|
|||||||||||||
|
|||||||||||||
This is an Intermediate Level course. After taking this course, mental health professionals will be able to:
This course is designed to acquaint the mental health professional (hereafter called “therapist”) with knowledge and skills for assessing a client’s or patient’s use of psychoactive substances and related concerns. Emphasizing the facts that many clients use drugs or alcohol in a problematic manner and that related concerns may emerge at any point in the therapeutic relationship, this course will prepare the therapist to adequately assess a client’s substance use whenever and however this important issue arises in mental health treatment. Furthermore, the course will instruct therapists in using the results of substance use assessments to determine appropriate treatment levels, formulate treatment recommendations, and make medical referrals (or other types of referrals) as needed.
First, the course will introduce reasons why therapists should be interested in and able to detect and address client substance abuse problems. Reasons include the high prevalence in the general population of psychoactive substance use disorders (PSUDs), the frequent comorbidity of PSUDs with other mental health issues, and the value of psychotherapeutic treatments for addressing PSUDs. Together, these factors point to the high likelihood that therapists will encounter PSUDs among other issues presented by clients in their caseloads.
Next, the course will present detailed information about substance use assessment in the context of ongoing mental health treatment. Screening, in-depth assessment interviews, diagnosis, and treatment placement guidelines will all be described along with tools for conducting appropriate assessments of a client’s substance use. The therapist will learn what questions to ask to screen for possible substance use problems as well as how to respond to either positive or negative results. When the results of an initial screen indicate a possible problem, further in-depth assessment is recommended. The course will thus train the therapist to thoroughly assess the client’s substance use and treatment history, related physical and psychological consequences of drug or alcohol use, environmental factors associated with the client’s substance use, and readiness for treatment and behavior change. An assessment template will be provided to guide the interview process. Guidelines will also be offered to help the therapist deal with possible client distortions of information, intoxication at the time of assessment, data privacy considerations, and bridging assessment data into treatment recommendations and/or referrals.
The course is based on three chapters from the book published by Routledge Counseling and Therapy With Clients Who Abuse Alcohol or Other Drugs: An Integrative Approach (Glidden-Tracey, 2005), by Dr. Glidden-Tracey, author of this course.
Every day huge numbers of people use drugs or alcohol for recreation, medication, celebration, stress management, worship, social lubrication, or escape. Although some substance use is considered normal, it is no secret that drug and alcohol consumption can become excessive or compulsive to the point where it disrupts normal human functions. The use and abuse of psychoactive chemicals bombard our society with controversies and complications, which eventually lead some individuals to seek professional psychotherapy or counseling. In therapy and treatment settings, evidence (to be considered shortly) points to rampant rates of disordered substance use among clients and patients, even when substance abuse is not presented as the problem of interest.
Sometimes clients initiate therapy specifically to address their problematic substance use because they are considering a change. Many other clients are responding to pressure from third parties when they show up for a therapy session to talk about substance use issues. Still other clients discuss substance use with their therapists or social workers not as a presenting problem, but only after many sessions have transpired. Drug or alcohol use may come up as a topic when the client gets ready or concerned enough to address it, or perhaps only when the attentive therapist probes for more information based on the client’s hints about substance use. Whenever and however the issue of substance abuse emerges in therapy among the issues the client is struggling to handle, a competent therapist is prepared to intervene.
The purpose of this course is to help prepare therapists to effectively assess clients’ use of psychoactive substances and, if such use is determined to be problematic, to make appropriate treatment recommendations or referrals. Hopefully, the course will also persuade therapists to consider skills for treating substance use disorders as necessary compositions in our repertoire. In this Section, I demonstrate that the likelihood of encountering substance-abusing clients is high and the spectrum of substance use disorders is multifaceted. To adequately treat the frequent and varied presentations of substance abuse issues in therapy, the therapist deliberately tailors therapeutic strategies to the expressed and assessed needs of each client. (A detailed account of treatment issues beyond substance use assessment is available in the book from which this course material is excerpted: Counseling and Therapy With Clients Who Abuse Alcohol or Other Drugs: An Integrative Approach (Glidden-Tracey, 2005)). Addressing substance use disorders, in many respects, parallels the course of therapy for other psychological disorders, but assessing, treating or appropriately referring clients with substance use disorders also confronts the therapist with distinctive features and barriers to the therapy process.
When discussing substance abuse, clients are stereotypically more withholding, deceptive, manipulative, hostile, or uncooperative in sessions. Such behaviors can make sense in the context of the strong reinforcing effects of substance use combined with the probable presence of either the need to hide illegal or otherwise sanctioned behavior, or external pressure to attend therapy sessions (if not both). These factors, along with the concomitant negative consequences of frequent or heavy substance use, create strong ambivalence about change in the substance user. The substance abuse treatment field is paying increasing attention to the importance of addressing client ambivalence about continuing drug or alcohol use (Miller & Rollnick, 1991, 2002).
The convention of distinguishing psychoactive substance use disorders from psychological problems and mental health disorders has historically resulted in treatments for substance use disorders that are relatively isolated from psychotherapeutic approaches. In recent years, however, the literature increasingly notes both the potential applicability of psychological models for treating problematic substance use (Miller & Brown, 1997) and the dearth of adequate training for psychologists and other mental health professionals to treat substance use disorders among their clients (Carey, Bradizza, Stasiewicz, & Maisto, 1999; Cheirt, Gold, & Taylor, 1994). Psychotherapy is promoted here as an appropriate and effective form of treatment to reduce problematic consumption of drugs or alcohol.
In the Sections to follow, I assume a model of assessment in which the therapist intentionally aims to create conditions of interaction that are conducive to the client’s behavioral change, including changes in substance use behaviors. With careful adaptations that are cognizant of the nature of substance use disorders, therapists can attempt to influence the quality of their relationships with substance abusing clients, the degree of structure in their assessment interactions, and the choice of client goals. These three domains of relationship, level of structure, and specification of goals are described by Moos (2003) as common factors of the contexts in which personal change occurs. Substance use assessment has the greatest potential to contribute to beneficial change in substance use behaviors when the quality of the relationship is high, the structure of the assessment is planful but flexible, and the process is collaborative, directly involving the client.
Therapists choose their approaches for particular clients by attending to the topical themes and behavioral patterns evident in the transaction between the therapist and client. Therapists track and interpret such patterns with most any material the client presents or exhibits to help detect problems and shape new options. In assessing and addressing substance use disorders, the therapist tries to develop the core conditions for behavioral change by specifically considering the following themes in the patterns of content and in sequences of events emerging across conversations between members of the helping relationship. Assessment may be conducted not only during initial contact with a client, but at any point at which the therapist detects reasons for possible concern about a client’s substance use behavior.
First, the therapist watches and listens for an identifiable pattern suggesting that the client has used psychoactive substances in a manner that invites or produces problematic consequences. A pattern is quickly obvious in some cases, like that of Karina, who enters therapy based on a medical referral (and her mother’s insistence) after an alcohol poisoning incident that resulted in Karina’s hospitalization. During intake, Karina admits that she drinks heavily several nights per week, stating with a mixture of pride and chagrin that she can drink twelve beers in two hours. She suspects her drinking is problematic, although she would rather not think about it.
With other clients, evidence of a pattern indicating substance abuse is more subtle, like with Andre, who presents with a sharp increase in obsessive thoughts and compulsive behavior since his father’s death the previous year. Over many therapy sessions, Andre gradually reveals that his father was an alcoholic who died of lung cancer after years of smoking cigarettes. Andre also mentions in passing that he uses marijuana to help him sleep because he has been plagued with nightmares since his dad’s funeral, and that he sometimes gets into fights with his fiancée after he has been drinking.
Many clients presenting for therapy or treatment exhibit no indications of substance use concerns. But when the therapist detects a pattern of topics and behaviors that suggest possible substance abuse, the next consideration comes into play.
Second, the therapist formulates an evolving conceptualization of the meanings the client attributes to personal substance use and the significance of those observed patterns in discussions of substance use with the therapist. Good thorough assessment provides a solid foundation on which to build an individualized conceptualization. Specific answers can be as diverse as the gamut of psychoactive substances and individuals who use them. The client’s cultural background certainly influences the client’s attitudes, beliefs, behaviors, and feelings with respect to the use of alcohol and drugs (Delva, 2000; Lee, 2001; Straussner, 2001). Conceptualizations can shift over time as the therapist becomes better acquainted with the client. I offer ideas in this course about how therapists can use the tasks of assessment to develop and utilize their understandings of their clients’ substance use or abstinence in the context of their clients’ lives. Additional ideas about linking this assessment approach to treatment planning, psychoeducation, intervention, relapse prevention, and termination processes are specified in Glidden-Tracey (2005).
Third, the therapist makes choices about how to communicate with the client regarding observed patterns of substance use and related issues. Therapists decide how and when to share perceptions of the meanings and consequences associated with these patterns in a manner that potentially increases the client’s motivation to reduce involvement in risky substance use behaviors. Appropriate therapeutic suggestions and responses depend on the cultural sensitivity of the therapist (Council of National Psychological Associations for the Advancement of Ethnic Minority Interests, 2003). Treatment literature in psychology and social work are available to enhance consideration of particular cultural factors (e.g., Corcoran, 2000; Delgado, 1998; Gitterman, 2001; Straussner, 2001). In this course, I emphasize important choice points linked with the interrelated tasks of assessment for substance abuse concerns. Furthermore, I encourage therapists to expand their clinical judgment skills to make effective treatment recommendations with clients who abuse substances.
A few words about terminology are in order. A slew of terms are used to describe psychoactive substance use disorders, ranging from the concise but vague addiction to the more precise but cumbersome chemical abuse, misuse, and dependence. Terminology differences result in part from the reality that substance use disorders can affect many aspects of an individual’s well-being, including medical, psychological, social, occupational, and spiritual arenas. Professionals from a broad array of fields are involved in addressing substance abuse and related problems, so debates (often heated) about appropriate terminology to characterize those problems quickly arise in discussions between interested professionals. Medically trained professionals speak of treatments, whereas psychologically trained providers describe their services as therapy. Writing from a social work perspective, Johnson (2004) indicates that “The definitions of use, abuse and dependency (or addiction) are indeed a difficult problem to settle, because each concept is bound up in culture, history, personal experience and subjectivity, folklore, and myth” (p. 5). Ambiguity about the distinction between the use and abuse of chemical substances further pervades society in general, making clear communication about the benefits and dangers of consuming alcohol and other drugs challenging at best.
