Treatment and Services for Alcohol and Other Drugs Clients

In the previous section of this module, you learned about the ethical and legal considerations and frameworks that you have to keep in mind when working with your AOD clients, such as delivering services that are up to a quality standard. You also learned how to manage your personal values, beliefs, and attitudes when working with your clients. This is especially important when you and your client have conflicting values and views on different matters. Other than that, you also learned about working with diverse clients, and how to respect and acknowledge their personal values and needs, such that as a a helping professional you do not create a barrier between them and seeking treatment.

As someone working in the AOD sector, one of the major components in your work is assisting your client in treatment seeking process. That means that you need to have a good understanding and be aware of the different AOD treatment and services available in your local area, such that you are able to identify the most appropriate treatment approach for your client. In order to achieve this, you will need to learn how to match your client’s readiness to change their AOD related behaviour with the most suitable treatment approach.

In this section of the module you will first learn about the Stages of Change model that helps you identify the most suitable treatment approach for your client. You will then be introduced to the different services and intervention strategies available for AOD clients. You will also learn about the different AOD treatment settings that are available in Australia.

The Stages of Change Model is also known as the Transtheoretical Model of Behaviour Change. It is the most commonly used AOD model to assist helping professionals to explain the process of behaviour change to clients and choosing the most suitable interventions for each client. This model also resonates with the person-centred approach that helping professionals are strongly encouraged to use when working with clients.

In the past, when an individual decides to change their AOD use behaviour, it was seen as a single event with the primary goal of them achieving abstinence. However, the stages of change model was developed and suggested that this change is a process and is dynamic and cyclical. It was initially developed through an examination of the process of self-change in tobacco smokers, but is now used in different health and social fields to inform behaviour change, for example, weight loss, exercise, and cancer screening (Prochaska et al., 1992, as cited in Stone et al., 2019). Prochaska and DiClemente (1992, as cited in Thombs, 2006) mentioned that many psychosocial and medical treatments have poor outcomes because clients may not possess a high level of readiness for behaviour change at the start of treatment program. Therefore, this reinforces the notion that stages of change model helps workers to tailor their client’s treatment approaches not only based on client’s needs, but also their readiness for change.

An individual typically moves through the five stages of change: precontemplation, contemplation, preparation, action, and maintenance (see diagram below). Initially, each individual can be in any stages of change and do not necessarily go through the model linearly. This means that every individual can enter the model at different stages of readiness to change a particular behaviour. As seen in the diagram, individuals could also spiral back to previous stages, and make a few attempts to change their AOD use before making a sustained change to their behaviour. You will learn about each stages of change in more details below.

Precontemplation

Clients who are in the precontemplation stage are often not considering to change their behaviour. Typically, they do not see that their AOD use is problematic; some of them view the positives of continued AOD use outweighing the negatives. Individuals in this stage are referred as “precontemplators” and are usually court-mandated clients and young people brought to treatment by their parents (Stone et al., 2019). Precontemplators are also known as “happy users”, as they are content in their AOD use. However, some individuals in this stage do not consider a change in their behaviour because they do not believe that changing is possible and achievable. Hence, it is important that you work with clients in this stage to explore the reason for their AOD use, such that they can have realistic expectations about the meaning of change for them.

For example, your client may be using illicit drugs to manage mental health symptoms. Recall that the National Drug Strategy emphasises on harm reduction approaches. When clients are in the precontemplation stage, when possible, provide your clients with information about harm reduction. It can be especially beneficial for these clients as the focus is on reducing risky AOD use rather than changing their AOD use (Stone et al., 2019).

Further, when working with clients who are in the precontemplation stage, you need to present yourself with a genuine and non-judgemental attitude to build a good rapport. As much as you want to help the precontemplators, remind yourself not to pressure them to change their behaviour immediately or give up on them prematurely when they refuse to change their AOD use. When they have a positive experience with you and the help-seeking process, they are more likely to re-engage with help seeking behaviour when they are more concerned about their AOD use in the future. So, remember to keep the doors open and continue the dialogue with them in a genuine manner and be ready to help them when they move to the next stage, contemplation.

