Standards for private organizations

2020 Edition

Mental Health and/or Substance Use Services (MHSU) 5: Clinical Counseling

The organization provides trauma-informed clinical counseling services that: 
  1. provide an appropriate level and intensity of support and treatment;
  2. recognize individual and family values and goals;
  3. accommodate variations in lifestyle; 
  4. emphasize personal growth, development, and situational change; and
  5. promote recovery, resilience, and wellness.


Ambulatory detoxification treatment programs include a range of therapies (e.g., cognitive, behavioral, medical, and mental health therapies), provided to persons served on an individual or group basis. Services aim to enhance the service recipient's understanding of addiction, completion of withdrawal management, and referral to an appropriate level of care for substance use treatment. The delivery of services will vary and depends on the assessed needs of the service recipient and his or her treatment progress. 
NA The organization provides Diagnosis, Assessment, and Referral Services only.
2020 Edition




Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning to attain recovery and wellness.
Examples: Organizational self-assessments can help evaluate the extent to which organizations’ policies and practices are trauma-informed, as well as identify strengths and barriers in regards to trauma-informed service delivery and provision. For example, organizations can evaluate staff training and professional development opportunities and review supervision ratios to assess whether personnel are trained and supported on trauma-informed care practices.
Note: Recovery is a holistic process of change where individuals learn to overcome or manage their diagnosed symptoms and conditions in order to improve overall well-being and achieve optimal health.
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Procedures for evaluating level/intensity of care and follow-up
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

MHSU 5.01

Clinical counseling services promote whole-person wellness and help the individual to develop the knowledge, skills, and supports necessary to:  
  1. manage mental health and/or substance use disorders; 
  2. cultivate and sustain positive, meaningful relationships with peers, family members, and the community; and 
  3. develop self-efficacy.

MHSU 5.02

Personnel assist persons served to: 
  1. explore and clarify the concern or issue;
  2. voice the goals she or he wishes to achieve;
  3. identify successful coping or problem-solving strategies based on the individual’s strengths, formal and informal supports, and preferred solutions; and
  4. realize ways of maintaining and generalizing the individual’s gains.
Examples: Personnel can help to engage and motivate persons served in this process by demonstrating, for example: 
  1. sensitivity to the needs and personal goals of the service recipient;
  2. a non-threatening manner;
  3. respect for the person’s autonomy, confidentiality, sociocultural values, personal goals, lifestyle choices, and complex family interactions;
  4. flexibility; and
  5. appropriate boundaries.

MHSU 5.03

Clinical personnel: 
  1. determine the optimal level and intensity of care, including clinical and community support services;
  2. follow up when an evaluation for psychotropic medications and medication-assisted treatment is recommended; and
  3. use written criteria to determine when the involvement of a psychiatrist is indicated.


Element (c) does not apply to detoxification treatment programs.