The following terminology is employed in this course. Substance refers to a nonfood chemical that alters psychological and neurological functions when consumed by a human being. In the context of this book, substances include alcohol, other licit drugs, and illicit drugs. Substance use refers to the consumption of psychoactive substances without evidence of a connection between that consumption and clinically significant problems or symptoms, whereas substance abuse implies evidence that consumption is problematic. (Note that the evidence specified earlier may be available to one but not both, or some but not all, members of a therapeutic relationship.) The general terms substance abuse and disordered substance use are used interchangeably in this course to encompass chemical abuse, misuse, and dependence, unless otherwise specified. This is based on the observation that all persons who meet the more restrictive diagnostic criteria for substance dependence will also meet the first criterion for substance abuse (recurrent problems linked to the person’s substance use). Diagnostically, then, substance dependence can be considered a more severe subset of substance abuse. By no means, however, are all substance abusers chemically dependent. In fact, the DSM-IV-TR second criterion for a Substance Abuse diagnosis states that the person being assessed has never met the criteria for Substance Dependence for a particular class of substances. (It is furthermore acknowledged that some experts in the field view substance abuse and dependence as exclusive rather than overlapping terms. Diagnosis is discussed in detail in Section 3.)
The term addiction is also widely used to refer to disordered substance use. The term has been extensively criticized, however, both for being too specific (when used to describe chronic disease processes that exclude less severe or obvious cases of substance abuse or misuse without dependence) and for being too general (when used to refer to habitual or compulsive behaviors other than substance abuse, such as disordered eating, Internet use, gambling, shopping, hair pulling, or sexual activity, to name a few). The equation of addiction with chemical dependence is a frequent definition, but such references to addiction and the treatment of addictions imply either that nondependent abuse of substances is outside the scope of interest or that all substance use is unhealthy or abnormal. Many psychologists and others who study or treat addictions are also interested not only in physiological disease processes and psychological disorders associated with chemical dependence, but also in addressing substance use behavior that puts the user at risk of encountering problems linked to their substance use. Because of ambiguities of definition, some experts recommend avoiding use of the term addiction even while acknowledging that common usage and convenience of the term virtually ensure continuing use of the word (Grilly, 2002). For purposes of this course, the term addiction is used to signify repetitive use of psychoactive chemicals in the face of resulting personal or interpersonal problems.
Psychotherapy and therapy are employed as interchangeable terms to refer to psychologically based treatment methods, applied here to substance use disorders. I view therapy as one subset among a larger set of treatments for substance abuse, including medical, pharmacological, educational, religious, and self-help treatment efforts. Therapy for substance abuse may be conducted independently or in concert with related treatments. However, I join ranks with those who dispute the common assumption that substance abuse needs to be treated in specialized programs separated from therapy as it is usually conducted. Outcome research consistently supports the relative efficacy of psychological treatments for addictions (Miller & Brown, 1997).
In the treatment of substance abuse, therapy can make an impact insofar as the participants actualize the potential for a meaningful human interaction to occur between them (Kell & Mueller, 1966). Therapists can use their culturally sensitive understanding of the sequences of dynamic events occurring in sessions to guide interactions with clients in therapeutic directions. Furthermore, a course of therapy can be most beneficial when the client actively collaborates in choosing and implementing the goals and strategies of therapy in a manner consistent with the client’s cultural expectations and values. Clients engaged in substance abuse often display interpersonal preferences, interaction patterns, and personal goals that look different from those of clients seeking help for other types of problems. Yet as cogently argued by Miller and Brown (1997), substance abuse involves types of behavior that are influenced by the same psychological principles that shape behavioral problems in general. The basic process of therapy can be undertaken with substance abusers even if the therapy relationship starts off on a different basis of initial rapport or follows a different motivational trajectory than with clients who voluntarily seek help for symptoms they acknowledge as problems.
My goal in this course is to further examine how therapists conduct substance use assessments with intentions to influence the structure, relationship, and goals of therapy to promote change with clients who abuse substances. I aim to explore how a therapist integrates knowledge of substance use disorders and of the personal change process with an individualized, culturally relevant conceptualization of each client in efforts to form a high-quality relationship with the client characterized by flexible structure directed toward negotiated client goals.
Substance use often starts when a person is still young. In the general population, survey data indicate that 48% of high school seniors have used illicit drugs at least once, with 51% of them reporting use of alcohol in the past thirty days and 33% of those to the point of intoxication (O’Malley, Johnston, & Bachman, 1999). Many experimenters use psychoactive substances without encountering substantial detrimental consequences. However, of the large numbers of people who experiment with substance use, some will go on to develop significant emotional, interpersonal, occupational, health, or legal problems associated with their substance use. The National Household Survey on Drug Abuse (SAMHSA, 1999) estimated that, from 1979 to 1998, lifetime use of any illicit drug ranged in prevalence from 31.3% to 35.8% of the U.S. population ages twelve and older. For alcohol, prevalence of lifetime use in the same sample ranged from 81.3% to 88.5%. Of those respondents who reported use of any illicit drug in the past year, 8.2% reported related health problems, 14.8% indicated emotional or psychological problems due to substance use, and 17.5% reported substance dependence. (Only 4.1% of this subsample reported receiving treatment for substance abuse in the past year.)
By adulthood, the mean probability of developing any substance use disorder during any year of adulthood is estimated at 1.8% (approximately 1 in 55) for alcohol and 1.1% (1 in 90) for other drugs, with two to three times higher rates of risk for young adults. Higher rates of prevalence are also reported for men than women across all categories of substance use disorders (Anthony, 1999; Ott, Tarter, & Ammerman, 1999). Lifetime prevalence estimates range from 8% to 13% for drug dependence (Anthony, 1999) and 14% for alcohol dependence (Kessler et al., 1994). Galanter and Kleber (1999) estimated that 18% of the US population will experience a substance use disorder in their lifetimes. Based on results of the National Comorbidity Survey, Kessler et al. (1994) estimate that 26.6% of the general population between ages 15 and 54 exhibit a substance use disorder in their lifetimes, with 11.3% prevalence within a given year.
Compared with other psychological problems, substance abuse is one of the most frequently occurring forms of mental health disorder in the general population. Anxiety disorders are the other most prevalent psychological disorders, with an estimated 14.6% of the population experiencing an anxiety disorder in their lifetime (Ordorica & Nace, 1998). These same authors further reported 13.3% estimated lifetime prevalence rates for alcohol use disorders and 3% to 7% lifetime prevalence rates of mood disorders.
Among client populations, rates of substance abuse and dependence are considerably higher than in the general population for at least two reasons. Persons with psychological disorders frequently try to relieve or escape from their symptoms of anxiety, depression, or other distress by using psychoactive substances. Furthermore, many habitual substance abusers develop psychological symptoms of depression, anxiety, or psychosis as the consequences of heavy drug or alcohol use. Galanter and Kleber (1999) estimated that 20% of patients in general medical facilities and 35% in general psychiatric units present with substance use disorders. These authors further stated that in some treatment settings the proportions of clients who abuse substances are even higher. Celluci and Vik (2001) found that their sample of licensed psychologists reported on average that 24% of their caseloads had substance abuse problems.
Client issues regarding substance use, abuse, and dependence arise in therapy in many different ways. Sometimes it is the initial presenting problem. A client may voluntarily seek therapy specifically to address drug and/or alcohol use that the client admittedly cannot control. Good examples are Barry, who was upset by his child’s reaction to Barry’s chaotic behavior under the influence of alcohol; and Kenisha, who was scared by the confrontation with negative health outcomes of her smoking.
In many voluntary cases where substance abuse is among the presenting problems, the client has been strongly urged to seek help by a concerned friend, family member, or other party with personal interest. Under such circumstances, the externally encouraged client may present the other person’s concerns or pressures as the actual problem. Even if the client acknowledges other problems, they may be defined in terms other than drug or alcohol use. Examples include the client who enters therapy in response to a spouse’s vow to end the marriage, or an employer’s threat to fire the client if she does not change problematic substance use. Such clients may express either ambivalence or outright denial that their substance use is problematic, and they are likely to view themselves to some degree as coerced rather than voluntary clients. Therapists working with clients like these need to know how to motivate clients to invest in therapy and internalize their focus.
Substance abuse issues also appear as problems presented by clients who have troubles with the legal system or other formal consequences, in addition to more private ones. For example, when a judge, probation or parole officer, or child protective service agency has mandated treatment for drug or alcohol problems, the client often views participation in therapy as voluntary only to the extent that compliance with the treatment mandate helps the client avoid less desirable sanctions, such as returning to jail or prison, or losing custody of or parental rights to one’s children. Clients who present the mandate to obtain treatment as their reason for seeking therapy are often convinced that their substance use is not genuinely problematic or that they do not really need substance abuse therapy, or both.
In contrast to the presentation of substance use issues in the initial phases of assessment and therapy, self-referring clients who first presented with mood, anxiety, career, or various other problems may bring up substance abuse concerns only in the middle or later phases of the therapy process. Sometimes substance use is addressed at the client’s initiation, like with Jerica, who confided to her therapist that she had been drinking a lot more since they discussed the possibility of revisiting memories of sexual abuse that Jerica endured as a child. In other cases, the issue is raised by the therapist, such as the previously mentioned case of Andre, whose therapist commented on Andre’s frequent hints about using marijuana to cope with bad dreams about his father in the months since his dad’s death.
The later emergence of substance use issues may be attributable to any number of factors, such as the client’s need to establish trust in the therapist before discussing sensitive issues, or the increasing acknowledgment over the course of therapy of the contribution of the client’s substance use to the original presenting problem. The client’s substance use may also emerge as a topic of concern if the presenting problem has been resolved to the extent that the client feels ready and able to tackle problems that were initially assigned lower priority or dismissed as irrelevant, or if the client’s substance use has changed or become associated with new problems that develop during the course of treatment. For examples, a client already in therapy for depression, anxiety, or grief may begin drinking or “drugging” more heavily in response to current stressors, or may be arrested for driving under the influence of drugs or alcohol. Clearly, the therapist’s approach to addressing the client’s stated issues regarding personal substance use will vary depending on how and when those issues come up in the therapy relationship. This course will focus on conducting appropriate substance use assessment whenever concerns emerge about a client’s substance use behavior.
