This is an Intermediate Level course. After taking this course, mental health professionals will be able to:
This course is based on the most accurate information available as judged by the author at the time of writing and revision. Psychological approaches to understanding and treating the abuse of psychoactive substances change and grow daily, and new information may emerge that supersedes some content in this course. This course will: (1) provide clinicians with an intermediate level of knowledge of substance abuse issues arising in psychotherapy; (2) equip them to use a face-to-face interview to assess a client’s substance use and related complications; and (3) prepare them to make appropriate recommendations based on assessment results. Given the vast range of abusable substances and the complexity of individual behavior, not every assessment context can be specified nor can efficacy be guaranteed, but the course will offer the clinician useful ideas and tools for responding to a wide spectrum of substance use disorders and concerns.
This course is designed to pique interest in the connections between mental health and substance use and to focus professional attention on client concerns associated with drug and alcohol use. The goals are 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 along with 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 able to recognize and address problematic substance use among clients. 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 following book: Counseling And Therapy With Clients Who Abuse Alcohol Or Other Drugs: An Integrative Approach, by Cynthia Glidden-Tracey (2005). Reproduced by permission of Taylor and Francis Group, LLC, a division of Informa plc. Updates to this course incorporate new information based on the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the third edition of the ASAM Criteria published by the American Society of Addiction Medicine (formerly known as the ASAM Patient Placement Criteria).
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 any 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)). Treatment planning is specifically addressed in the companion ContinuingEdCourses.Net course, Might as Well Face It, There's Addiction Among Your Clients: Treatment Planning.) 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 disordered substance use, 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; Miller, 2006, Tatarsky, 2010).
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. 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 with clients. 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 listens for an identifiable pattern suggesting whether 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. She states 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. Andre eventually discloses that he sometimes gets into fights with his fiancée after he has been drinking – appalled that the last time he hit her.
Many clients presenting for therapy exhibit no indications of substance use concerns even if they report an occasional drink or the medical use of a drug. But when the therapist does detect a pattern of topics and behaviors that suggest a possible substance use disorder, the next consideration comes into play.
Second, the therapist conceptualizes the apparent meanings the client attributes to personal substance use. The therapist considers the significance of those emerging patterns in discussions with the client about substance use. Good thorough assessment provides a solid foundation on which to build an individualized conceptualization of the role that alcohol or drugs play in the client's life. 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 (Carlson, 2006; 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). Many of these issues are also included in the companion ContinuingEdCourses.Net course, Might as Well Face It, There's Addiction Among Your Clients: Treatment Planning).
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 associated meanings and consequences in a manner that potentially increases the client’s motivation to reduce involvement in risky substance use. 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; Holder, 2006; 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 use substances in risky or unhealthy ways.
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) indicated 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). In an influential text from a psychology perspective, Carroll and Miller (2006) stated, “There is a further value to the discipline of avoiding the jargon, labels, and pejorative terms commonly used in this field….We chose the term ‘troublesome use’ …precisely because it…shook us loose from comfortable custom. This in turn helped us to clarify some working assumptions” (pp. 5-6). 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. In fact the DSM-5 omits the previous “abuse” and “addiction” terminology of the DSM-IV. Page 485 notes that “the word addiction is not applied as a diagnostic term in this classification, although it is in common usage in many countries to describe severe problems related to compulsive and habitual use of substances. The neutral term substance use disorder is used to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing, compulsive drug taking. Some clinicians will choose to use the word addiction to describe more extreme presentations, but the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation.
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. Substance abuse, misuse, or disordered use 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.) Bridging from conventions associated with the long standing DSM-IV to the recent DSM-5, the general terms substance abuse and substance use disorder are used interchangeably in this course to encompass chemical abuse, misuse, and dependence, unless otherwise specified. From a DSM-IV standpoint, his was based on criteria indicating that all persons who met the more restrictive diagnostic category for substance dependence would also meet the first criterion for substance abuse (recurrent problems linked to the person’s substance use). Diagnostically, then, substance dependence could be considered a more severe subset of substance abuse. Acknowledging that not all substance abusers are chemically dependent, the DSM-IV-TR second criterion for a Substance Abuse diagnosis stated that the person being assessed had never met the criteria for Substance Dependence for a particular class of substances. The DSM-5 deliberately employs the term substance use disorder to reflect a single spectrum defined by severity of the disorder with the less value laden term use rather than abuse. (Diagnosis is discussed in detail in Section 3.) However since collapsing these terms and adding qualifying adjectives does not as succinctly distinguish nonproblematic use from troublesome misuse, and because the term substance abuse is likely to remain in the lexicon of the layperson for some time yet, the terms will, again, be used interchangeably.
