The referral process is essentially the same whether a client is currently in one's practice or the client comes in for an initial evaluation. The only difference with the existing client is that he or she may have presented for some problem other than substance abuse or chemical dependency. As the process of therapy ensues, the evidence of chemical and/or substance abuse begins to surface. When it becomes apparent to the professional that referral to a program or professional with specific expertise in the treatment of addictions must be made, the referral begins.

It is difficult to tell clients that chemical dependency is their primary diagnosis and needs to be addressed. Be it denial, or just resistance to less than pleasant news, no one wants to hear this diagnosis. If the news is coming from a therapist who they trust, it might be a little easier to accept. If the client has just come in for an initial assessment, it is even more difficult to build trust and credibility in a relatively short time such that the client will accept and follow through on the outcome of the evaluation. Either way the therapist runs the risk of losing the client because they do not accept the diagnosis or the concomitant recommendations. In any event, if the diagnosis is not presented in a palatable way, the client may not get the treatment he or she needs.

After the diagnosis has been presented and at some level accepted, the next steps in the referral process can begin. With evaluation being an ongoing process, counselors need to address the following points:

• Is he or she likely to suffer during detoxification?
• Is the client a danger to himself or to others?

If the answer to either or both of the questions is clearly "yes," the client will need a period of hospitalization. If the answer to both is "no," clear and specific information is necessary regarding quantity and frequency of consumption of mood-altering chemicals, confirmed by blood and urine analysis, with referral to a physician for confirmation that the client is cleared to participate in outpatient therapy without physical danger. If the client is evidencing either suicidal or homicidal ideation, he or she will need to be hospitalized until emotionally stable.

Again, if one answers "no" to both questions, the client can likely tolerate a social detoxification process. But, does he or she need primary inpatient or residential treatment to undergo social detoxification? The counselor needs further knowledge and information to make that decision.

The following questions can elucidate the clinician's decision-making process about whether the client would be appropriate for outpatient treatment or is in need of inpatient care.

• What is the client's level of support from family, friends and work?
• Is the client gainfully employed?
• Would this employment be classified as stable and long term?
• Is the client capable of remaining abstinent while in his/her work environment?
• Is the client's social environment one that would facilitate abstinence?
• What is the client's level of involvement with his/her family?
• How would the client be affected by his/her absence from family?
• How would the client's absence from work affect his/her financial condition?

A strong consideration to use private individual and/or intensive outpatient therapy should occur if:

• healthy support from family, friends and coworkers is strong
• client is gainfully employed and that employment has been stable and long term
• client is able to maintain abstinence while in his/her work environment
• client's social environment is supportive of his/her continuing recovery
• client has adequate level of involvement with family
• client's financial status is good or there will be a significant negative impact to the family from his/her extended absence from work

If any one or combination of the foregoing conditions is a serious threat to the client's ongoing abstinence, there is a much greater likelihood that the appropriate recommendation will be for inpatient, residential treatment or extended care.

Private individual outpatient therapy is the least formally structured form of chemical dependency treatment. Given that the treatment of choice for chemical dependency is group therapy, individual therapy can be viewed as a means for the counselor to prepare, judiciously and discreetly, an individual to engage in group therapy. Individual therapy can be highly successful with socially anxious people who are in need of forming a strong therapeutic bond prior to engaging in group therapy. It is also effective for initially treating certain "high-profile" individuals.

Intensive outpatient therapy, a step up in intensity from individual outpatient treatment, is an effective means of allowing individuals to participate in chemical dependency treatment at night while continuing to work during the day. A serious threat to continuous abstinence should trigger a referral to inpatient or residential treatment.

Managed-care companies might disagree with this approach to the treatment of chemical dependency. However, because managed care tends to disallow the emotional, environmental and social triggers for substance abuse treatment, it remains incumbent upon the referring professional to make the most ethical, accurate and appropriate recommendation to the client and his or her family about the appropriate level of care.

The professional with chemical dependency experience may assess the client as needing inpatient treatment and extended care, but the insurance company or its managed-care arm may disagree.

Most (not all) managed care companies would have individuals who are not either suicidal or homicidal in an intensive outpatient program repeatedly rather than to pay for one affordable residential treatment program. Treatment professionals have watched revolving-door intensive outpatient treatment under the auspices of managed care since the mid-to late 1980s. True, there were abuses of insurance benefits. What worked in the process of clients receiving treatment prior to the advent of managed care when treatment professionals were adamant about helping people get sober works now.

While there have been significant improvements in the process of treatment, adherence to patients' rights, improved credentialing for counselors, and getting rid of "bark strip" therapy in favor of "choice" based treatment, what works now is basically what worked then: primary treatment followed by a stay in a halfway house.