It is worth mentioning, too, that in addition to the relatively large proportion of clients experiencing substance abuse problems or disorders, there are also many more people who face the detrimental consequences of substance abuse without seeking or receiving therapeutic help. Anthony (1999) cited field survey estimates indicating that, for every treated case of drug dependence, at least three persons with similar symptoms go without treatment. Some of these individuals also do not consider their drug or alcohol use to be a problem (although other people around them might), nor do they see any personal need for therapy (although others affected by their substance use may seek services). However, many others recognize some problems associated with their use and still do not obtain treatment for a variety of reasons. They may be ashamed to ask for help in light of the stigma associated either with losing control over substance use or with engaging in psychotherapy, or both. Even if they are aware of treatment options, individuals with limited finances, possibly exacerbated by an expensive drinking or drug habit, may be unable or unwilling to pay for therapy. Furthermore, many users are highly ambivalent about their use, and a person’s cognizance of a drug or alcohol problem can frequently be overridden by the pleasure, relief, and liberation that same person experiences, even temporarily, from continued substance use.
The focus in this course is primarily on providing appropriate assessment to substance abusing clients and those at risk who have sought therapeutic services. Interested professionals may also be involved in extending information about the availability and desirability of services to potential clients. Furthermore, by consuming, translating, and adding to the research literature on substance use disorders and their treatment, mental health professionals and researchers are in a position to help reduce the high personal and social costs of drug and alcohol abuse and dependence.
Whether treated or not, substance abuse issues occur within the broader context of an individual’s life and culture. Consideration of the interrelationship between a person’s substance use and other aspects of that person’s life is crucial to understanding not only what maintains the disorder, but the factors that can maintain resolution of substance use disorders (Moos, 2003). Many substance abusers simultaneously struggle with other, usually related problems, such as marital difficulties or occupational concerns. Individuals who meet diagnostic criteria for a substance use disorder may also meet the criteria for one or more other psychological disorders at the same time. The determination that a person simultaneously exhibits symptoms of a substance use disorder and some other psychological disorder is sometimes referred to as dual diagnosis, but the term comorbidity is preferred here for its ability to reflect the reality that a substantial number of clients suffer from more than two disorders at once. The National Comorbidity Study (1994; cited in Ordorica & Nace, 1998) estimated that one sixth of the US population had a history of three or more disorders including alcohol dependence. A 1997 follow-up study (also cited in Ordorica & Nace, 1998) found that fully 86% of alcoholic women and 78% of alcoholic men had a lifetime co-occurrence of an additional mental disorder.
The substance abuse treatment field is increasingly recognizing that substance use disorders frequently coexist with other diagnosable disorders (Westermeyer, 1998) and personal problems (Miller & Rollnick, 2002). In response, there is a major trend toward improving the quality and integration of treatment approaches for comorbid disorders (Frances & Miller, 1998; Polcin, 1992). To address the full scope of a client’s problems, a treatment provider needs to assess the presence and nature of concomitant difficulties, and plan treatment according to the findings of initial and ongoing assessments. Effective treatment planning and implementation for clients with comorbid disorders and multiple problems require the therapist to be adept at assessing, diagnosing, educating, motivating, and intervening with complex clients. Also, the therapist may need to coordinate efforts with other members of a treatment team. Continuing education about the causes, manifestations, pathophysiology, clinical course, and treatment outcomes of addictive disorders also helps therapists to conduct appropriate treatment, referrals, and consultations regarding clients with comorbid disorders. Certainly this need for enhanced information and communication among professionals trying to integrate treatment efforts also points to the essential role of researchers in translating their findings for practical application as well as generating new knowledge about addictive processes.
Anxiety Disorders. Aside from multiple substance use disorders, anxiety and mood disorders occur most frequently along with substance use disorders. However, virtually every DSM–IV Axis I and II disorder has been observed in combination with substance abuse or dependency (Ott & Tarter, 1998). Persons with anxiety disorders, compared with nonanxious controls, have a doubly high risk of substance use disorders, with alcohol users exhibiting higher rates of anxiety disorders than either cocaine or opiate users (Ott, Tarter, & Ammerman, 1999). Attempts to determine which disorder is primary are complicated, but research suggests that, among alcoholics, generalized anxiety tends to precede alcohol use disorders, whereas most other anxiety disorders among alcoholics are alcohol-induced (Ordorica & Nace, 1998).
Mood Disorders. Clinically significant depression also occurs approximately twice as frequently among substance abusers. Evidence indicates that secondary depression is substantially more common than primary depression, particularly among men (Ott et al., 1999). Among women, however, depression leads to excessive alcohol consumption in about 66% of cases. Gender differences in the risk of mania have also been observed, with alcoholic men three times more likely than the general population and alcoholic women ten times more likely to develop manic symptoms over a lifetime (Ordorica & Nace, 1998).
Personality Disorders. Personality disorders also frequently co-occur among substance abusing populations, especially antisocial and borderline personality disorders. Engaging in interpersonal violence or behavior that violates social norms has been found to predict illegal drug use (Ott et al., 1999). Among alcoholic client populations, men were four times more likely and women twelve times more likely to meet the criteria for one of these two personality disorders compared with the general population (Ordorica & Nace, 1998). Family history studies suggest a genetic link: The children of parents with substance abuse disorders often exhibit externalizing behavior disorders as early as age three, whereas the adopted out children of biological parents with antisocial personality disorders show greater than average tendencies to develop conduct disorders, attention deficit disorders, and substance abuse disorders (Ott et al., 1999).
Psychotic Disorders. High comorbidity rates have also been documented between substance use disorders and psychotic disorders—namely, schizophrenia. Clients with one of these disorders are four times more likely to also meet the criteria for the other (Ordorica & Nace, 1998; Ott et al., 1999). Some evidence suggests that alcoholism is likely to develop after the onset of schizophrenia (Ordorica & Nace, 1998). With stimulants and hallucinogens, however, chronic use by vulnerable persons preceding the development of psychotic symptoms predicts the earlier onset of schizophrenia (Ott et al., 1999).
Implications of Comorbid Disorders. Most cases of comorbid disorders, with the exception of anxiety, have been associated with higher morbidity and poorer prognosis for clients (Ott et al., 1999). Aside from that observation, there is little agreement about the meaning, relevance, and implications of comorbid disorders. Hyman (2000) argued that society has systematically underestimated the extent of comorbidity and the significance of associated problems. Evidence of the high rates of substance abuse among client populations and the frequent incidence of comorbid disorders suggest it is likely that substance abuse concerns will emerge in many therapy relationships.
Many psychotherapists and trainees are quick to acknowledge the far-ranging extent to which their clients’ lives have been touched by substance use. Even so, at least anecdotally, many mental health counselors and psychotherapists consider substance abuse treatment as a separate treatment modality, further expressing low interest in addressing a client’s substance use issues in therapy. Such therapists may claim insufficient training or lack of motivation for working with clients exhibiting substance use disorders.
A major problem with this state of affairs is that, regardless of whether or not a therapist has the skills or interests to counsel clients with substance use problems, many clients will be using substances, some in a problematic manner. The potential consequences of substance abuse, whether sporadic or continuous, can range from annoying to life-threatening, and can certainly exacerbate other complications the client is addressing in therapy. Thus, it is important for a therapist to detect and respond to indications of a client’s possible substance abuse or dependence. Even if a therapist’s specialty lies elsewhere, when substance abuse concerns are evident, the therapist should be able to facilitate appropriate treatment or referral.
Therapists are wise to develop adequate knowledge about their own feelings and attitudes toward people who use drugs and alcohol, most likely including people the therapist knows personally as well as users in the abstract sense. Personal experience with substance use or abstinence will also undoubtedly influence the therapist’s own beliefs about drug or alcohol consumption as well as opinions about people who drink or use drugs. Knowledge and beliefs about cultural factors influencing substance use practices and abuse potential have additional impact on therapeutic approach and competence. Therapists’ feelings, attitudes, and experiences in turn shape the approaches they take with clients who admit substance use.
The therapist’s perspective on substance use will not just mold the treatment options the therapist is willing to consider with the client; it will also contribute to the responses evoked in the therapist during the therapy interaction. The more therapists are attentive to their own beliefs about and responses to persons who abuse substances, the better they will be able to utilize that awareness to track the therapy process. Among other cues, therapists can use their own reactions to each client to determine what facilitates and what hinders the interactions between them, and what needs to happen to mobilize therapists’ effectiveness at points of impasse (Kell & Mueller, 1966).
The therapist who holds avoidant, condescending, or other negative attitudes toward persons who drink or take drugs will be challenged to maintain or rekindle a therapeutic alliance when such therapist attitudes are elicited in sessions. Examples of difficulties that therapists may need to address in themselves include feelings of responsibility for clients’ substance use or sobriety, or countertransference reactions associated with the therapist’s own experience with an addicted parent, relative, or friend. Biases may also be created by a therapist’s positive attitudes toward substance use. Therapists who view drug or alcohol use in favorable terms may be tempted to minimize or normalize a client’s substance use concerns, perhaps even joking with clients about use. In each case, the therapist will do well to consider how the client’s interests would best be served in response to such therapist inclinations.
A client’s cultural identification and background may further influence a therapist’s reactions to the client’s substance use history. Accurate and sensitive (rather than biased) attention to cultural differences is crucial for effective assessment and treatment. If the therapist holds stereotypes that substance abuse is less common in certain socioeconomic or ethnic groups, for example, that therapist might overlook the importance of assessing substance use for certain clients. Alternatively, a therapist might pathologize a client’s substance use if unacquainted with the cultural significance of certain practices in the client’s culture. Therapists are thus encouraged to learn and explore the cultural implications of a particular client’s substance use, and also to assess the impact of working with culturally different clients on the therapist’s attitudes and approach.
At many points in a course of therapy, the therapist is in a position to make choices about how to intervene in that moment, about whether and how to initiate a topic or respond to something the client has said or done. Therapists’ awareness of their own feelings and intentions toward the client, both in that moment and over time, provides cues and criteria for deciding on an approach. The effective therapist uses knowledge of personal beliefs and values regarding substance use and abuse to weigh assessment and intervention strategies. The potential barriers posed by inadequate therapist self-knowledge regarding work with substance abusers need to be addressed.
Because this aspect of therapist self-awareness can be complicated by the therapist’s own mixed, biased, or unclear cognitions about substance abuse, supervision and consultation can be crucial in the therapist’s development of substance abuse assessment and treatment skills. Supervision and specialized training aim toward helping trainees recognize and surmount obstacles to progress in therapy (Powell, 2004). I contend that whether an impasse in the therapeutic relationship is attributed to the client’s resistance, the therapist’s countertransference, or the interpersonal dynamics unfolding between them, the therapist’s effectiveness in reactivating momentum depends in large measure on the therapist’s deliberate use of self-awareness in choosing interventions. Supervision that balances support, structure, and challenge for the trainee can foster these complex skills in the diffuse area of substance use disorders.