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 "process addictions."). 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). It has already been pointed out that the DSM-5 no longer uses the term addiction as a diagnostic label due to uncertainties with the definition and derogatory connotations. Still, the main heading for that entire section is titled “Substance-Related and Addictive Disorders.” For purposes of this course, the term addiction is used to signify repetitive use of psychoactive chemicals continuing in the face of resulting personal or interpersonal problems, indicating the most severe manifestations of substance use disorder.
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 use disorders may be conducted independently or in concert with related treatments. However, I join ranks with those who dispute the common assumption that all disordered substance use needs to be treated in specialized programs separated from therapy as it is usually conducted. Changes in health care provision in recent years emphasize integrated treatments and interdisciplinary team approaches (Dougherty, Lyman, George, Ghose, Daniels, & Delphin-Rittmon, 2014; Mee-Lee, et al., 2013). Outcome research consistently supports the relative efficacy of psychological treatments for addictions (Miller & Brown, 1997; Bowen, Witkiewitz, Clifasefi, Grow, Chawla, Hsu, Carroll, Harrop, Collins, Lustyk & Larimer, 2014; Dougherty, et al., 2014).
In the treatment of substance use disorders and concerns, 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 misuse 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 use disorders involve 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 have problems with disordered or troublesome use of psychoactive 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. In more recent reports, SAMHSA (2010) estimates were that in 2009, 21.8 million Americans (8.7%) older than eleven years of age had used an illicit drug in the month preceding the survey. The most commonly reported illicit drug used by this large sample was cannabis (marijuana), with 16.7 million or 6.6% users in the past month.
For alcohol, prevalence of lifetime use in the 1999 sample ranged from 81.3% to 88.5%. In the SAMHSA 2010 report of results from the 2009 National Survey on Drug Use and Health, approximately 51.9 percent of respondents aged twelve and over reported drinking alcohol in the past month, projected to indicate 130.6 million people. Nearly one quarter (23.7%) reported binge drinking, with rates higher among young adults aged 18-25.
With respect to tobacco use, in 2009 current (past month) use of tobacco products were reported by 27.7% of Americans aged twelve or older. SAMHSA (2010) estimated that this number represents 69.7 million people in that age range. Rates of reported tobacco use decreased from 2002 to 2009, but cigarette use among twelve to seventeen year olds remained steady between 2008 and 2009.
In the 1999 SAMHSA survey, 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.) Looking more broadly at the full sample surveyed in 2009, SAMHSA (2010) estimated that 22.5 million Americans (8.9% of the population aged twelve or older) were diagnosed with substance dependence or substance abuse using DSM-IV criteria. This number remained stable from 2002-2009. Of those meeting dependence or abuse criteria in 2009, 15.4 million persons were diagnosed for alcohol related disorders but not illicit drugs. In 2009, estimates are that 9.3% of the population over eleven years of age needed treatment, but only 1% (and 11.2% of those considered in need of treatment) received specialty treatment in a substance abuse facility. It is not clear whether treatment or therapy from other sources was assessed in this survey.
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; Holder, 2006; 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 psychoactive substance use disorders 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, including prescribed medications, recreational drugs or alcohol. Furthermore, many habitual substance users 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 use 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 use 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 s/he 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 use 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 assessment or therapy are often convinced that their substance use is not genuinely problematic or that they do not really need treatment, 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 use 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 cannabis 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 mention, too, that in addition to the relatively large proportion of clients experiencing substance use 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. SAMHSA (2010) estimates based on extensive survey results were that of the 20.9 million Americans over the age of eleven who needed but did not receive substance abuse treatment in 2009, 1.1 million (5.1%) said they felt they needed drug or alcohol treatment. Of these, 34.9% reported making an effort to get treatment, while 65.1% reported they made no effort.
The focus in this course is primarily on providing appropriate assessment to substance using clients and those at risk of related problems 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 risky, excessive, or troublesome use of drugs and alcohol.
Whether treated or not, substance use disorders 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 users 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 terms comorbidity or co-occurrence are preferred here for their 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. Mueser, Drake, Turner, & McGovern (2006) reported that high comorbidity of substance use disorders and mental health problems is evident in the population in general, with rates even higher (upward of 50%) among persons receiving treatment for either disorder.