Contemplation

Most individuals who start AOD treatment are in the contemplation stage. Typically, clients in this stage still enjoy the benefits from their AOD use, but prompted towards thinking about change due to noticing unwanted consequences such as having relationship problems or work performance issues. As a result, they can experience internal conflict due to the confusing discrepancies between positives and negatives, and may remain in this stage for a long time because they may not know how or what to change regarding their behaviours.

As a helping professional, you should create a space in which your clients can feel safe to explore all the different aspects about their AOD use, such as the reasons behind their AOD use and the unwanted consequences that they experienced. However, it is important that you do not get too far ahead and overestimate your client’s readiness to change by staying objective.

Clients in this stage are usually just beginning to notice and acknowledge the negative consequences of their AOD use. If you only focus on the negative side of their AOD use, clients may feel the need to be defensive and may rationalise their AOD use and retreat from changing their behaviour. Therefore, you have to remain objective and together, explore and realistically evaluate the ambivalence that your client may be experiencing and steer them towards the direction of change, i.e., preparation stage (Stone et al., 2019). This can be done through the use of strength-based approach by focusing on your client’s strengths and acknowledging their struggles.

Preparation

Clients in this stage are aware that the negatives of their AOD use are greater than the positives. They have made a decision to change and are typically receptive to discuss treatment and intervention options, as well as seeking to plan how to put that change into effect. Read below an extract from Washton and Zweben (2006, p. 177) regarding strategies to help clients who are in the preparation stage.

You learned that the Stages of Change model is very useful for the AOD sector in assessing the readiness of clients to change their behaviour. It is also helpful in assisting helping professionals to match clients’ needs and readiness to change with the appropriate treatment and/or support services. Now you will learn about the different treatment and interventions that are available for AOD clients in their process to change their AOD use. You will also learn about the different treatment settings that provide AOD services.

In an earlier section of this module, you learned about the prevention strategies based on the guidelines from the National Drug Strategy, which aimed to minimise harm of AOD use and its impacts. Those strategies are mainly primary interventions (aimed to delay or prevent onset of AOD use) and secondary interventions (aimed to detect AOD use early and prevent its progression that may lead to problematic use). In this part of the Study Guide, we will be focusing on the tertiary prevention, which aims to improve the quality of life of individuals who uses AOD and reduce and managing any symptoms that arise from excessive AOD use.

Recall that you learned about the National Framework for Alcohol, Tobacco, and Other Drug Treatment. It introduced the AOD treatment service system in Australia which consists of three different interventions. We will look at the different treatment interventions based on how they were categorised according to their intervention aims. It is important to remember that these interventions are not mutually exclusive, i.e., an individual can receive treatment across two different intervention categories. The three types of interventions are interventions to reduce harm, interventions to screen, assess, and co-ordinate care, and intensive interventions. You will learn more about each intervention below, as outlined in the National Framework (adapted from Department of Health, 2020).

Interventions to Reduce Harm

Treatment interventions under this category have the aim to reduce immediate or short-term harms, while engage and support individuals as well as referring them into treatment, if required. The goal is to reduce any immediate or short-term harms associated with AOD use. It also aims to provide individuals with opportunities to improve their physical, mental, social, and emotional well-being. Typically, interventions to reduce harm are the first points of contact with healthcare for individuals who use AOD. Individuals are also able to receive further information about the different treatment and support services, and if required, referral to these services. These interventions include:

• Sobering up shelters: providing a safe place for individuals who are severely intoxicated.
• Needle and syringe programs: supplies sterile injecting equipment for individuals to inject drugs; ensure individuals do not reuse and share needles to decrease injection-related harms and spread of blood borne viruses. Individuals are also provided with information on how to avoid and reduce the risks of blood borne viruses such as HIV and Hepatitis C.
• Supervised consumption centres: also known as the Medically Supervised Injecting Centre (MSIC). Provides a safer and clean space for individuals to inject drugs such as heroin or ice under the supervision of medical staff. They also provide health services such as overdose management and pathways into treatment and support services. There are currently two MSIC sites in Australia: Kings Cross in Sydney and North Richmond in Melbourne.
• Drop-in-services: individuals are able to have immediate access to various AOD services and resources. If more intensive and coordinated services are required, appropriate referral pathways will be provided.
• Peer support: Educate their peers to use AOD in safer way or reduce the consequences of their AOD use. It can also be in the form of self-help groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). These groups are based on the “12 Steps Program” which encourages personal and spiritual growth. They act as a support system for individuals whereby members attend meetings to share their stories of AOD use and recovery.
• Overdose prevention: Training programs provided for individuals who use opioid or those around them, so that they know how to reverse opioid overdose by using naloxone. There is also a distribution of naloxone for those who are likely to witness overdose.
• Family support: To provide support for family members of individual who uses AOD. This can be in the form of family and generalist support group or peer-based programs; and if appropriate, brief interventions or single session therapy for family members or significant others can also be provided. If more intensive support is required, then they will be given the appropriate referral.

Interventions to Screen, Assess, and Co-ordinate

These interventions aim to identify and assess harmful consumption patterns, facilitate referral to more intensive interventions when required, and to provide coordinated care and case management. It is also important to ensure there is an appropriate match between the individual’s needs and the interventions that are offered to them. These can occur over a single occasion or several occasions. As a helping professional, you should also try to reduce any barriers (both real and perceived) that prevent the individual from accessing further AOD treatment.

These interventions include:

• Screening and brief intervention: Ensures that individuals who are experiencing harm from AOD use are provided with appropriate information, support and the opportunity to seek for further assistance. This is typically delivered in primary settings as all health care providers have the responsibility to screen their clients/patients for any harms from AOD use.
• Assessment services: Provide the opportunity for an assessment of the individuals’ needs and matching to support services. This is an ongoing process as there is a need to continually assess the match between the treatment received and individual’s needs and goals.
• Consultation liaison services: Provides an opportunity for individuals who are admitted into hospital due to AOD use to be assessed and receive an appropriate patient-centred care planning.  The service also facilitate the provision of clinical care to patients/clients with seeking help with AOD use in a hospital setting.
• Case management and care co-operation: Ensures the links are made between clients and health or social welfare services. It also ensures that the individual’s care is coordinated across care settings and systems. Individuals who receive AOD treatment often also require supports from other services and systems such as housing, employment, child protection, etc., and these requires co-ordination. With effective case coordination services, clients are able to receive continuity of care between services and systems. It is worth noting that the client should have full knowledge and consent before the commencement of coordination between agencies/services.

Intensive Interventions

Intensive interventions are therapeutic and evidence-informed, and focuses on the individual’s behaviour change and enhancement of their physical and mental health, and their social and emotional wellbeing. The aims of these interventions is to establish a continuing relationship with client with regular communication and ensure that they receive ongoing support. Depending on the client’s needs and goals, there may be a formal transfer of care to another service provider or ongoing contact and support with the same service provider. There are four broad types of intensive interventions:

• Withdrawal management services: It helps individuals to reduce or cease prolonged AOD use in a safe and supportive environment. Withdrawal management is an acute treatment that can provide short-term outcomes and medications are used occasionally to help with withdrawal symptoms. However, withdrawal management are not meant to result in sustained behaviour change. Instead, appropriate planning for continual treatment, care, and support is important to ensure the positive behaviour change is sustainable.
• Psycho-social counselling: These involves evidence-informed talking therapies that focus on assisting individuals to develop specific skills based on their personal treatment goals. These can be psychological or practical skills to help individuals reduce AOD use and its harms. Therapies that are most commonly used for AOD treatments are Cognitive Behaviour Therapy (CBT), Motivational Interviewing (MI), Mindfulness, and Acceptance and Commitment Therapy (ACT). Counselling interventions can be delivered individually or in a group setting.
• Rehabilitation: This is a treatment program that integrates a range of services and therapeutic activities. Rehabilitation is typically intensive and can include counselling, behavioural treatment approaches, social and community living skills, relapse activities, and recreational activities. Some programs integrate halfway houses, which are supervised houses in the community whereby individuals are able to obtain support to transit and reintegrate into their community and life out of treatment. There are programs available that are specially designed and dedicated for specific populations such as women and mothers with children. Some programs are governed by and dedicated to Aboriginal and Torres Strait Islander peoples.
• Pharmacotherapy: Medications can be used to treat problems brought upon by AOD use. The treatment duration can be prescribed for a range of duration, from short to long-term treatment, and according to the individual’s treatment goals. Pharmacotherapies are used in different ways for different clients, for example, reducing cravings, preventing withdrawal symptoms, or producing an aversive reaction when used with another drug. The medications are typically prescribed by someone who is approved to do so and dispensed through a specialist clinic or a community pharmacy.