Through careful assessment, the therapist tracks patterns in the interaction with the client to generate change in the client’s substance use behavior. Then based on these observed patterns, the therapist makes predictions about how the client will respond to selected interventions, which the therapist then implements. The client’s actual responses give the therapist more information that can be used to assess progress and formulate additional hypotheses to guide further intervention. Therapists addressing clients’ substance abuse issues are encouraged to monitor three types of patterns that are likely to evolve, including: (a) the meaning of psychoactive substance use in the client’s narrative, (b) the predictable dynamic phases of therapy relationships in general, and (c) the individualized interpersonal style exhibited by each client, particularly how that style is expressed and modified through substance use behaviors. Together, an understanding of these interwoven patterns can guide choices of intervention.
The first type of pattern becomes relevant when concerns about the client’s substance use arise, whether generated by the client or therapist, early in therapy or later. Therapy is unlikely to rectify those concerns without assessing the significance the client attributes to personal substance use. Knowledge of the second pattern, expressed through assessing and anticipating the therapy process as it unfolds, helps the therapist gauge the progression of therapy. Thus, as client ambivalence and relationship tensions emerge, therapists perceive these as useful and predictable phenomena, rather than barriers to change. The third pattern becomes evident as the therapist and client interact. Through ongoing assessment comprised of direct observations and experiences of the client, along with material the client shares in session, the therapist develops a conceptualization of the role of the client’s substance use in self-expression and interpersonal transaction.
Thorough and sensitive assessment of a client’s substance use creates a foundation for a course of therapy to address problems associated with substance abuse. This instructional course will help therapists develop these essential skills of substance use assessment.
Despite the extensive interplay of substance abuse and other psychological problems, the assessment and treatment of substance use disorders has historically been isolated from other mental health therapies. American society has interpreted excessive drinking and drug use quite differently than other behavioral indicators of mental health problems, at least partly in response to real and presumed differences that characterize the populations who exhibit addictions compared with other psychological disorders. (For example, contrast angry, risk-taking, defiant persons who deny personal responsibility for their actions with sad, anxious, insecure, or passive persons who voluntarily seek help to alleviate their problems.) Depending on their own interests and experiences, different types of professionals have been drawn to working with these stereotypically distinguished client populations. The addictions and substance abuse treatment field evolved separately from “mental health” treatment on the assumption of both disciplines that substance use disorders are distinct problems requiring a specialized form of treatment. Although the need for skills specific to substance use disorders is not in question here, I argue that the distinction has been greatly exaggerated to the point of neglecting significant overlap between addictions and other mental health disorders.
The problem, hinted at in Section 1 and elaborated more fully in this Section, is that the separation of the addictions and mental health treatment arenas has led to fragmented treatment efforts for the many individuals whose lives are complicated by multiple, interwoven disorders and problems. Some clients have been told they must address their substance abuse before their commitment to change is taken seriously and before any other concerns are addressed. Other clients have mentioned significant drug or alcohol use to therapists who gave the issue cursory attention because the therapist either considered the issue secondary or minimal, or did not know how to adequately assess or intervene with substance abuse concerns. Still further clients have been referred to additional professionals to deal with their “other” problems. Such referrals can be appropriate when treatment efforts are coordinated, but frequently the therapist on the left hand has little knowledge of what the right-hand therapist is doing. In any of these fractured attempts at treatment, the confounded problems of the client are more than likely to continue unabated.
Fortunately, recent developments in scientific understanding of the addictions, their connection to psychological concerns, and their effective treatments are changing the relationship between the substance abuse and mental health fields in the direction of increasing integration. There is still, however, much room for improvement. In hopes of stimulating further attention to promoting integration of the treatment fields, I first present several factors contributing to the historical and continuing isolation of the substance abuse treatment field, followed by discussion of several bases of growing integration of service delivery. Finally, I suggest some ideas for further enhancing the cross-pollination of psychological, mental health, and addictions treatments.
Despite increasing recognition of the extent to which substance abuse co-occurs with other psychological symptoms, several sets of factors contribute to the continuing low interest and effort put forth by many therapists and mental heath therapists toward addressing substance abuse concerns. This section explores social system factors, professional turf issues, client characteristics, and therapist concerns that contribute to the segregation of substance abuse from other mental health treatment considerations.
The social system in which addictions operate provides mixed messages to psychoactive substance users. A great many people drink alcohol or take drugs for purposes of recreation, celebration, ritual observance, temporary escape, or therapeutic intent. The high rates of “normal” social use of alcohol and medical use of drugs can make it difficult to distinguish between use and abuse. If “lots of other people are doing it,” seemingly without adverse long-term consequences, then moderate and even heavy substance use can be more easily rationalized as unproblematic than, say, depression or anxiety, symptoms of which are rarely described as normal, common, and desirable for most people. The distressing and debilitating impact of mood or anxiety disorders not only defines the sufferer as different from normal, but also frequently motivates the individual to seek help to relieve the suffering. Compulsive substance use, in contrast, can be superficially equated with normal indulgence and additionally produces pleasurable immediate outcomes that reinforce continued use rather than problem identification. Thus, among society’s mixed messages are that (a) people with mood or anxiety disorders need and deserve help (although not without a stigma that something is wrong or abnormal), but (b) people with substance use disorders are hard to pick out from normal substance users, and (c) once substance abuse clearly emerges as a problem, the person with the problem is “pretty far gone” and probably with limited hope for regaining normal status, considering the persistent nature of substance use disorders.
Mixed Messages About the Nature of Substance Use. The ambiguity of alcohol and drug abuse is further obscured by confusion deeply embedded in the social system about moral versus medical interpretations of the problems associated with substance abuse (Thombs, 1999). When alcohol or drug abuse is viewed as a moral issue, substance users are considered responsible for controlling their own behaviors. From this perspective, the user is presumed to have some ability to decide whether to take that drink or drug, and sympathy for the person’s distress or dysfunction depends on the willingness the person exhibits to exercise that power. If viewed as a medical problem, substance abuse is thought to render the user unable to control his drinking or her drug use. Although at face value these two perspectives appear logically incompatible, social attitudes toward addictive behaviors often seem to imply that both are simultaneously true—that persons with substance use disorders are worthy of contempt for not exercising control over their excessive use even though they are presumably incapable of exerting that control.
Debate Over Appropriate Response to Substance Abuse. These mixed messages are reflected in the criminalization versus treatment debate over the appropriate means of responding to the problems associated with substance abuse. The moral view of addictions leads to decisions to punish substance abusers with stigmatizing attitudes, fines, and even incarceration. The medical perspective yields the conclusion that substance abusers need therapeutic treatment to reduce the deleterious impact of their drug or alcohol use. This debate is further complicated by the currently frequent stipulation of substance abuse treatment as a recompense for drug-related offenses, including driving a motor vehicle under the influence of alcohol or drugs. A major difficulty with allowing the courts to mandate treatment for substance abusers in legal trouble is that treatment under such conditions is understandably perceived as a punishment rather than as humane help. Mandated clients typically attend treatment grudgingly, if at all, and treatment providers for this population often encounter great difficulty motivating such clients to participate productively in mandated treatment. Some would argue that the decriminalization of drugs would permit greater provision of appropriate treatment to voluntary clients, who would presumably be more motivated to seek help if not required to reveal behavior deemed illegal to get treatment (Olson, Horan, & Polansky, 1992). Others maintain that decriminalization of drugs is a bad idea because it would remove some of the incentives available to promote the delivery of treatment to many who risk harm to self or others through their abuse of drugs or alcohol, but still deny a problem (Frances & Miller, 1998).
Economic Impact. In addition to philosophical and legal debates about the nature of substance abuse and its treatment, society is confronted with economic concerns. The estimated costs of substance abuse to society are staggering. Much has also been made of the relative costs of arresting, trying, and incarcerating drug offenders versus attempting to treat them therapeutically. Analyses clearly indicate that medical and psychological treatment is more effective and efficient in reducing the high costs associated with substance abuse (Ershoff, Radcliffe, & Gregory, 1996; Holder & Blose, 1992). Such results are leading to initiatives in a handful of states across the United States to reform drug sentencing laws, promoting mandatory treatment instead of prison time for nonviolent first-time offenders. Justifying and implementing these changes is also expensive, with proponents of different approaches competing for funds to support relevant research, training, and the provision of services.
In summary, society takes multifaceted and conflicting perspectives on the problems of substance abuse and chemical dependency, complicating the distinction between use and abuse. This confusion is further evident in the debate over whether substance abuse is by nature a moral or a medical problem, with controversial implications for how society should respond to the problem. Arguments about the relative merits of punishment versus compassionate care for persons who abuse psychoactive substances are alive, well, and unresolved in discussions of current drug policy and substance abuse treatment.
This complex societal backdrop sets the stage for the dialogue between mental health and substance abuse treatment providers. The attitudes, practices, and controversies mentioned earlier have defined addiction as a problem that emerges when a person loses or relinquishes control over an otherwise normal behavior, and the resolution of the problem presumably requires reestablishing behavioral control at least initially by the imposition of external means of control. The type of therapist a client seeks out tends to vary according to how the client perceives the problem and the impetus for seeking help. Not surprisingly, different individual therapists are also drawn toward different client presentations. Therapists in the addictions field frequently see clients who present themselves for assessment and treatment at someone else’s request or demand, be it an employer, doctor, caseworker, judge, exasperated spouse, scared parent, or worried family member. Mental health therapists, in contrast, more commonly see clients who present with complaints about subjective distress or dysfunction from which the client wants relief. These generalized differences in client styles and therapist interests have shaped the evolution of different treatment philosophies in response to the needs of distinct populations as distinguished by presenting problems. The result has been the development of separate professional fields and different professional identities for therapists who primarily treat addictions versus other mental health concerns.