The substance use treatment field recognizes that substance use disorders frequently coexist with other diagnosable disorders (Mueser, et al., 2006; Westermeyer, 1998) and personal problems (Miller & Rollnick, 2002). In response, and with the passage of parity laws for mental health and substance use treatments and of the Affordable Care Act, the trend is toward improving the quality and integration of treatment approaches for co-occurring disorders (Dougherty, et al., 2014; 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 co-occurring 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 an integrated 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 co-occurring disorders. Certainly this demand 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), and the DSM-5 acknowledges the frequent comorbidity of substance use disorders and other mental health diagnoses (APA, 2013). 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 persons with substance use disorders. 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 persons involved with excessive substance use, 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 use 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 or co-occurring 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. The DSM-5 indicates that the evidence for high comorbidity was among the factors contributing to the move away from the multiaxial system of documenting diagnoses in the DSM-IV, and toward a nonaxial system allowing for more fluid boundaries between diagnostic categories over the lifespan (APA, 2013, pp. 5 & 16). Evidence of the high rates of substance use disorders among client populations and the frequent incidence of comorbid disorders suggest it is likely that substance use 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 treatment of substance use disorders 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 use disorder. Even if a therapist’s specialty lies elsewhere, when concerns about a client’s substance use 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. Freimuth (2009) explored how stereotypes about who uses substances and especially pessimism about what it means can limit a professional’s assessment and bias outcome expectations with clients regarding actual or potential substance use. The more therapists are attentive to their own beliefs about and responses to persons who use psychoactive 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, doubts or fears about how the client will react if asked about substance use, 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 use disorders are 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, both normal and disordered,to weigh assessment and intervention strategies. The potential barriers posed by inadequate therapist self-knowledge regarding work with substance users 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 use and related disorders, supervision and consultation can be crucial in the therapist’s development of substance use 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 activating 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 use 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 excessive or risky substance use. This instructional course will help therapists develop these essential skills of substance use assessment.
Despite the extensive interplay of substance use disorders and other psychological problems, the assessment of substance use and treatment of associated 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. In relevant professional terms, the newest manual for diagnosing mental disorders (DSM-5; APA, 2013) distinguishes “internalizing” and “externalizing” disorders, with anxiety and depression as examples of the former, and substance use disorders among the latter.) Depending on their own interests and experiences, different types of professionals have been drawn to working with these distinguishable 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 substance use and other mental health disorders.
The problem, hinted at earlier in this course and elaborated on 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 use problem before their commitment to change is taken seriously and before any other concerns can be 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 use 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 use and mental health fields in the direction of increasing integration. There is still, however, much room for improvement (Carroll & Miller, 2006). 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 use 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 use disorders co-occur with other psychological symptoms, several sets of factors contribute to the continuing low interest and effort put forth by many therapists and mental health 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 use disorders 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 medicinal 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 use is further obscured by confusion deeply embedded in the social system about moral versus medical interpretations of the problems associated with substance use (Thombs, 1999). When disordered alcohol or drug use 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 use 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 use. 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 risky or addicted substance users 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 related 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 users 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). The expanding debate about medical uses of cannabis (Holland, 2010) and the implementation in twenty-three states plus Washington DC (http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881) of laws permitting the use of medical marijuana add further complexity to discussions of this issue.
Economic Impact. In addition to philosophical and legal debates about the nature of substance use disorders and their 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 misuse psychoactive substances are alive, well, and unresolved in discussions of current drug policy and substance use treatment.
This complex societal backdrop sets the stage for the dialogue between mental health and substance misuse 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 externalizing and internalizing 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. Freimuth (2009) gave an interesting perspective on historical foundations, outlining how the twelve-step approach evolved in response to dissatisfaction with addiction treatments available in the early twentieth century, including recommendations for mental health intervention only for dually diagnosed “mentally ill chemical abusers” (MICA) with severe impairment. These and related factors contributed to 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 use 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 (Freimuth, 2009; 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 use 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 treatment approaches for substance use disorders 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). In the case of comorbid disorders, according to Mueser, et al. (2006) support is limited for traditional approaches separating the provision of substance misuse and mental health interventions, while empirical support for integrated treatment models has been found with severe mental illnesses. These authors indicated that integrated models have yet to be sufficiently tested with less severe comorbid anxiety, mood, or personality disorders. In 2014, Doughtery et al. introduced a series of articles on evidence for the effectiveness of a range of behavioral services for mental health and substance use problems, in which they concluded that “Although a number of practices are backed by strong evidence and are effective, the overall effectiveness of a number of other services has not been validated sufficiently because of a lack of adequate research. The evidence for these services does not yet meet the standards found in other sectors of health care research; however, some services show promise on the basis of the limited evidence available, and they deserve further study.”
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, clients manifesting substance use disorders 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 misusing 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 using 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 previously discussed 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 use treatment, it is also instructive to consider individual therapist factors. Freimuth (2002, 2009) 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 misuse substances, stigmas associated with substance abuse treatment providers, and therapist ambivalence about personal substance use history.