Treatment Settings

Now that you learned about the AOD treatment system in Australia and the three broad types of interventions provided, we will now look at the treatment settings that these interventions are delivered at. While some of these settings provide general healthcare (e.g., general practitioner practice), some are dedicated to provide AOD treatments (e.g., drug residential rehabilitation centre). Of course, AOD treatments are not limited to these settings, but can also be provided in other settings such as infectious disease services, maternity services, youth services, and more. Sometimes, individuals may receive integrated care at a single setting that provides holistic care across different areas that the individual requires.

As a helping professional you will have to work together with your client to choose the most appropriate treatment setting, based on their treatment needs and goals. For example, a client may be admitted into the hospital to manage their withdrawal symptoms. At the same time, they also receive counselling services from the hospital counsellor to work on their AOD use. However, another client who is in the maintenance stage of the model only requires weekly check-ins to keep their behaviour change in check. This client does not need to be admitted into the hospital but only need to attend weekly self-help groups in their community. Now we will look at the different AOD treatment settings in more detail (adapted from Department of Health, 2020).

Standalone Specialist AOD Settings

• Non-residential settings: Non-residential withdrawal services is also known as outpatient withdrawal services. These services support individuals to withdraw from AOD use in a safely manner, including clinical withdrawal assessment and withdrawal treatment. This is usually done through a stop of or gradual reduction of AOD use, with health professionals in the community to monitor withdrawal symptoms. These services are provided for individuals who are at low risk, have a supportive social system, and stable housing. However, individuals in rural areas may also access non-residential services (Manning et al., 2018).
  There are also day rehabilitation programs which offer a more structured environment for individuals to attend education, support, and counselling services for set times during the day and remain living at their home. Clients who require a more flexible option may opt to enter a day rehabilitation program for their AOD treatment (NSW Health, n.d.).
• Residential settings: There are two types of residential settings: residential rehabilitation services and residential withdrawal services. The earlier provides a safe and supported environment in a community-based setting for individuals and has a range of interventions are offered such as counselling that focuses on mutual self-help and peer community, and strategies to help individuals reintegrate into the community. The latter service is for individuals to safely withdraw from AOD dependence in a supervised setting, typically a short-term stay in a supervised residential or hospital facility.
  Usually, residential services are for clients who experience severe consequences of harms from AOD use and unable to receive adequate support at their home setting. There are also residential withdrawal services for youths who experience significant harm from AOD use.
  Because residential services provide the individuals with a structured environment to assist with their recovery, when their treatment ends, they may experience lapse or relapse. This may be due to different reasons such as losing the structure or returning to places where previous AOD use took place. Therefore, aftercare and ongoing support for individuals are extremely important to support them in making sustainable behaviour change.
• Outreach: Some AOD service providers locate and provide treatment to individuals who require interventions. It is not an intervention in itself, but an approach that many service providers use to assist individuals who needs help. There are different types of outreach programs put in place, such as Assertive Street Work, whereby helping professionals actively locate individuals who require but are not in AOD treatment in various public locations such as parks and the streets. Another program is Detached/Mobile Outreach where helping professionals focus on structured and planned work to provide support for clients in agreed settings such as client’s own home (MacBean et al., 2015).
• Home-based: Similar to non-residential services, individuals are able to withdraw from their AOD use in a safe manner at their home. Individuals will get regular home visits from an AOD nurse and supervising general practitioner; the GP prescribes medications required, and dispensed daily or every few days depending on potential non-medical use. Home-based treatment setting is suitable for individuals with only developed dependence on one drug and have no significant comorbidities or complex withdrawal history (Manning et al., 2018).
• Telephone services: Alcohol and other Drugs Information Service (ADIS) telephone services are usually the first point of contact of AOD-related services for individuals who uses AOD and those around them. Individuals can obtain private and confidential counselling and assistance from these service providers, as well as other AOD-related resources such as information, self-assessment tools, and referral for treatment.
• Online AOD work, e-health: E-health interventions create opportunities to overcome traditional barriers that may have deterred individuals from seeking help or treatment for their AOD use. For example, the cost of face-to-face counselling may be too expensive for an individual; online counselling is an alternative as they are usually at a significantly lower cost or no cost.
  There are also online forums available that individuals can interact and discuss with other individuals who use AOD to support and encourage each other during the treatment progress. For example, Counselling Online Forums is a safe space for peer support on recovery and moderated by health professionals 24/7.
  Recently, many mobile applications become available for individuals who wish to manage their AOD use and reducing their cravings. There are also mobile applications that uses psychological approaches to manage AOD use such as meditation guide to reduce daily stress and anxiety which in turn reduces chances of AOD use.
  These digital services are extremely important because most of them provide 24/7 services to those who require immediate support or information outside of business hours (Health Victoria, n.d.). Helping professionals may also establish communication with their clients via emails. For example, Turning Point offers online counselling services, whereby individuals can access counselling services via online chat or email.