With increasing awareness of the large degree of intersection of substance abuse behaviors and mental health symptoms, the philosophical differences between addiction treatment providers and other mental health therapists are easily polarized into competitive turf issues. Dialogue necessary for integrating treatment of complex disorders can break down in the face of discrepant assumptions. Substance abuse treatment providers frequently view mental health problems as symptoms or outcomes of addictive behaviors, whereas mental health therapists consider substance abuse to be a symptom or indicator of an underlying psychological disorder (Mee-Lee, 2001a). Addictions treatment therapists tend to first address the client’s chemical use on the assumption that no productive work can be done to deal with other issues until the substance use has been substantially reduced or eliminated. Mental health treatment providers typically concentrate initially on alleviating symptoms of emotional distress, attending to substance use concerns only if these fail to disappear in reaction to an affective treatment focus.
Although to some extent these differing approaches reflect appropriate responses to the manner in which the client’s problem is presented, Section 1 also demonstrated that the comorbidity of substance abuse and other mental health disorders is both extensive and pervasive. Polarized treatment perspectives have at times resulted in some therapists downplaying the significance of certain problems or the interactions among symptoms. The isolation of addictions from other mental health problems has led to the development of different treatment methods and terminologies that can inhibit communication between interested parties, which in turn leads to further isolation. Training programs and credentialing processes have emerged independently, to a large degree, with substance abuse treatment approaches emphasizing disease, denial, and therapist detachment, while minimizing the utility of medication and the focus on process. Mental-health-oriented treatment approaches have tended toward the opposite emphases, focusing on psychological and behavioral factors, pharmacological interventions, and process factors in therapy (Mee-Lee, 2001a).
Three frequent characteristics of clients who seek assessment of their substance use contribute to the isolation of the addictions treatment field; these include low treatment motivation, interpersonal behaviors that inhibit relationship development, and ambivalence about changing substance use behavior.
Lack of Intrinsic Motivation for Treatment. The frequent absence of voluntary client participation in substance use assessment has already been mentioned, but further exploration of the implications of this first factor is warranted. A client who is showing up only to satisfy some third party – to avoid more undesirable consequences of nonattendance – is likely initially to not take the therapist or the assessment process too seriously. Resistance in the form of spotty attendance or reluctance to provide information, set goals, or engage in interventions all require the therapist to employ assessment strategies and interventions designed to motivate the client’s attendance and participation.
Interpersonal Styles Not Conducive to Building Affiliative Relationships. Second, substance abuse clients may exhibit interpersonal behaviors that interfere with the development of therapeutic bonds, regardless of how they were referred for treatment. Thus, in addition to having the knowledge of motivational strategies, addictions treatment providers must also be skilled at working through trust issues that arise when clients engage in subterfuge to disguise illegal or otherwise sanctioned behaviors. Substance abusing clients sometimes avoid straightforward communication with their therapists about the consequences of their substance use. Three commonly observed client maneuvers are expressions of open hostility (to get the therapist either to turn away or counter with hostility that justifies withholding trust), using charm and denial to mask manipulative or antisocial tendencies, and displaying perceptions of themselves as “out of control,” often with stated preferences for operating from such a disinhibited state. To work effectively with such clients, the therapist needs to be willing to work hard to develop rapport and be able to facilitate meaningful relationships in the presence of relationship conflict paired with the absence of trust.
Ambivalence About Substance Use. A third client factor that helps distinguish the addictions treatment field is the high degree of ambivalence clients typically feel about reducing or giving up use of their substance(s) of choice. Although often by the time clients seek professional help many punishers are in place to discourage continuing substance use, and although the detrimental consequences and how to avoid or deal with them are articulated in treatment, clients still remain vividly aware of the strong, immediately reinforcing quality of drugs or alcohol. Substance abusing clients can benefit from guidance in acknowledging, confronting, and coping with ambivalent feelings and powerful impulses.
The next Section of this course will present assessment strategies incorporating attention to the client characteristics described above. Additional detail about therapeutic approaches to address these client factors is offered in Glidden-Tracey (2005). Interested readers will also want to consult germinal works on motivational interviewing to address client ambivalence about change (Miller, 1995; Miller & Rollnick, 1991, 2002), harm reduction strategies to minimize risk associated with substance use (Marlatt, 1998; Marlatt & Tapert, 1993), and relapse prevention methods to help clients maintain treatment gains (Marlatt & Donovan, 2005; Marlatt & Gordon, 1985). These are among the powerful therapeutic tools developed to work with clients who abuse drugs or alcohol and who exhibit the characteristics described earlier.
To intervene with clients exhibiting any or all of the prior factors, therapists clearly need to learn skills that differ in degree or even in kind from assessment and therapy skills developed by those who primarily treat other mental health disorders. These particular client factors and necessary skills help separate the addictions field from other mental health care. Yet to more fully appreciate the isolation of substance abuse treatment, it is also instructive to consider individual therapist factors. Freimuth (2002) mentioned some of the attitudinal and emotional barriers that can interfere with therapists’ efforts to address possible substance use among their clientele. Three categories of provider issues are discussed in this section, including stigmas associated with clients who abuse substances, stigmas associated with substance abuse treatment providers, and therapist ambivalence about personal substance use history.
Stigmas Associated With Clients Who Abuse Substances. First, consider mental health therapists who are reluctant to work with clients who bear the stigma associated with the abuse of drugs or alcohol. Persons diagnosed with chemical dependencies or even less severe substance abuse disorders typically have poor prognoses, in part due to the conception of addiction as a lifelong disease. Its consequent problems are viewed as intractable, and expected progress is minimal. Therapists may anticipate that working with this population will be tedious, overwhelming, and frustrating at best, and hopeless at worst. Some therapists offer the following rationale for declining to work with substance use disorders: “I don’t work with alcoholics (or addicts) because they don’t really want to stop drinking (or using).” Some therapists also raise questions about how much expertise and how many resources should be invested in people with chronic problems and limited prognosis.
In addition to the expectation of a slow journey on a rocky road to the client’s recovery from substance abuse, some therapists hesitate to wrestle along the way with the myriad factors that may impede treatment efforts. Legal entanglements, medical problems, occupational or educational difficulties, and symptoms of comorbid psychological disorders are among the complications that substance abusers bring to discuss in treatment. Cultural differences between client and therapist may further obfuscate attempts to address problematic substance abuse. Many therapists may be unwilling or feel unable to sort through these issues and address their ramifications.
Another stigmatizing concern about clients seeking addictions treatment relates to the likelihood of encountering volatile negative affect and hostile behavior. Even the anticipation of working with clients who openly express anger, provoke interpersonal conflict, deny responsibility for their behavior, or blame others for their problems can be daunting. The prospect of working with substance abusers who are referred for treatment because their drug or alcohol use has been associated with violence toward others or themselves, or occurred in consequence with other criminal activity, leads some therapists to reject work in the addictions field because of fears, insecurities, or sheer lack of desire to professionally tackle such difficult and troubling interactions.
Stigmas Associated With Substance Abuse Treatment Providers. A second individual provider factor that contributes to the isolation of addictions therapy is the extent to which therapists shy away from treating addictions due to stereotyped and real characteristics associated with substance abuse treatment providers and their job environments. Confrontation and the deliberate induction of crisis have historically been recommended (e.g., Bratter, 1975) to therapeutically engage clients exhibiting the characteristics described earlier, but some therapists view such confrontation as incompatible with their mental health training and philosophies, and perhaps their own professional styles.
Furthermore, historical and economic factors have contributed to treatment environments in which minimal credentials have been required of addictions treatment providers. Many agencies assign excessive caseloads to therapists with masters, bachelors, or associates degrees operating at low rates of pay, although it is questionable whether clients are being adequately treated under such circumstances. Although these job characteristics reflect some real constraints on the addictions treatment field, they also foster the perception of addictions treatment provider as a low-status occupation. Many aspiring therapists may be discouraged from working with addictions by this perceived imbalance between high job demands and low compensation and status.
Traditionally, the addictions treatment field has placed strong emphasis on the importance of spirituality in facilitating recovery from chemical dependency. This too may stigmatize addictions treatment and its providers in the eyes of more scientifically trained and oriented professionals. Good arguments can be made for the value of adding spiritual ingredients to the recipe for behavioral change, but some psychologists undoubtedly have ruled out work with addictions due to discomfort or disagreement with the treatment field’s insistence on spirituality as a component of treatment.
One other stereotype of addictions treatment providers also certainly contributes to the isolation of the field from other mental health therapies. A high proportion of addictions therapists may well have been former substance abusers who became motivated to enter the field through their own process of recovery from a drug or alcohol abuse problem. Many who have traveled this career path are sincerely motivated to pass on what they have learned to help others in similar predicaments, and many are skilled, effective therapists. However, some therapists may shun work with addictions to avoid being perceived as someone with a personal history of addiction. The stereotype is self-perpetuating: as if only a person who has lived through an addiction would be willing or able to work with other chronic substance abusers—besides, what other work would an ex-addict be qualified for anyway? The argument here is not that this stereotype is accurate, but that it may be pervasive enough to discourage interest in addictions among psychologists and mental health professionals who do not want to be thus stereotyped or do not want to work in environments populated by other therapists who might fit the stereotype. This stigma is linked to a third therapist factor that contributes to the isolation of the substance abuse treatment field.
Therapist Ambivalence About Personal Substance Use History. So far this section has accounted for the likelihood that some psychologists and mental health professionals avoid the addictions field to rule out associating with the types of clients, therapists, and job demands that characterize the field (accurately or otherwise). It is also crucial to explore the extent to which a therapist’s interest in treating substance use disorders, however they arise in therapy, reflects the therapist’s own feelings about his personal experience with substance use. It has already been noted that American society is one in which the moderate consumption of alcohol and certain other drugs is widely practiced and largely condoned. Members of many other cultures also engage in regular use of psychoactive substances. Therapists, of course, are also social beings who participate to varying degrees in activities that involve the use of alcohol or other drugs (Good, Thoreson, & Shaughnessy, 1995).
The societal controversies surrounding the meaning of substance use and the response to substance abuse affect therapists in both their personal and professional lives. Observations and discussions with therapists and trainees frequently reveal considerable ambivalence and confusion about addressing client substance use in light of personal experience with substance use or with other users. Legitimate questions that arise include “If I myself (now or in the past), drink or use drugs, even to excess on some occasions, how can I challenge another person’s excessive use without being a hypocrite?”, “where does one draw the line between normal use and substance abuse?”, and “if a client denies a problem or the need for treatment, who am I to impose my own values about substance use on this person? How can I be sure I’m not imposing my own conflicts about personal experience with use or with users?” Issues of countertransference and appropriate professional responsibility confront therapists working with clients involved in risky substance use.