Stigmas Associated With Clients Who Misuse Substances. First, consider mental health therapists who are reluctant to work with clients who bear the stigma associated with drug or alcohol use disorders. Persons diagnosed with chemical dependencies or even less severe substance use disorders typically have been given 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 a substance use disorder, 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 users bring to discuss in treatment. Cultural differences between client and therapist may further obfuscate attempts to address problematic substance use. 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 users 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 Use 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 misusers who became motivated to enter the field through their own process of recovery from a drug or alcohol use disorder. 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 use 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 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 misuse 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 disordered substance use?”, 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 use treatment. Despite the difficulties, some people with substance use 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 use disorders 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 use disorders 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 use 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 (e.g., Andrzejewski, McKee, Baldwin, Burns, & Hernandez, 2013; Apkarian, Neugebauer, Koob, Edwards, Levine, Ferrari, Egli, Regunathan, 2013; Koob, 2006; Luo, Xue, Shen, & Lu, 2013; Vassoler, Byrnes, & Pierce, 2014; 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 misuse 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, at least under certain conditions of exposure (Hart, 2013). 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). In addition to impact on the brain’s reward system, heavy or excessive drug and alcohol use also dysregulate the functions of neurotransmitter systems by which the brain responds to stress (Koob, 2006).
These neural mechanisms not only help explain compulsive behaviors involved in seeking and consuming drugs; they further suggest a neurochemical link between substance use disorders 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; Koob, 2006). Research is also clarifying the learning and motivational factors that influence substance use (e.g., Andrzejewski, 2013; 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 use disorders (e.g., Annis, Schober, & Kelly, 1996; de Leon, 1993; Carroll & Rounsaville, 2006; Epstein et al., 2003; Humphreys & Gifford, 2006; Leshner, 1997; McClellan, 2006; Miller, Meyers, & Tonigan, 1999; O'Malley & Kosten, 2006; Rawson, Obert, McCann, & Marinelli-Casey, 1993; Witkiewitz & Marlatt, 2004; Witkiewitz, Lustyk, & Bowen, 2013). 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 (Miller & Carroll, 2006). 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 disordered substance use does require some specialized skills and knowledge, efforts at treating substance use disorders 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 use, 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 use problems and mental health concerns is generating efforts to improve collaboration among researchers and therapists from various perspectives. Some medical, psychological, and other substance use 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 treatment of substance use disorders.
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.
Psychological models for facilitating behavioral change describe the process 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 widely used among treatment providers 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 (2006), 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 use concerns among their clients, many others are content to leave the assessment of substance use and the treatment of identified disorders to someone else’s purview. As long as substance use disorders 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 use 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 use issues continues to be desirable or even possible in the future of therapy practice and training. The enactment of parity laws and the Affordable Health Care Act point to increased recognition of the importance of improving treatment of substance use disorders through integrated health care.
As reviewed earlier, data indicate that among psychotherapy clients and potential clients, high proportions have used, do misuse, or will misuse alcohol or drugs in their lifetimes. Many other clients are indirectly affected by interpersonal contacts with substance users. 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 (Martin, Burrow-Sanchez, Vaughan, Iwamoto, & Glidden-Tracey, C., 2013). 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 use 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 use disorders, 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 use treatment literature.
Occupational and educational concerns are embedded in the stories so many substance users 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 using 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-using 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 using 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 use disorders, 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 use, but individual therapists are likely to discover much professional satisfaction and personal reward from the gains in which they participate with substance misusing 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 use treatment experience treating substance use disorders. The time is ripe for training programs and continuing education to include expanded emphasis on substance use 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 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. As emphasized by Donovan (2008), the function of assessment varies depending on the point of the client’s treatment and recovery during which the assessment takes place. At the outset of therapy or when substance related concerns are identified, assessment focuses on the individual triggers and risky circumstances associated with the client’s substance use and relapse potential. As therapy progresses, assessment and acquisition of the client’s skills for coping with theses triggers and situation is paramount, along with focus on the client’s self-efficacy for using these growing skills. As therapy comes to a close, assessment concentrates on “the degree to which the individual is confronted by high risk situations…and the frequency and nature of coping skills used (p. 15).
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 criteria for determining diagnosis and level of recommended treatment for the spectrum 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 misuse 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 drug or alcohol use symptoms are incorporated into a diagnosis. The new diagnostic criteria in the DSM-5 redefines substance use disorders as a spectrum defined by the presence and severity of symptoms instead of the mutually exclusive diagnostic categories (Subtance Abuse and Dependence) of DSM-IV-TR (APA, 2000). The DSM-5 includes 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. 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. Prediction of potential relapse and effective relapse response also appear to require more than a single baseline assessment early in treatment (Donovan, 2008). Continuing assessment is thus important for understanding the significance of all that information in terms of both client behavior and the therapy relationship. Preventing relapse and minimizing harm if relapse occurs further depend upon assessment of the multiple and interacting determinants of an individual’s relapse potential taking distal, proximal, immediate, and transitional factors into account (Donovan, 2008). 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,written, or online formats 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 positive screen or laboratory test result alone does not verify a disorder, nor does a negative result by itself rule out a diagnosis (APA; 2013). Screening procedures help decide if additional assessment is justified.
