What treatment approaches might you consider using with Rick?

A Client Assessment Using the Six ASAM Dimensions

Rick is a 42-year-old White male brought to the city hospital following a DUI accident that resulted in him breaking his collarbone and arm. Rick’s blood alcohol level (BAL) was .42 at the time of his arrest, and this was his second DUI in the past 12 months. Rick’s BAL for his first DUI was .12, and he was approved for Accelerated Rehabilitative Disposition (ARD), a pretrial intervention program for nonviolent offenders with no prior record. During the trial for the second DUI, the judge requested a substance abuse evaluation and is considering remanding Rick to treatment in lieu of incarceration. The counselor completed an assessment of Rick using the six ASAM dimensions and made a treatment recommendation.

Dimension 1: Acute Intoxication and/or Withdrawal Potential Rick demonstrated increased tolerance. Based on reported usage, he is at elevated risk for physiological withdrawal. Concerns exist given his pattern of continued use, his high BAL, and his inability to stop drinking on his own. He meets criteria for Level 3.2-WM (Clinically Managed Residential Withdrawal Management).

Dimension 2: Biomedical Conditions and Complications With the exception of his current medical complications, Rick did not present any specific health problems or complications due to alcohol. He is not on any medications. He meets criteria for Level 1 (Outpatient Services).

Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications Rick has problems managing anger and often fights with his spouse and coworkers, especially when he is drinking. He lacks coping skills and can be quite reactive when confronted about his alcohol use. Interpersonal skills, specifically communication skills, are poor. He does not take responsibility for his actions and tends to blame others for his problems. He lacks self-efficacy, motivation, and cognitive awareness to make the necessary changes at this point. He meets criteria for Level 3.3 (Clinically Managed Population-Specific High-Intensity Residential Services [adult level only]).

Dimension 4: Readiness to Change Rick is at the precontemplative stage of change. He does not see his use as a problem and believes he can control his drinking without any assistance. He feels others are not understanding him and is in denial about his usage and amount. He is defensive and angry when discussing his alcohol use. He meets criteria for Level 3.3.

Dimension 5: Relapse, Continued Use, or Continued Problem Potential Rick’s potential for relapse is very high without intensive treatment. He lacks skills and resources to maintain sobriety. He denies having any friends who do not drink or who provide positive support systems. Without intensive treatment and an established supportive network, his prognosis for maintaining sobriety is very poor. He meets criteria for Level 3.3.

Dimension 6: Recovery/Living Environment Rick has alienated his wife and family. He does not have a good relationship with his wife and does not care what she thinks about his drinking. He has refused to attend 12-step meetings and thinks they are a waste of time. His current support system cannot assist in helping him maintain recovery. His social activities revolve around drinking. He meets criteria for Level 3.3.

Recommendation to the Judge Rick meets criteria for Level 3 for five of the six dimensions. Treatment recommendations are as follows: complete inpatient/ residential treatment detoxification protocol followed by Level 3.3 residential treatment (adult level only). Length of stay will depend on progress on all six dimensions and should be reevaluated after 4 weeks. Step down to Level 2.1 intensive outpatient treatment following successful discharge from Level 3 care.

Discussion Questions

1. What treatment approaches might you consider using with Rick?

2. As the counselor, what issues would come up for you as you work with Rick?

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