Although these personal, professional, and societal factors constrict the provision of comprehensive help to people encountering trouble associated with their alcohol or drug use, there is much reason for optimism about the future potential of substance abuse treatment. Despite the difficulties, some people with substance abuse problems do succeed at reducing harmful behaviors and their consequences. Many do learn from working through their past problems to engage in more productive activity and to contribute responsibly to society. Regardless of the stigma and the barriers, many scientists and therapists are so concerned about the detrimental impacts of substance abuse and drug policy on the mental, physical, and social health of the populace that they are dedicating their efforts to better understanding and treating the problem.
As already described, substance abuse problems have been frequently treated in isolation from other types of psychological problems. Over recent decades, the War on Drugs and related drug policies have resulted in large numbers of citizens being convicted and incarcerated for the possession and use of psychoactive substances (Anderson, 2003). Recognition of the limited successes or even, some would argue, the outright failure of prior efforts to reduce drug and alcohol abuse have stimulated new studies of addiction and new strategies for coping with it. Scientific investigation of the neurobiology of addictive behaviors has tremendously expanded our knowledge of how the brain, both structurally and functionally, is altered under the influence of alcohol and drugs (Wise, 1988, 1998). Not only does this research shed light on the basic nature of addiction, it also spotlights avenues leading toward enhanced understanding of the connections between substance abuse and other emotional, cognitive, and behavioral disorders.
Neurobiological research on addiction has focused on the mesolimbic dopamine pathway (MDP) to the nucleus accumbens region of the brain. Often referred to as the “reward center” of the brain, the nucleus accumbens provides pleasure when stimulated by specific actions of dopamine, serotonin, and other neurotransmitters. Both humans and animals will continue to engage in behaviors that stimulate the MDP, and in turn the nucleus accumbens, even if hard work is required to maintain the reward. Drugs, including nicotine and alcohol, stimulate the MDP either by rapid intensification of the effects of dopamine or indirectly by influencing the actions of other neurotransmitters that normally modulate or inhibit dopamine’s role in MDP stimulation. Repeated drug use over long periods exposes this region of the brain to surplus levels of dopamine, which is thought to decrease the body’s natural production of dopamine, causing a reduction in the number and sensitivity of dopamine receptors in the mesolimbic dopamine pathway (Thombs, 1999).
These neural mechanisms not only help explain compulsive behaviors involved in seeking and consuming drugs; they further suggest a neurochemical link between substance abuse and other psychological disorders, such as depression and eating disorders, in which abnormal neurotransmitter functions have also been implicated. Actions and effects of psychoactive substances are described in more detail in several texts (e.g., Austrian, 2000; Glidden-Tracey, 2005; Grilly, 2002). Research is also clarifying the learning and motivational factors that influence substance use (Baker et al., 2004).
In addition to brain studies, addictions research has also made great strides in understanding the effective components of treatments of substance abuse (e.g., Annis, Schober, & Kelly, 1996; de Leon, 1993; Epstein et al., 2003; Leshner, 1997; Miller, Meyers, & Tonigan, 1999; Rawson, Obert, McCann, & Marinelli-Casey, 1993; Witkiewitz & Marlatt, 2004). Treatment for substance use disorders tends to be most effective and lasting when the full scope of problems (emotional, social, occupational, medical, legal, etc.) can be addressed with the client. Also, clients are more motivated to engage in treatments that acknowledge the client’s definition and experience of their problems and permit the client to exercise choice in addressing those problems.
Taken together, these bodies of evidence support the conclusion that, although the treatment of substance abuse does require some specialized skills and knowledge, efforts at treating substance abuse hardly need to be independent from other psychotherapeutic approaches, and in fact can be usefully combined. Because both empirical and clinical findings point to the overlap in substance abuse, mood, anxiety, and other disorders, the arenas in which relevant therapy is provided are necessarily becoming more integrated.
Increasing awareness of the confluence of substance abuse and mental health concerns is generating efforts to improve collaboration among researchers and therapists from various perspectives. Some medical, psychological, and other substance abuse treatment providers are working toward establishing a common terminology to promote better communication among members of treatment teams. Active debates on controversial issues within the addictions knowledge base include attempts to address policy and program barriers to integrated substance abuse treatment.
Significant improvement in the ability to motivate client participation in therapy constitutes a crucial factor in integrating treatment efforts. Mee-Lee (2001a) noted traditional differences between the substance abuse treatment field’s insistence on client accountability for change and the mental health treatment emphasis on supportive care. Confronting reluctant clients with personal responsibility for their behavior frequently yields anything but a sincerely motivated intention to change. Conversely, encouraging clients to return only when they are ready to receive compassionate care is likely to be equally unmotivating for some clients. Integrated approaches that balance care and accountability throughout treatment are proving to be better motivators.
Recent models for facilitating behavioral change describe the process of change as one of distinct stages. Identifiable transitions between stages can be promoted, according to such models, by a therapist who can accurately identify and empathize with the client’s present stage and who can help the client explore the meaning and implications of change in terms of the client’s own experience. The transtheoretical model of change (Prochaska, DiClemente, & Norcross, 1992) is becoming widely used among substance abuse treatment providers (and the model is certainly applicable more broadly) in attempts to strike a balance between encouraging responsibility and expressing compassion for the client’s change process.
The transtheoretical model of the change process fits well with the parallel development of motivational interviewing techniques. In summary, such interventions involve meeting the client at the place from which the client is willing to work and utilizing whatever the client brings to treatment to prod change in a (hopefully) positive direction. Interested readers may also wish to consult Miller and Rollnick (1991, 2002) and Rollnick and Morgan (1995).
Although some psychologists, social workers, and mental health therapists are interested and involved in working with substance abuse concerns among their clients, many others are content to leave the assessment and treatment of substance abuse to someone else’s purview. As long as substance abuse could be defined as a separate entity and its treatment could be considered an independent specialty, therapists could, if they chose to, fairly easily rule out or refer clients presenting substance abuse concerns. Some therapists, for example, have traditionally delineated their scope in terms of helping the motivated client and the “worried well.” It is currently questionable whether a focus narrow enough to exclude substance abuse issues continues to be desirable or even possible in the future of therapy practice and training.
As reviewed in Section 1, data indicate that among psychotherapy clients and potential clients, high proportions have abused, do abuse, or will abuse alcohol or drugs in their lifetimes. Many other clients are indirectly affected by interpersonal contacts with substance abusers. Given the increasing documentation of connections between substance abuse and other concerns close to the hearts of many psychologists, therapists, counselors and social workers (e.g., psychological disorders, diversity concerns, occupational issues, lifespan development, and social justice), therapists can no longer deny the need for at least basic expertise regarding substance abuse assessment. Where indicated by assessment, the therapist should also be able to facilitate effective treatment or referral. The populations that therapists aim to serve are likely to receive more appropriate treatment once therapists acknowledge the prevalence of substance abuse among their clientele and embrace the relevance of skills for assessing and treating addictions.
In addition to becoming better equipped to meet clients’ multiple needs, the mental health professions are likely to benefit in other ways from more extensively incorporating an addictions emphasis. As research and clinical experience continue to generate richer knowledge about addiction, substance abuse, and recovery processes, the scientific respectability of the addictions field is improving, and the trend toward empirically based, integrated therapy approaches is evident. Additionally, psychological and mental health specialties are uniquely poised to make cutting-edge contributions to the addictions treatment field. Diversity concerns, interpersonal processes, and supervision and training issues are exceedingly relevant, yet underaddressed in the substance abuse treatment literature.
Occupational and educational concerns are embedded in the stories so many substance abusers have to tell. Consider a client who reveals that now that she has started therapy, she is becoming convinced that her daily marijuana habit to combat boredom will subside once she can find a college major she truly enjoys. Or how would a therapist work with another client who says he goes on drinking binges to avoid thinking about his grades and test scores, which are much lower than he knows he is capable of achieving? Or still another client, who just finished a term of incarceration for a drug selling offense and tells his therapist with all apparent sincerity that he wants to get a good job and be a good citizen and role model for his kids, but he also knows how much quicker and easier he could make money by returning to illegal activities? How might a therapist respond to the client who confesses that he has been drinking heavily and is planning to drop out of college because he is reluctantly starting to believe his alcoholic, physically abusive, working-class father who keeps telling the client he will never be any better than his old man? Not only can such clients pose fascinating challenges, but therapists with an occupational specialization have a great deal to offer these clients and many more like them.
Considerations of diversity and social justice are crucial in the delivery of effective prevention and treatment to substance abusing populations. Substance use, for better and for worse, cuts across virtually all segments of society. Essential components of substance abuse treatment include the therapist’s sensitivity to the sociocultural factors shaping a client’s history and pattern of substance use. When the therapy participants differ in cultural or socioeconomic backgrounds, the therapist will need skills in utilizing multicultural interpersonal dynamics in the interaction between the therapist and the client. If social or institutional policy discriminates against a substance-abusing client, the therapist may have a role to play as an advocate for social justice.
Psychologists interested in therapy practices and processes have developed a substantial research base addressing clinical supervision and training. However, the literature on therapy for substance abuse is only beginning to address appropriate training and supervision to address the particular needs of a substance abusing clientele (e.g., Powell, 2004). As substance abuse treatment is “mainstreamed” into mental health care, competent supervision and comprehensive training models are needed to disseminate and help integrate both empirically and clinically derived findings to trainees and clinicians working with addictions and comorbid disorders. Clinical supervisors and trainers have a tremendous role in developing and monitoring the skills of therapists who will be on the front lines of treatment.
In this Section, I considered factors contributing to the historical isolation of treatments for chemical addictions from therapies for other mental health concerns. Despite the sociocultural, professional, and personal factors that may discourage some therapists from working with substance abusers, however, evidence is emerging of trends toward increasing integration of an addictions focus with mental health treatments. I reviewed the influence of accumulating neurobiological understanding of addictive processes, advancing development of relevant treatment models and methods, and increasing professional collaborations, all of which hold great promise for helping to more effectively address problems linked to the misuse of alcohol and other drugs.
Not only do clients and the helping professions stand to profit from prioritizing attention to substance abuse, but individual therapists are likely to discover much professional satisfaction and personal reward from the gains in which they participate with substance abusing clients once biases against working with such clients are addressed and newly available knowledge is acquired, further developed, and applied. Considering the extent to which substance use disorders are intertwined with numerous social issues, work in the addictions specialty permits therapists to make substantial, lasting impact in areas of great social interest, concern, and need. The trends indicated earlier also point to a potentially expanded market for individuals who acquire specialized skills and knowledge in addictions research, prevention, and therapy. Many therapist job descriptions include preferences for applicants with substance abuse treatment experience. The time is ripe for training programs and continuing education to include expanded emphasis on substance abuse assessment, treatment, and referral, and for both scholars and therapists to explore the range of contributions they are specially equipped to make to the understanding of substance use disorders and their therapeutic treatment. This course contains some ideas and suggestions for those who would move farther in that direction by incorporating thorough substance use assessment skills into their professional toolboxes.