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 use 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 CAGE-AID adapted the original measure to include screening for drug problems as well as alcohol concerns (Brown & Rounds; 1995), with good psychometric support for its sensitivity and specificity.
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). The MAST can be self-administered, including 25 yes/no items referring to behaviors and consequences associated with heavy drinking without specifying a time period. Scores of 4-10 points indicate a possible problem and the need for further in-depth assessment. Scores greater than ten are thought to reflect alcohol dependence. Shorter forms of the MAST are available (Freimuth, 2009), as are versions to screen for other drug use for both adults and adolescents (DAST; Skinner, 1982).
Two Item Con-joint Screen (TICS). 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.
The AUDIT. The Alcohol Use Disorders Identification Test is comprised of ten questions developed by the World Health Organization to detect risky drinking patterns (Saunders, Aasland, Bebor, De La Fuente & Grant, 1993). An individual can self-administer the AUDIT in a professional’s office or online: https://www.drugabuse.gov/sites/default/files/files/AUDIT.pdf. Items are scored from 0-4 points. The first three items assess quantity and frequency of alcohol use, and the remaining items assess problems in the past year linked to alcohol use. Total scores of 8 or more for men and 6 or more for women are interpreted as indicators of hazardous alcohol use. The first three items are also at times used alone as a briefer screen called the AUDIT-C, with scores of 4 or greater for men and 3 or greater for women indicating recommendation for further substance use assessment (Bush, et al., 1998; Bradley, et at., 2003).
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 use are discussed shortly, 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 risk or problems regarding drinking or drug use.
Passing through a screen indicates that the client has answered “no” to all questions used to detect substance use 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 disordered substance use 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 be tested using 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 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-5 (American Psychiatric Association, 2013) 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 changed in several ways from the DSM-IV, and these revisions are also summarized below.
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 and in the companion ContinuingEdCourses.Net online course Might as Well Face It, There's Addiction Among Your Clients: Treatment Planning). The American Society of Addiction Medicine (ASAM) has published and revised criteria to guide treatment (Mee-Lee, 2001b; Mee-Lee, Shulman, Fishman, Gastfriend, & Griffith, 2001; Mee-Lee, Shulman, Fishman, Gastfriend, & Miller, 2013). These criteria can help determine the level and progression of care that best serves clients with particular severities of substance use disorders. The ASAM Criteria are presented after the DSM-5 diagnostic criteria, and together these two frameworks are used to shape the subsequent discussion of substance use assessment.
With these purposes of diagnosis and planning 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 DSM-5 (APA, 2013) classifies disorders directly related to psychoactive substances into two general categories: substance use disorders and substance-induced disorders. The latter include Intoxication and Withdrawal among the syndromes that can be induced by exposure to or ingestion of substances including illicit drugs, alcohol, medications, or toxins. To a large extent, each of the 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.
Across these general diagnostic categories, the DSM-5 offers further specification of characteristics that indicate disordered use or induced syndromes connected with each class of substances. The DSM-5 identifies ten classes of abused substances and associated disorders. These classes consist of alcohol, caffeine, cannabis (marijuana), hallucinogens, inhalants, opioids, sedative/hypnotic/anxiolytic drugs, stimulant drugs including amphetamines and cocaine, and tobacco. An additional category covers other or unknown substance-related disorders (covering steroids, nitrous oxide, and self-administration of prescription drugs, among others). Each of these classes of drugs that are often taken to excess have in common the direct activation of the brain reward system involved in reinforcing behavior and producing memories.
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. The DSM-5 points out that in the broader physiological sense of the word, not every type of intoxication is associated with disorder (APA, 2013), which is consistent with the phenomenon of nonproblematic social use of substances or taking prescribed medication.
Every class of chemical substances listed in the DSM-5 is capable of producing an intoxication syndrome with the exception of tobacco, and each type of substance has specific sets of characteristic symptoms of intoxication following recent ingestion of or exposure to that substance. For example:
Sedative Intoxication disorder may be diagnosed by inappropriate sexual or aggressive behavior and mood lability following ingestion of a barbiturate or benzondiazapine, with slurred speech, unsteady gait, or stupor among the possible indicators of the disorders.