Primary treatment followed by an extended-care stay in a halfway house is often the appropriate recommendation for the client, even though this is counter to the managed care zeitgeist. The differences now versus during the days prior to managed care are that primary treatment is conducted in residential treatment centers rather than high-cost hospitals, and family therapy is being integrated into the client's treatment process from the beginning of primary treatment to the end of extended care.

Chemical dependency is a family illness and yet, primary treatment has generally focused the family on confrontation of the identified patient. Recently, improvements in the technology of the treatment process have enabled some progressive treatment centers to return to what works: primary treatment followed by extended care and the integration of family therapy and the 12 Steps into the continuum of care.

Because of the complexities of the referral process in general and the referral process in regard to extended care, additional focus needs be given to this specialized portion of the referral process. Many principles used above will be appropriate in making the referral to extended care. In addition, the information can help the professional deepen his technical understanding of the process because there are differences between referral to a primary treatment professional or program and referral to extended care.

The following explanation may help to quell the confusion that can and sometimes does arise regarding the differences between the terms "extended care" and "inpatient treatment."

Extended care is not inpatient. Inpatient is done in a hospital or freestanding treatment center based facility. The patients spend each day on site, unless they need medical treatment not available on site. They eat, sleep, go to group therapy and AA is usually brought in to them. Toward the end of their stay, they may go out one night to an AA meeting. Their meals are prepared for them and the housekeeping staff cares for their rooms.

In extended care, while the patients may be initially on site, they start going out to AA meetings and other group activities almost immediately. They work toward the next level when they either leave the premises to search for employment or to start school. Some extended-care programs also instruct the patient in a life-skills program.

Referral to extended care is more often now the exception rather than the rule. By the time an individual is referred to extended care, he or she may have been through two or three primary treatment processes. They may have been to inpatient, outpatient or both but the problem is that each time they have gone through treatment the illness builds a stronger and stronger resistance to the treatment of their addiction. Anecdotally, the best time to get sober is the first time. Repetitious treatment for short periods of time is like taking an antibiotic which has been prescribed for ten days with the instructions to complete the whole prescription and stopping after one starts to feel better in four or five days. The reason the physician instructs the patient to take all of the antibiotic is so that the bacteria are completely killed. If the bacteria are not completely killed they build up immunity to the medication and the next time the doctor needs to prescribe an antibiotic it must be much stronger to kill the infection. In treatment language, the client becomes "treatment smart."

The disease of addiction is like an infected wound. It has to be continually cleaned out until it heals and even then, without maintenance it remains highly susceptible to infection. Extended care allows time for a complete cleaning and for the full healing of the infection to take place.

Why does a client repeatedly revolve through detoxification, intensive outpatient, and primary inpatient treatment without a successful referral to extended care? There are many reasons to consider. First, the context of treatment under the auspices of managed care is "three to seven days detoxification and referral to intensive outpatient."

Second, referral to extended care is "treatment technology" that has been "lost or forgotten" by most treatment centers.

Third, many of the referring professionals today are credentialed at the master's levels but have no "real life" experience with the treatment of addictions. Fourth, programs with large amounts of "bricks and mortar" and large administrative overheads have the tendency to be driven strictly by the financial component of the treatment process. For the client to get the appropriate type and level of treatment there must be a balance between "doing the right thing" for the client and meeting the budget.

Programs with a large administrative and clinical/medical overhead are much less likely to be able to do the "right thing" when it comes to the business of filling beds or filling their collateral programs — thus, the revolving door.

Finally, the client may not accept the recommendation and/or referral to extended care. However, professionals must be sure that they and their programs are doing all that they can to facilitate the referral. Lip service to the foregoing four principles by the professional is not enough, and in so doing they may well undermine appropriate referral recommendations. The newly sober alcoholic/ addict can be at once both resistant and yet impressionable.

While primary treatment is often only an initial introduction to the recovery process, many people can successfully complete primary treatment and are ready to be discharged directly to a 12-Step program and/or an outpatient therapy setting. The patient's response to treatment is, of course, dependent upon the patient's level of pathology, the patient's current mental and physical condition, their ability to tolerate the intensity of the treatment process, and their motivation and efforts to achieve full recovery.

When the patient's pathology is severe, and the patient has a low level of ability to tolerate the intensity of the primary treatment process or he is not generally motivated, he is usually not able to acquire all of the skills and/or address all of the psychological issues related to his illness in the time allotted in a primary setting to be able to remain sober without significant additional support. Thus, the rationale for considering referral to extended care.

The following clinical issues are offered for consideration as possible rationale for recommending a client to an extended-care program.

This list is not exhaustive and there may be additional reasons to support an extended-care referral. Any of the following conditions in and of themselves are sufficient to trigger the need for clinically considering an extended-care referral. As the number of conditions (see below) increases, the criteria that supports the clinical decision increases for an extended care referral recommendation.