The life stories of substance using clients are so diverse, and the spectra of drugs and alcohols and combinations thereof so broad, that assessment and diagnosis of substance use problems are fascinating but rarely simple, brief, or straightforward processes. The information a client is inclined to provide in an initial meeting often looks quite different from the picture the client is willing and able to reveal after the client gets to know the therapist and to understand the therapy process. Although the importance of incorporating continuing assessment throughout the therapy process can certainly be underscored for any client, careful attention to ongoing assessment of new information about a client who uses psychoactive substances is especially crucial due to the established tendencies of such clients to distort information. The substance abuse therapist thus needs to be skilled at detecting and deciphering relevant details the client offers in early phases of assessment, and she must also remain open and attentive to additional data emerging as therapy progresses. It is essential for the therapist to maintain the flexibility of entertaining not only new information that confirms previous diagnostic impressions, but also evidence indicating that the therapist’s conceptualization of the client and the corresponding plan of intervention need to be revised.
In this Section, the time frames of ongoing assessment are described along with criterion sets for determining diagnosis and level of recommended treatment for different manifestations of substance use disorders. Because of the vast number of psychoactive substances with abuse potential and the copious pathways into problematic substance use, it is recommended that therapists who assess and treat substance use disorders be both well versed in knowledge of widely utilized frameworks and related considerations, and also highly skilled in the application of carefully reasoned and adequately justified clinical judgment.
Jarvid presents himself for a mandated substance use assessment following an arrest for trespassing. He claims he has no memory of the incident beyond waking up in an acquaintance’s house, but he swears he was not drinking that night, and that he has not done so in the past year of recovery from a former alcohol problem.
Tatlyn confides to her therapist in their third session that she has just confirmed her pregnancy, which Tatlyn had suspected (but never mentioned) for a couple months. Tatlyn admits great worry about the fact that she used drugs (which she is now admitting for the first time) on several occasions before she knew she was pregnant. She is evasive in response to the therapist’s question about drug use since finding out for sure.
Ross has been attending therapy sessions for several weeks to address his lack of confidence with women. He claims that in most social and professional situations, he is extroverted and has a wicked wit that makes him popular. However, in dating contexts Ross feels paralyzed by fears of rejection. His history of romantic relationships includes a breakup over two years ago with a woman he had thought he would marry, followed by a long series of brief sexual flings with multiple partners. Ross mentions seven weeks into therapy that he drinks before dates, sometimes starting at noon, to allow himself to be funnier and more charming. Probing further, the therapist learns that his fiancée left in part because she became fed up with Ross’ drinking habits.
Anna is brought by her mother to meet a therapist for assessment after repeated detentions in middle school for arguing with classmates and teachers. When asked about substance use as part of the routine assessment, Anna replies that she has not yet tried drugs or alcohol, but she figures she will at some point. She explains that she is the youngest of five, and that all her older siblings have experimented with drugs and alcohol, so she sees it as a “God-given inevitability” that she will, too.
Each of these clients demonstrates circumstances where further assessment of substance use is needed to determine the presence and nature of current problems and risks. The phases of assessing for substance use disorders begin with screening to determine the need for more thorough assessment. Screening instruments and procedures can be used to identify clients who may be engaging in problematic substance use, experiencing negative consequences of substance use, or be at risk for developing a substance use problem. Standard intake procedures utilized in formal initial assessment of virtually all clients in psychotherapy typically include questions about personal and family history of substance use. This type of screen built into a standard assessment that touches on broad aspects of personal functioning sometimes offers the first hint of a possible substance use issue. With other clients, acknowledgment of substance use may be first mentioned well past the standard intake assessment. In such cases, an alert therapist screens at that point for indications of risk or abuse associated with the client’s substance use.
If an initial screen indicates any reason for concern, a more extensive clinical assessment interview can be conducted to explore in more breadth and depth the nature of the client’s actual substance use and its implications, as well as the degree to which initial concerns are founded. Written assessment inventories may also be used. If the results of the assessment either confirm or suggest reasons for continuing concern about the client’s substance use, ongoing assessment during subsequent therapy sessions of the patterns and consequences of the client’s consumption of drugs or alcohol, along with the client’s response to therapy, is warranted.
When thorough substance use assessment indicates the presence of disordered use, the information available about the client’s patterns, frequency, intensity, and severity of abuse are incorporated into a diagnosis. The widely used diagnostic criterion sets from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV; American Psychiatric Association, 1994, 2000) include two general diagnostic categories of substance-related disorders: those induced by exposure to or ingestion of a substance (Intoxication and Withdrawal), and disorders of substance use (Abuse and Dependence). Each of these general categories is further subdivided into disorders associated with the use of particular psychoactive substances, all of which are described later in this Section. Once the therapist and client agree to undertake a thorough substance use assessment, initial diagnostic impressions are formulated with the therapist’s understanding that initial diagnosis may change with new information about the client, including revelations about actual behavior or indications of changes in behavior.
Even when the initial screening or assessment does not clearly suggest a substance use problem, the emergence of later information can create circumstances that should prod the attentive therapist into initiating further screening and assessment. Also, with clients diagnosed or treated for substance use disorders, new information about the client’s past or present substance-related concerns that comes out after initial assessment may well be different from earlier information. Continuing assessment is then important for understanding the significance of all that information in terms of both client behavior and the therapy relationship. Follow-up assessment of progress achieved in therapy is typically carried out as part of the termination of therapy. In some cases, assessment of changes maintained beyond the end of treatment may also be conducted.
Screening for substance use problems consists of asking brief sets of questions used to detect problems or rule out concerns about a person’s drug or alcohol use (Doweiko, 2002). The screening questions may be administered in spoken or written form by psychological, medical, or educational professionals, or even by an individual who is worried about personal use. Computerized screening is possible, and biological testing of urine, blood, or breath is also broadly utilized in some treatment contexts. Emerging technology further permits laboratory testing of saliva, sweat, or hair to detect the presence of illicit drugs (Verebey, Buchan, & Turner, 1998).
A screening may be conducted at the first hint of a problem, such as the passing mention during intake of heavy drinking a few nights per week. The need for screening may arise later in therapy, too. Consider Ross, the client described earlier lacking confidence with women. Ross mentions during Session 7 that his unusually irritable mood that day is due to a bad hangover, which the client promptly dismisses as “no big deal.” Even if the therapist has never witnessed Ross in such a foul mood before and has not previously considered substance abuse as one of this client’s problems, her current memory of Ross’ comment at intake that he “parties a lot” causes her to reflect on the mixed messages in what the client has told her about his substance use so far. Imagine that Ross told this therapist at intake that his alcohol consumption was no different from any normal person and that he had no troubles associated with drinking. Although the therapist may have taken this information at face value at intake, now the therapist cannot help noticing that today’s hangover, despite Ross’ attempts to downplay it, has certainly compromised his state of mind. Not a problem? Perhaps not, but the responsible therapist should ask some additional questions to provide a finer screen besides the client’s assurances and attempts to change the subject.
The CAGE. Screening instruments ask a few questions that have been widely observed to discriminate persons who exhibit substance use problems from those who do not. Used to screen for alcohol problems, the mnemonic device CAGE prompts treatment providers to inquire about a client’s typical substance use and its aftereffects. The CAGE instrument (Ewing, 1984) presents four questions and an acronym for screener recall: Have you ever felt you ought to CUT DOWN on your drinking? Have people ANNOYED you by being critical of your drinking? Have you ever felt bad or GUILTY about your drinking? Have you ever had a drink (EYEOPENER) first thing in the morning to steady your nerves or to get rid of a hangover? An affirmative response to any one question triggers further assessment.
The MAST. The Michigan Alcoholism Screening Test (MAST; Selzer, 1971) is another instrument widely used to screen for alcohol problems; it is particularly useful for detecting dependence, but not for less severe problems (Doweiko, 2002).
Other Screening Questions. To identify possible disorders associated with substance use in addition to or instead of alcohol, Brown, Leonard, Saunders, and Papasouliotis (1997) recommended asking two simple questions: In the last year, have you ever drunk or used drugs more than you meant to? Have you ever felt you wanted or needed to cut down on your drinking and drug use? Doweiko (2002) cited these authors’ findings that 45% of persons answering “yes” to one item and 75% of those answering “yes” to both items were diagnosed with substance use disorders.
A positive result, indicating a possible problem, leads the screener to recommend more extensive assessment. Often the screener is an educational, social services, or medical professional who refers the client to a specialist for further substance use assessment. The screener and assessor may also be the same person, if qualified. If the screener is a mental health professional and the screening suggests a reason for continuing concern, the professional should either conduct a thorough substance use assessment or refer the client to an appropriate assessor.
It is important not just to list, but also to discuss the options with the client, including exploring the client’s reactions to the recommendation for further assessment. A good screener can offer a rationale for more extensive assessment that is relevant to the client’s circumstances and appeals to the client’s motivations. For example, with a resistant or skittish client, the screener might say,
Your answers to my questions suggest this is worth further attention. We haven’t talked about this enough yet for me to say you do or don’t have an alcohol [or drug] problem, but I’d like to propose that we look at this in more detail. I suggest we spend some time together assessing your experiences with alcohol [and/or drugs] so we can decide together whether or not there is reason to be concerned. Would you be willing to take me up on that recommendation?
Methods of assessing substance abuse are discussed shortly in this Section, but if the screener decides to refer the client, some follow-up is advisable to enhance the chances that the client will make contact with the referred assessor. Referral without follow through to facilitate contact may result in an ambivalent or reluctant client’s loss of momentum or failure to receive services. If the client has been referred elsewhere for substance use assessment and possible treatment, but the screener is continuing to work with the client on other issues, follow-up to the screening includes requesting a report of the assessment as well as considering with the client, and possibly the other treatment provider, how to coordinate the components of the client’s counseling and therapy.
When the client’s responses to screening questions are negative, as in the case of Anna (the middle-school student with older siblings who use substances), the screener in an ongoing relationship with the client still has responsibilities to educate the client about risk where relevant. While the therapist communicates trust in the data provided by the client, the therapist also keeps listening for any further indicators of substance abuse risk or problems.