Stimulant Intoxication may be displayed in hypervigilance, anxiety, anger, or interpersonal sensitivity among the behavioral changes following recent use of cocaine, amphetamines or other stimulant drugs, with at least two physiological symptoms resulting, such as dilated pupils, chills, nausea, agitation, or psychomotor retardation.
Substance use assessors should be familiar with and have easy access to criteria for diagnosing Substance Intoxication.
As a substance is gradually metabolized and 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. Often withdrawal symptoms are the opposite of intoxication symptoms, as hyperactivity, insomnia, agitation or anxiety in withdrawal from sedative drugs or dysphoric mood, fatigue, or trouble sleeping during withdrawal from a stimulant drug. An individual exhibiting Substance Withdrawal reports significant distress or impairment in fulfilling important roles or activities because of the withdrawal symptoms. (Other Substance-Induced Mental Disorders associated with cognitive, mood, anxiety, psychosis, sleep, or sexual function problems are briefly listed in the DSM-5 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 is included in the DSM section on neurocognitive disorders, and Substance/Medication-Induced Anxiety Disorder is covered in the section on Anxiety Disorders.)
The presence of an intoxication or withdrawal disorder 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 psychoactive substances. Information indicating patterns of repeated intoxications or withdrawal problems serves as the basis for further assessment for substance use disorders.
Substance Use Disorders. The DSM-5 diagnoses Substance Use Disorders in terms of symptoms suggesting that a person continues to take a psychoactive chemical into his or her body in spite of significant problems linked to the person’s alcohol or other drug use. Among the innovations introduced in the DSM-5, describing disorders on a single spectrum of severity of the disorder was applied to substance-related and addictive diagnoses. Pathological patterns of substance use behavior can be exhibited in impaired control of use, social impairment due to use, risky use of drugs including alcohol, and pharmacological criteria. The DSM-5 now clusters criteria for diagnosing substance use disorders into those four groupings, and severity of the disorder is determined by the numbers of criteria met by the person being assessed. Substance use disorders can occur with any of the ten classes of psychoactive substances except caffeine, and are labelled, described and coded according to the particular substance(s) a person uses, such as Alcohol Use Disorder or Cannabis Use Disorder.
For readers familiar with the DSM-IV criteria, the former diagnoses of Substance Abuse and the more severe Substance Dependence are no longer used in the DSM-5. Both were 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 required only one recurrent behavioral manifestation of impairment or distress, whereas a diagnosis of Dependence rested on the client’s meeting at least three out of seven possible criteria. The diagnoses were mutually exclusive in that the second criterion for Substance Abuse Disorder stated that the client’s “symptoms have never met the criteria for Substance Dependence for this class of substances” (p. 183). Essentially, the criteria for Substance Abuse and Substance Dependence have been combined into a single list to characterize the spectrum of Substance Use Disorders, with a couple notable exceptions. Recurrent legal problems related to substance use, which were formerly included in the Substance Abuse criteria, have been eliminated; and strong cravings to use a substance have been added to the diagnostic criteria for Substance Use Disorders.
Specifically, the DSM-5 criteria for diagnosing Substance Use Disorders are grouped into four types of symptoms.
Impaired control over substance use is reflected in the first four criteria:
1) ingestion of larger amounts or over longer time periods than intended
2) wishes or failed efforts to control substance use
3) excessive time spent in substance-related activities, including obtaining, using and recovering
4) cravings or strong urges or desired to use the substance specified by the diagnosis.
The next grouping of criteria expresses social impairment due to excessive substance use:
5) resulting failure to fulfill obligations at home, work, or school
6) continued use despite recurrent interpersonal or social problems associated with substance use
7) neglect of previously important activities because of substance use
The third set of criteria indicates risky use of psychoactive substances, such as:
8) using alcohol or other drugs in physically hazardous situations, like smoking in bed or driving while intoxicated
9) continued use despite known physical or psychological problems associated with substance use
The fourth criteria group reflects the presence of the pharmacological symptoms of:
The diagnostic thresholds have also been modified in the DSM-5: the presence of at least two out of ten or eleven possible symptoms are now required for diagnosis of any Substance Use Disorder. (Only ten symptoms are listed for Hallucinogen or Inhalant Use Disorders because withdrawal symptoms have not been established and documented for humans with these two classes of drugs.) When 2 or 3 symptoms are in evidence, the use of a particular substance is considered mild. With 4 to 5 symptoms present, the diagnosis would be a moderate disorder; severe substance use disorders are diagnosed when 6 or more symptoms are manifest.