1. To remove the client from a "using" environment where the environmental triggers will make it very difficult if not impossible for the client to remain sober on an outpatient basis. (See number 3 below).
2. The client needs more time to address his addiction/alcoholism than the time offered by primary treatment. This may be due to the standard length of the treatment process, the per diem cost of primary treatment in private pay circumstances or to the insurance company's refusal to continue to certify inpatient days.
   Extended care is often a cost-effective alternative to an extended in-patient stay when financial resources are limited.
3. The client has had multiple treatment failures on an in-patient or an intensive outpatient basis. Many times, clients become "treatment wise" as noted above and know how to function in a standard treatment setting but have not removed the using "triggers" from their environment or developed the skills to remain sober over the long term.
   Therapeutic removal from their environment for an extended period can often provide a safe interval of time to allow the cues to vanish. In addition, a gradual reintegration into the community is often much more therapeutic and likely to facilitate long-term sobriety than rapid re-entry.
4. The client is young, single and has no established career employment. Many young people today have little or no employment or employment seeking skills, and they often have few or poorly developed social and/or self-care skills; learning these skills is usually an integral part of an extended-care program.
   Some extended-care programs offer vocational guidance and assistance as well. Finally, being single, he or she often has no family to support thus, making it easier for them to accept the recommendation.
5. The client is dual diagnosed and/or is dual addicted. Many young people today began using drugs and/or alcohol at such an early age that they did not successfully negotiate the developmental process of adolescence and the treatment field is seeing more and more people entering treatment with many more psychological and/or psychiatric diagnoses than their alcoholism/addiction alone. As with any complex medical illness, the more diagnoses. the more complicated the condition and the longer recovery is likely to take. If a client is dual addicted (using two or more substances in an addictive manner) this further complicates the treatment process and extends the time necessary to successfully treat the illness. When a client is addicted to both alcohol and other drugs, there is often a significant increase in the illnesses' resistance to treatment.
6. The family needs time to heal before the client returns to the home or family environment. Often, the client's family is so debilitated by the ravages of the "disease" and the client's "diseased" behavior that they need time to grow, heal and to establish their treatment and support groups so that they will not unwittingly enable the client when he returns home. It often takes more time for the family to engage in a recovery process than it does the client. Most families that have family members who suffer from alcoholism and/or drug addiction do not believe that they are involved in the client's illness and have great difficulty recognizing their participation in the client's illness. When this is the case, especially with young people, returning the client to the family environment before the family has the opportunity to establish a strong recovery and/or therapeutic support network can easily "set up the client and/or his family" for relapse.
7. The client needs time to heal before returning home or to the family environment. As related to number 6 above, if the client will be returning to a family environment that is resistant to therapeutic involvement in the recovery process, the client will need additional time to acquire the skills and ability to develop the support groups necessary to remain sober in such a non-supportive environment.
   Effective referral to extended care is like an intervention conducted to move a client into a treatment process. A single person can conduct an intervention when the conditions are right, but usually during an intervention the referring professional needs the support of everyone who is concerned about the client for the intervention to have a chance of being successful. Professional experience dictates treating referral to extended care as a "second intervention." This approach is much more effective than simply asking the client and/or his family if they are willing to accept an extended-care recommendation. The client's "disease" wants out of the treatment process as soon as possible and that usually does not include a willing acceptance of referral to extended care any more than a person waking up one day and saying, "I think I'll check myself into treatment." While that does happen, self-referral to treatment is rare.
   Thus, acceptance of referral to extended care simply by asking the client is usually not likely to happen either. It is always better to formally present the recommendation to the client and to his family than to assume that they are in agreement with a referral recommendation. This way there is no confusion and, thus, less opportunity for the "disease" to get its "tentacles" into the process and thwart the continuation of necessary treatment.

The referral recommendation needs to be presented as early as possible in treatment so that the client has the opportunity to work through his resistance and to be supported by his peers, his family and the other people who care about him.

A successful transition of the client and his family to the extended-care facility begins early in treatment and is completed when the client is admitted to the extended-care facility.

Referral to treatment can be a complex therapeutic process. The guidelines presented herein can help professionals determine the level of acuity needed to treat the client and which client will succeed within a particular treatment program.

Extended-care referral is presented as a recommendation that must be evaluated due to its effectiveness in facilitating long-term recovery. Finally, presenting the diagnosis and treatment plan is much more likely to be accepted when structured as an intervention process than by any one person approaching the client with referral recommendations. 

William C. "Bill" Calkins, LCSW, BCD, BCSAC, is the founder of St. Christopher's Halfway House in Baton Rouge, Louisiana. As private practitioner, he has specialized in adolescent substance-abuse treatment and extended care for nineteen years. He may be reached at www.stchris-br.com.