Passing through a screen indicates that the client has answered “no” to all questions used to detect substance abuse problems. A client who “passes through” the screen may well have no problems associated with alcohol or drug use. However, in some cases, clients will “pass” because they have not been entirely accurate in providing answers.
Options When Negative Results Are Ambiguous. If the screener suspects that substance abuse is occurring despite the client’s negative reply to screening questions, the screener has at least two viable options. First, the screener can tell the client that, because of the honor system, the screener will take the client’s answers at face value, but that the screener also acknowledges some evidence that contradicts the client’s responses. Screeners are advised to share specifically both what they have heard their clients say and any contradictory evidence, and to inform clients that all this information will also be documented. Of course, this means the therapist should carefully record the content of the discussion as well as the client’s responses to the screening questions. The therapist should also continue listening for and commenting on any additional indicators of problems that might arise. This is not to imply that the screener should take the stance of waiting to catch the client in a mistake or a lie (and the therapist will need to be prepared to discuss the chosen professional stance with a skeptical or accusing client), but rather to encourage therapists to keep open both the possibilities of the client’s subjective truth and alternative interpretations.
Second, the screener with lingering doubts about the client’s honesty (with self or the screener) may ask the client to submit to biological testing. Obviously such testing provides an even finer screen for substance use, although actual detectability depends on the type of drug, the size of the dose, the frequency and recency of use, the route of drug administration, individual differences in metabolism, the time of sample collection, and the sensitivity of the specific test (Verebey, Buchan, & Turner, 1998). Furthermore, a laboratory detection of substance use is not automatically equivalent to a determination of chemical abuse. Still the client’s reaction to the request for a urine, breath, or blood test reveals another useful piece of information to the screener. Clients who willingly or even grudgingly comply because they have “nothing to hide” are less likely to elicit ongoing concerns about deceptive self-report during screening, compared with clients who refuse to be tested. Although refusing clients offer various reasons (e.g., citing their rights to privacy, freedom from coercion, medical conditions, menstrual periods, etc.), refusal of a breathalyzer, urinalysis, or blood test to screen for substance use is viewed by many professionals as equivalent to an admission of recent use.
The screener should be further aware that “treatment-savvy” clients develop and share means of achieving negative biological test results—for example, by ingesting concoctions designed to “cleanse” the client’s system of drug residues before the test, or by substituting someone else’s bodily fluids to avoid a “dirty drop.” Thus, if the screener chooses to request that the client be “dropped” (tested using laboratory analysis of drops of the client’s urine or blood), or an alternative approach, the screener will find the results most useful if the tests are conducted as soon after the screening interview as possible, and if the screener remembers that both false positives and false negatives can occur with biological testing (Doweiko, 2002).
Motivational Factors. The screener who plans to refer the refusing client or a suspected false negative client for additional assessment and possible treatment is wise to attend to motivational and relationship factors at this point. An attitude of “I know you’re lying and I’m going to prove it” or “I’ll give you enough rope to hang yourself” is not likely to facilitate client participation. Even a reluctant client is more willing to proceed with a therapist who communicates the message,
If you say you haven’t been using drugs, I believe you because I take people at their word. But that also means I will be honest with you and tell you that some other things I’ve picked up about you don’t fit with what you’re telling me. Let me tell you my observations and concerns, and then I want to hear what you think about them.
Positive or ambiguously negative screening results, then, can be used as the basis for recommending that the client participate in a more detailed substance use assessment interview. Screeners should adequately document the type of screen and results along with any salient information about the client’s behavior, appearance, or responses to the screening process. Any recommendations or referrals discussed with the client should also be recorded. Any client screened may be provided with psychoeducational or motivational resources about using substances safely if at all, identifying substance use problems in self or others, or engaging in therapy for substance use concerns.
At the point where a concern is raised and supported by screening results, in-depth assessment of a client’s drug or alcohol use is conducted with two related purposes. First, the assessor collects information to determine whether the client’s substance use and related behaviors meet the diagnostic criteria for abusive, dependent, or otherwise disordered consumption. In general terms, diagnosis involves critical analysis to determine the nature and cause of a disorder through examination of the patient history and relevant clinical data. The DSM–IV (American Psychiatric Association, 1994, 2000) criteria are among the most widely utilized frameworks for diagnosing substance use disorders, and are thus presented next as guidelines for assessment. The criteria for substance use disorders were not changed in the 2000 Text Revision of the DSM–IV.
If, in fact, the assessment supports the conclusion that the client is at risk of developing or is already exhibiting a substance use disorder, the second purpose of assessment is to determine the appropriate level and format of recommended treatment, setting the stage for the development of a treatment plan (a topic covered in Chapter 6 of the Glidden-Tracey book on which this course is based.). The American Society of Addiction Medicine (ASAM) has published and revised placement criteria (Mee-Lee, 2001b; Mee-Lee, Shulman, Fishman, Gastfriend, & Griffith, 2001) to help determine the level of care that best serves clients with particular severities of substance use disorders. The ASAM placement criteria are presented after the DSM–IV diagnostic criteria, and together these two frameworks are used to shape the subsequent discussion of substance use assessment.
With these purposes of diagnosis and placement in mind, the assessor is encouraged to also build rapport with the client in efforts to engage the client in the assessment interview. The assessor who can connect on an affective level with the client and share the client’s story is better able to motivate the client to consider the treatment recommendations the assessor makes toward the end of the assessment interview.
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV, American Psychiatric Association, 1994, 2000) classifies disorders directly related to psychoactive substances into four general categories: Intoxication, Withdrawal, Abuse, and Dependence. Substance Abuse and Dependence are both considered disorders of substance use behavior, whereas Intoxication and Withdrawal are among the syndromes that can be induced by exposure to or ingestion of substances including illicit drugs, alcohol, medications, or toxins. To a certain extent, each of the four general categories of substance-related disorders can be manifest by users of various different substances, which allows for conceptualization and documentation of the common factors among substance-related disorders.
In addition to these four general diagnostic categories, the DSM–IV offers further specification of characteristics that indicate disordered use or induced syndromes connected with each class of substances. The DSM–IV identifies eleven classes of abused substances and associated disorders. These classes consist of alcohol, amphetamines, caffeine, cannabis (marijuana), cocaine, hallucinogen, inhalant, nicotine, opioid, phencyclidine (PCP), and sedative/hypnotic/anxiolytic drugs. Additional categories include polysubstance dependence and other or unknown substance-related disorders (covering steroids, nitrous oxide, and self-administration of prescription drugs, among others).
Substance-Induced Disorders. Exposure to a psychoactive substance can occur through deliberate ingestion or accidental or intentional poisoning. Disordered Substance Intoxication refers in the context of assessment to a syndrome of reversible psychological or behavioral changes caused by exposure to a drug (including alcohol) that influences the person’s central nervous system functions. Furthermore, to meet the criteria for a diagnosis of disorder, these changes induced by intoxication will be maladaptive in that they contribute to the individual’s distress or impairment within the person’s social and environmental circumstances. Every category of chemical substances listed in the DSM–IV is capable of producing an intoxication syndrome, and each type of substance has specific sets of characteristic symptoms of intoxication following recent ingestion of or exposure to that substance. Substance use assessors should be familiar with and have easy access to criterion sets for diagnosing Substance Intoxication.
As a substance is gradually eliminated from the body of a substance user, particularly after a period of abstinence from or reduction of prior heavy use, the user may experience symptoms of withdrawal. Substance Withdrawal Disorders are diagnosed when the substance user experiences the withdrawal symptoms typical of the type of drugs ingested as interfering with normal functions. An individual exhibiting Substance Withdrawal reports significant distress or impairment in fulfilling important roles or activities because of the withdrawal symptoms. (Other Substance-Induced Disorders associated with cognitive, mood, anxiety, psychosis, sleep, or sexual function problems are briefly listed in the DSM–IV section on Substance-Related Disorders, but further described in detail in sections of the manual that cover the types of disorders induced by exposure to a chemical substance. For example, Substance-Induced Delirium and Persisting Amnestic Disorder are both included in the DSM section on cognitive disorders, and Substance-Induced Anxiety Disorder is covered in the section on Anxiety Disorders.)
The presence of intoxication or withdrawal at the time of assessment alerts the assessor to the possible need for medical attention and appropriate referral, to be discussed shortly. The very behavior of showing up to a professional consultation under the influence of substances calls into question the individual’s judgment regarding appropriate times to use substances. Information indicating patterns of repeated intoxications or withdrawal problems serves as the basis for further assessment for substance use disorders.
Substance Use Disorders. Among the general disorders of intentional use, Substance Dependence can be considered a more severe subset of Substance Abuse. Both are defined as “a maladaptive pattern of substance use leading to clinically significant impairment or distress . . . occurring in a 12-month period” (American Psychiatric Association, 1994, pp. 181–182). The first criterion for Substance Abuse requires only one recurrent behavioral manifestation of impairment or distress, whereas a diagnosis of Dependence rests on the client’s meeting at least three out of seven possible criteria. The second criterion for Substance Abuse Disorder states that the client’s “symptoms have never met the criteria for Substance Dependence for this class of substances” (p. 183). In conducting an assessment of a client’s use of a particular substance, it is most practical to start by looking for the presence of Dependence, and, if Dependence can be ruled out, to next determine whether the client also meets the first criterion for Substance Abuse. This procedure is more efficient because every Substance Dependent client will meet the first criterion for Abuse, but not all clients who abuse substances will meet the more restrictive criteria for Dependence. If the more severe problem cannot be ruled out, there is then no need to assess for Abuse. If Dependence can be ruled out, the client meets the second criterion for the diagnosis of Abuse, but must still be assessed with respect to the first criterion.
To be diagnosed as
ContinuingEdCourses.Net is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. ContinuingEdCourses.Net maintains responsibility for this program and its content.
ContinuingEdCourses.Net is approved by the Association of Social Work Boards (ASWB) to offer continuing education for social workers, through the Approved Continuing Education (ACE) program. ContinuingEdCourses.Net maintains responsibility for its courses. ASWB provider #1107.
ContinuingEdCourses.Net is approved by the National Board for Certified Counselors (NBCC) as an NBCC-Approved Continuing Education Provider (ACEP) and may offer NBCC-approved clock hours for events that meet NBCC requirements. ContinuingEdCourses.Net solely is responsible for all aspects of the program. NBCC provider #6323.