11) withdrawal (both to be elaborated below)
The last two criteria of tolerance and withdrawal describe effects of the chemical consumed on the user’s body. Tolerance is defined as either the physiological need for greater amounts of the substance to become intoxicated or “high,” or the experience of reduced effects with continuing use of the same amount of a substance. Withdrawal occurs when the concentrations of a substance decline in the blood or tissues of the heavy user after stopping or reducing use, resulting in physiological or psychological symptoms of discomfort that often prompt the person to resume substance use to eliminate or avoid the withdrawal symptoms. Withdrawal takes on different characteristic symptoms depending on the specific substance(s) being abused. (Factors contributing to the development of tolerance and withdrawal are detailed in Chapter 4 of the Glidden-Tracey book from which this section is excerpted.)
The assessor asks clients general questions about their experiences of tolerance and withdrawal, which for some clients may require providing definitions in language the clients can understand. Revisiting the earlier example of the pregnant client – Tatlyn questions what the therapist means by tolerance. The therapist replies, “Did you ever need to use more and more of the drug to get the same feeling of high, or ever find that you couldn’t get the kind of highs you used to with the same amount of the drug?” In addition, the assessor should directly ask whether the client has experienced the symptoms of withdrawal and tolerance associated with the criterion sets linked to the substances the client has been using. As mentioned earlier, the withdrawal symptoms for alcohol and other sedative drugs include hyperactivity, agitation, and anxiety, whereas withdrawal from stimulant drugs like cocaine or amphetamines encompasses dysphoric mood, fatigue, and either retardation or agitation of psychomotor functions. This, of course, means that the substance use assessor should become familiar with the substance-specific criteria as well as the general criteria, and he or she should have access to appropriate reference material (such as an available copy of the DSM-5) to prompt thorough assessment.
A client can meet the criteria for a substance use disorder without exhibiting either tolerance or withdrawal, and in the DSM-IV, such a disorder was specified as Substance Dependence Without Physiological Dependence. This subtype label as well as the Dependence diagnostic category have been omitted in the DSM-5 due to continuing confusion and debate about the extent of overlap and distinction between dependence, tolerance, and withdrawal. The diagnosis of a substance use disorder without evidence of either physiological tolerance or withdrawal still reflects a client’s tendency to persist in self-administering a drug of choice despite significant problems connected with that compulsive use. These individuals may organize their life activities around obtaining and using their preferred substance(s) and recovering from the effects. They may try to regulate or control their consumption, perhaps having tried to limit the amount they ingest or quit using altogether, but have been largely unsuccessful in those efforts. Like Ross, who kept drinking heavily after the love of his life threatened to leave if he did not control his drinking, clients may sacrifice relationships, give up formerly gratifying activities, or abandon important responsibilities to continue using. Even when faced with knowledge of severe adverse health, vocational, social, or psychological consequences of substance use, as the pregnant Tatlyn is, the substance dependent person keeps on taking the drug of choice.
The DSM-5 includes additional course specifiers to reflect changes in substance use behavior over time. Often during therapy, the client diagnosed with a substance use disorder engages in a period of abstaining from or greatly reducing consumption of a drug or alcohol. Sometimes the client even enters therapy already abstinent, but still working on coping with the impact of prior substance dependent behavior. Jarvid, the client in the opening example, was arrested for trespassing when someone he just met reported Jarvid passed out in the man’s home, allegedly uninvited. Jarvid was referred for substance use assessment based on these circumstances as well as his documented history of Alcohol Dependence, although he insisted that he had not had a drink or used recreational drugs in over a year. In such cases, where the client stops exhibiting the criteria for a substance use disorder for some time (at least three months according to the DSM-5, changed from only one month in the DSM-IV), the remission specifiers can be applied to clarify the diagnosis.
Early Remission now refers to the period from three to twelve months after the client no longer engages in behaviors characteristic of a substance use disorder. The exception is craving: a person in remission from a substance use disorder might continue to experience urges or desires to drink or use drugs, and this can be assessed and addressed in planning treatment and relapse prevention. Early Remission is distinguished from Sustained Remission, occurring for more than twelve months, because the first year of remission is frequently a time when the temptations and cravings to resume substance use are strongest, and the risk of relapse is high. The DSM-IV specifiers of Full or Partial Remission have been removed from the DSM-5 criteria defining the spectrum of substance use disorders.
For clients who have in the past but do not currently meet criteria for substance use disorder, and are presently undergoing medical or other intensive intervention where access to substances is restricted, the specifier of In a Controlled Environment are applied instead of remission course specifiers. This specifier is applied when the client is in a closely supervised, substance-free environment, such as a jail, hospital, or therapeutic community. For opioid use disorders and tobacco use disorders, an additional specifier of On Maintenance Therapy may be indicated when the person being diagnosed is taking medication prescribed to reduce cravings for the abused substance by substituting a safer alternative, such as methadone or buprenorphine for an opiate dependent person or nicotine replacement medication for someone with tobacco use disorder.