Primary Health Care Settings

• General Practices: Provides general and brief healthcare services for individuals; provides referral to appropriate treatment and service providers if required. General practitioners also prescribe medications for individuals who are receiving pharmacotherapy.
• Community Health Centres: Provides a range of services and programs for individuals. For example, screening assessments, appropriate referrals, counselling services, and needle and syringes programs. However, each centre provides different services, and not all services are available across all centres.

Tertiary Health Care Settings

• Inpatient hospitals: When individuals experience severe withdrawal symptoms with severe medical and/or mental health issues, they may be required to be admitted into the hospital. This is so that they can receive complex medical treatment and support if required, and typically also receive intensive psychiatric support if presented with co-occurring mental health issues (Health Victoria, n.d.).
• Ambulatory, outpatient hospital services: Deliver services to individuals who are not admitted in the hospital. These can include services at hospital outpatient clinics, day programs, and community-based AOD services.
• Telephone, online, e-health
• Healthcare in the home: Similar to non-residential services, individuals may receive integrated care from health professionals across different treatments and services at their home. Individuals who are living in rural areas or do not require intensive healthcare support and treatment may opt to receive this service.

Other Settings where AOD Services are Provided

• Aboriginal Community Controlled Health Organisations – They provide dedicated AOD treatment services and integrated care for the Aboriginal people who are impacted or at risk of being impacted by AOD and its harms. This can include social and cultural support, psychological therapies, and medical treatment.
• Pharmacies – Individuals receiving pharmacotherapy may be required to collect their prescribed medication from a pharmacy daily. Trained pharmacists typically dispenses the medication to the individual and supervise the individual to ensure that the required dose is taken. Some individuals are allowed to take away their doses and administer them at home.
• Youth services – Young people (typically up to 21 to 25 years old, depending on each jurisdiction) have specific needs that are different from adults who are seeking AOD treatment, hence they require services that are dedicated to them. Family-based approach is typically used when working with youths, whereby other services such as education, housing, child protection, family services, etc., may be included to deliver an effective treatment for the youth. Interventions can include outreach and support, withdrawal management, and residential rehabilitation.
• Mental health services – According to Marel et al. (2016), 35% of individuals with substance use disorder have at least one co-occurring mental health disorder such as anxiety disorder. This shows that individuals who require AOD treatment often require access to mental health service too. Therefore, a holistic approach needs to be adopted for individuals who are presented with mental health issues such that mental health treatment and AOD treatment are provided (Marel, et al., 2016). As a helping professional, you have to be aware that your client may use AOD as a coping strategy to manage their mental health symptoms.

