Introduction to the Counseling Profession

Chapter 13

Addictions Counseling

Chapter Topics

Introduction

“It is implied in the title of this chapter that there is not one kind or type of addiction. There are many. Depending on how addiction is defined, there could be a countless number of addictions. The most common throughout history is addiction to certain chemicals or substances, such as alcohol and other drugs.”

Types of Addictions

Substance Related Addictions

Non-Substance Related Addictions

Behavioral Addictions

Process Addictions

Foundations of Addictions Counseling

“Problematic substance use is a common and widespread problem that is related to and is closely intertwined with many other problems. These include physical and mental illnesses, crime, unemployment, violence, family disruption, vehicular accidents and fatalities, financial strain and poverty, malnutrition, trauma, homelessness, and suicide.”

Nicotine, alcohol, and illicit drug use were responsible for approximately 46% of deaths not attributable to disease, infection, or unintentional injuries.

One-third of completed suicides and more than 45% of suicide attempts between 2003 and 2009 involved the use of alcohol and other drugs.

Any adverse childhood experience (ACE) was associated with a two- to three-fold increased likelihood of drinking alcohol by age 14.

Foundations of Addictions Counseling

It is estimated that between 60-80% of persons in the criminal justice system have a substance use problem.

The presence of a psychiatric illness also greatly enhances problematic substance use.

Approximately 43% of all clients enrolled in substance abuse treatment were diagnosed with a co-occurring mental health disorder.

The expansion of theories of addiction has ushered in a greater array of prevention and treatment services intended to provide relevant, engaging, individualized, and evidence-based or effective care.

“For at least the past 200 years in U.S. history, problematic substance use (primarily alcohol) has been viewed as an immoral or sinful activity and addiction as a vague, nonspecific disease.”

Addictions Counseling. Prevention, and Intervention

Addressing these barriers is essential for counselors, regardless of their practice setting.

This means referring to substance use problems as maladaptive behaviors, not as character defects; defining addiction as a multifaceted and complex chronic condition, not as a simple or an easily defined disease resulting from willful misconduct, an absence or morals, or a loss of willpower; and describing the array of services available to effectively prevent, treat, and manage addiction.

“For persons with substance use problems, there remain many barriers to appropriate care. The lack of health care coverage and an inability to afford the cost of treatment is the most common reason given for not receiving treatment for problematic alcohol or drug use, even among persons 12 years old and older who recognize the need for treatment.”

Addictions Counseling. Prevention, and Intervention

Common Components of Evidence-Based Practices

Support, structure, goal direction

Rewards and rewarding activities

Abstinence-oriented norms and models

Self-efficacy and coping skills

Addictions Counseling. Prevention, and Intervention

Evidence-Based Practices

Motivational Interviewing

It is a method of communication intended to help clients mobilize their own internal resources for change.

It is a therapeutic style not a collection of techniques.

It uses fundamental listening and attending skills in a strategic, directive, or purposeful manner to guide clients through their own process of change.

These skills are often referred to by the acronym OARS: asking Open- ended questions, providing sincere Affirmations, extending empathic Reflections, and periodically offering a Summary of content.

Addictions Counseling. Prevention, and Intervention

Evidence-Based Practices

Motivational Enhancement Therapy (MET)

It is a brief intervention and an adaptation of MI that provides students or clients with personalized and structured feedback.

Feedback includes comparisons of student- or client-reported alcohol use relative to their peers and health information and is presented in a candid and nonjudgmental manner.

Once awareness has been enhanced and persons begin to talk about changing their behavior, they are encouraged in an affirming, collaborative, and non-confrontational manner to develop a personalized plan for healthy change.

Addictions Counseling. Prevention, and Intervention

Evidence-Based Practices

Twelve-Step Facilitation Treatment

Twelve-step facilitation (TSF) is a treatment designed to help clients find and participate in Alcoholics Anonymous (AA) 12-step self-help fellowship meetings, and to internalize and endorse the philosophy of AA.

Unlike AA, TSF is a treatment conducted by a professional counselor that can be delivered in individual sessions.

Addictions Counseling. Prevention, and Intervention

Evidence-Based Practices

Cognitive-Behavioral Treatment

CB treatments represent an extensive collection of interventions that apply learning theory to observable behavior as well as to thoughts and emotions.

Principles of classical and operant conditioning are used, along with principles of social learning theory.

