a lifestyle of sobriety.

·        ATP Step 9-2:  The Goal:  A goal is a measurable outcome goal and the projected date by which it will be completed.  The goal is a statement of the desired successful outcome of treatment.  The goal should be expressed in a concrete and specific manner that allows the client to develop a concrete visual image of exactly what his or her life will look like when this problem is resolved.

·        ATP Step 9-3:  The Action Plan:  An action plan is a tightly linked sequence of activities that describes the exact steps that will be taken to achieve the stated goal.  Each step of the action plan is concrete and specific and is linked to s specific treatment activity (individual group, or Pyschoeducation sessions) and homework assignment designed to help the client to complete the activity.

      An action plan describes a sequence of action steps that will be used to achieve the stated goal.  Each step of the action plan identifies:  (1)  a specific clinical process;  (2)  a preparation homework assignment;  (3)  the type of clinical session (individual therapy, group therapy, Pyschoeducation) in which the assignment will be processed;  (4)  the date and time of the clinical session;  (5)  the resources that will be available to the client for preparation and completion of the action step, and (6)  an outcome evaluation scale.

·        ATP Step 9-4:  The Outcome Evaluation:  The outcome evaluation is a quality assurance tool that measures the level of goal attainment for each individual step of the action plan and for the overall level of goal attainment for the treatment plan using a ten point scale (0 = No goal attainment;  5 = partial goal attainment;  10 = full goal attainment.

·        ATP Step 9-5:  Referral:  The final step in developing a comprehensive treatment plan with a client is to completing a confirmed referral to the appropriate level and type of treatment that can supervise the completion of the treatment plan.  In some programs, the clients will complete the treatment plan under the supervision of the therapist who completed the assessment, in other programs the client will be referred to another therapist within the agency or to another agency to complete the treatment plan.

Model Treatment Plans:  Model treatment plans for each of the CENAPS® Core Components are presented in the description of each.

References & Bibliography Used In Developing ATP
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              <Go To ATP Bibliography>

ATP was developed as result of over 30 years of clinical experience by 
Terence T. Gorski and continuous updating based upon the emerging 
clinical literature.  To review the bibliography of sources used to develop 
ATP click here <ATP Bibliography>

Related Article

Guidelines for Safe Drinking (04-10-01):  A Summary By Terence T. Gorski

Summary:  According to Dr. Mary Dufour A standard drink equals: 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80 proof distilled spirits.  A safe or moderate level of drinking (i.e. how much a person can drink without being at risk of incurring negative biopsychosocial consequences) is no more than two drinks per day for men and no more than one drink per day for women.  The people who should not drink at all for health reasons are:  (1) Children & Adolescents;  (2) People who cannot or will not keep their consumption within the "safe levels" described above;  (3) Women who are pregnant or trying to conceive; (4) People who plan to drive or engage in other activities requiring skill or psychomotor coordination;  (5)  People using prescription or over-the-counter medication that adversely interacts with alcohol;  (6) People who are in recovery from alcoholism or other forms of substance abuse or have a past history of serious problems related to the use of alcohol or other drugs; and (7) People who have family members with serious alcohol or drug problems should be especially careful to limit their consumption to safe levels and to stop all drinking if the safe levels are exceeded consistently for any reason.

 

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