Find Out More

You learned that digital services are one type of service available to AOD clients, such as telephone support and online counselling. Are you aware that each jurisdiction has their own confidential telephone counselling, information, and referral service that operates 24 hours? Visit this website to find out the number that is relevant to your jurisdiction, or even when you are assisting an individual who may be from another territory: Phone and online services: State by state.

If you are unsure which jurisdiction the individual belongs to, you can call the National Alcohol and other Drug Hotline (1800 250 015). They provide free and confidential advice about AOD, and will automatically direct the caller to their jurisdiction’s Alcohol and Drug Information Service for further assistance.

After going through the services and treatment settings available in Australia, you now have a better idea of how to help your client in terms of the most appropriate care that aligns with their treatment needs and goals. You learned that you have to provide your clients with the available and suitable treatment options during the preparation stage of the model. However, if your client appears intoxicated, withdrawn, distant, or non-receptive after your explanation, do not pressurise them into discussing their treatment plan immediately. If they are deemed low-risk, continue establishing rapport with them and focus on harm minimisation approaches when they use AOD.

Recall the No Wrong Door Approach that you learned in the previous section. Asa, you will definitely come across individuals or clients that may not match the service you or your organisation provides. Therefore, you have to remember that you need to guide them towards the right service provider so that they can receive appropriate care and support.

Find Out More

In order to help you familiarise yourself with the services available in your local area, visit this toolkit developed by the Association of Alcohol and Other Drug Agencies NT (2015): Identifying local referral pathways.

Then, look at page 94 to 96 of the toolkit and complete the template to identify the different service types for your clients that are available in your jurisdiction/local area.

Now that you learned about the different treatment and support services that are available in Australia, you should be more confident in assisting individuals such that you guide them to receive the appropriate care they need. Remember, you have to take into consideration each client’s treatment goals and needs (e.g., do they have complex needs, do they require withdrawal management services) before developing a treatment plan. And of course, you have to empower your client to be part of the informed decision-making process. Additionally, you also learned about the different settings that services can be delivered.

Department of Health. (2020, September 16). National framework for alcohol, tobacco and other drug treatment 2019-29. https://www.health.gov.au/resources/publications/national-framework-for-alcohol-tobacco-and-other-drug-treatment-2019-29

Health Victoria. (n.d.). Alcohol and other drug treatment services. https://www2.health.vic.gov.au/alcohol-and-drugs/aod-treatment-services

MacBean, R., Hipper, L., Buckley, J., Tatow, D., Podevin, K., & Fewings, E. (2015). Queensland alcohol and other drug treatment service delivery framework. https://insight.qld.edu.au/file/235/download

Manning, V., Arunogiri, S., Frei, M., Ridley, K., Mroz, K., Campbell, S., & Lubman, D. (2018). Alcohol and other drug withdrawal guidelines. https://www.turningpoint.org.au/sites/default/files/inline-files/Alcohol-and-Drug-Withdrawal-Guidelines-2018.pdf

Marel, C., Mills, K. L., Kingston, R., Gournay, K., Deady, M., Kay-Lambkin, F., Baker, A., & Teesson, M. (2016). Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings. https://comorbidityguidelines.org.au/pdf/comorbidity-guideline.pdf

Massachusetts Institute of Technology. (2022, February 24). [Photograph of clinical treatment]. https://news.mit.edu/2022/deep-learning-technique-predicts-clinical-treatment-outcomes-0224

NSW Health. (n.d.). About alcohol and other drug treatment. https://www.health.nsw.gov.au/aod/Pages/about-treatment.aspx

Stone, J., Marsh, A., Dale, A., Willis, L., O’Toole, S., Helfgott, S., Bennetts, A., Cleary, L., Ditchburn, S., Jacobson, H., Rea, R., Aitken, D., Lowery, M., Oh, G., Stark, R., & Stevens, C. (2019). Counselling guidelines: Alcohol and other drug issues. https://www.mhc.wa.gov.au/media/2604/mhc_counselling-guidelines-4th-edition.pdf

Thombs, D. L., & Osborn, C. J. (2019). Introduction to addictive behaviours. The Guilford Press.

Washton, A. M., & Zweben, J. E. (2008). Treating alcohol and drug problems in psychotherapy practice: Doing what works. The Guilford Press.