CB treatments thus are developed and implemented on the assumption that substance using behaviors are learned through processes of conditioning, including observing others use substances.

Addictions Counseling. Prevention, and Intervention

Evidence-Based Practices

Contingency Management and Community Reinforcement

Also based on CBT principles. They are very specialized practices specifically based on operant conditioning principles, such as positive and negative reinforcement.

CM and CRA both use behavioral contracting to systematically reorganize a person’s environment by increasing the rate of reinforcement for abstinent behavior and reducing or eliminating the rate of reinforcement for substance using behavior.

Addictions Counseling. Prevention, and Intervention

Common Practices and Formats

Alcoholics Anonymous (AA)

Group Support and Treatment

Consultation with the Client’s Referral Source

Screening for Biological Markers

“There are common practices associated with addictions counseling whether or not specific evidence-based practices are implemented.”

Addictions Counseling. Prevention, and Intervention

Determining Levels of Care

The American Society of Addiction Medicine (ASAM) Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC-2R) incorporates criteria that address co-occurring disorders, including what are referred to as dual diagnosis capable programs:

The ASAM PPC-2R assesses all clients (adults and adolescents) on six dimensions :

1.Acute intoxication and/or withdrawal potential.2.Biomedical conditions/complications.3.Emotional, behavioral, or cognitive conditions/complications.4.Readiness to change.5.Relapse, continued use, or continued problem potential..6.Recovery/living environment.

Addictions Counseling. Prevention, and Intervention

Determining Levels of Care

Clients are then assigned to one of five basic levels of care that are on a continuum of increasing intensity:

1.Early Intervention2.Outpatient Services3.Intensive Outpatient4.Residential/Inpatient Treatment5.Medically Managed Intensive Inpatient Treatment

Diversity and Advocacy in Addictions Counseling

Ethnic and Racial Diversity

Cultural norms, practices, and beliefs – as well as environmental, social, and economic factors – all likely influence the substance use behaviors of persons of various cultures, races, and ethnicities.

Specific Populations

Adolescents, Women, Older Adults, LGBT, Veterans and Military Persons, People who are Disabled, People who are Homeless

“Diverse populations may have unique experiences or circumstances related to substance use and addiction, and it is important for counselors to be aware of and understand these differences in order to work effectively with clients and to advocate for them.”

Diversity and Advocacy in Addictions Counseling

Advocacy

Advocacy in the addictions can be accomplished through various mediums.

Being familiar with resources.

Keeping abreast of current research and treatment practices for diverse populations.

Learning about the legislative and environmental issues that affect persons experiencing addictions.

“Advocacy in the counseling profession emphasizes how counselors can “become active voices and conduits for social/political change at the macrolevel of intervention as well as advocating for client empowerment at the individual and the systemic levels.”

Evaluation Methods Screening: Helps clinicians determine whether or not a substance use problem exists.

Assessment: Assessment differs from screening in that assessments are continuous in nature and provide comprehensive information not only about the topic of concern, but also about multiple areas of the client’s life.

CAGE TWEAK MAST

SASSI AUDIT

The Addition Severity Index (ASI)

Evaluation Methods

Diversity and Ethical Considerations

Counselors must consider clients’ personal and cultural contexts when evaluating substance use problems.

It is also important to consider how individuals from different cultural groups may react to evaluation.

Counselors must take into account discrepancies between the population with which the instrument was normed and the culture of the client.

Counselors must diagnose with care and be sensitive to cultural influences as well as historical and social prejudices that may lead to misdiagnosis.

Diagnosis Substance Use Disorders: Includes Substance Dependence and

Substance Abuse

Substance-Induced Disorders: Includes Substance Intoxication and Substance Withdrawal as well as other disorders that occur as a result of substance use.

Currently, the DSM-IV-TR uses a “bi-axil” diagnostic approach to Substance Use Disorders.

o First Axil: Diagnostic criteria for Substance Dependence describe biological, behavioral, and psychological manifestations.

o Second Axil: Substance Abuse describes consequences incurred as a result of substance use.

Research Burgeoning scientific discoveries in genetics, pharmacotherapy, and

neuroscience have expanded the number of prevention and intervention options.

The current emphasis on evidence-based practice has placed the spotlight not only on effective prevention and treatment approaches in the addictions (e.g., motivational interviewing), but also on ineffective and potentially harmful practices.