The Distinction Between Remission and Recovery. Some controversy exists over whether a client who has met the criteria for a Substance Use Disorder at any point over a lifetime should thereafter be considered to still have the disorder even after a long period (several years) of Sustained Remission. (Is it true that “once an alcoholic, always an alcoholic”?) Does a person diagnosed with severe substance use disorder ever relinquish the diagnosis? If so, under what conditions? Is total abstinence necessary for recovery? Additional debate about the need for total abstinence assuming the chronic nature of addictions has generated high levels of tension between addictions researchers and treatment providers (Thombs, 1999).
The majority of treatment programs for substance use disorders promote abstinence as a goal, although some research findings indicate that controlled drinking or moderate use may be a viable strategy for some clients (Harris & Miller, 1990; Miller & Hester, 1980; Sobell, Wilkinson, & Sobell, 1990). Many substance abuse experts are skeptical at best about the therapeutic potential of attempts to resume moderate social drinking (Buelow & Buelow, 1998; Doweiko, 2002). The DSM-IV (American Psychiatric Association, 1994) specified that the distinction between Full Sustained Remission and complete recovery depends on the length of the disorder, the duration of the remission, and the need for continued evaluation. The DSM-5 does not appear to comment further on a time if or when sustained remission ends in complete recovery. The authors of the 2013 ASAM Criteria state their goal to offer more flexible definition of recovery as “effort…in the direction of a consistent pursuit of abstinence, addressing impairments in behavioral control, dealing with cravings, recognizing problems…and dealing more effectively with emotional responses” (p. 427). Remission is defined on the next page of the ASAM Criteria as “a state of wellness where there is an abatement of signs and symptoms that characterize an active addiction,” further specifying that “many individuals in a state of remission remain actively engaged in the process of recovery.” Buelow and Buelow (1998) offered the following conditions under which they believe that clients should be encouraged to maintain total abstinence from mood-altering substances:
1. Repeated failure to cut down the amount or limit the frequency of drinking or use of other legal drugs
2. Use of illegal drugs
3. Physical problems that alcohol or other drugs can exacerbate in any way
4. Pregnancy or risk of pregnancy
5. Prior dependence on, or addiction to, any drug
6. Concurrent use of medications known to be affected by alcohol or other drugs
7. Prior decision to abstain
Thombs (1999) noted the need for more comparative research to address this controversy.
Considerations made in revising the criteria for substance use disorders from DSM-IV to DSM-5 are addressed in Martin, Chung, and Langenbucher, (2008). Use of these diagnostic categories and criteria is discussed at length later in this section. First, an additional framework is presented for choosing an appropriate level of treatment in light of assessed client characteristics.
In addition to the DSM diagnostic criteria for substance-related disorders, the assessment process to be offered in this section is modeled in part from the ASAM Criteria (Mee-Lee et al., 2013) developed by the American Society of Addiction Medicine (ASAM). ASAM’s guidelines for recommending level of care and determining appropriate services incorporate six dimensions of the assessed severity of a person’s disordered use of substances or addictive behaviors. The newly revised ASAM Criteria define addiction as “the pathological pursuit of reward or relief.” Using these dimensions, clients or patients are assessed in terms of:
1. Acute Intoxication and/or Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions or Complications
4. Readiness to Change
5. Potential for Relapse, Continued Use, or Continuing Problems
6. Recovery/Living Environment
The ASAM Criteria help decide and plan, based on the assessed levels of severity and functioning along each of these six dimensions, which level of care and types of treatment are the most appropriate for the client’s needs. Levels of care range from:
0.5 Early Intervention
1. Outpatient Services
2. Intensive Outpatient Partial Hospitalization Services
3. Residential/Inpatient Services
4. Medically Managed Intensive Inpatient Services
The 2013 ASAM Criteria now provide more specific points between each level to better distinguish the intensities and formats of care within each level. An example is the gradation implied between levels 2.1 (Intensive Outpatient Services) and 2.5 (Partial Hospitalization Services). The ASAM framework permits the assessor to develop a “multidimensional risk profile (the acuity, urgency, and priority of clinical risk of each assessment dimension) [which] integrates all of the biopsychosocial data [about the client] into a more succinct summary” (Mee-Lee, 2001b, p. 2). This summary can be used to match the client with treatment modalities and services that best fit the assessed priorities. This is facilitated using detailed tables, which cross dimensions of client substance use with levels of treatment, and which describe the characteristics of clients who fit each cell. The ASAM Criteria are useful for assessing the severity of a substance use problem whatever the specific diagnosis. Furthermore, the ASAM guidelines can help a therapist determine whether adequate care can be provided through that therapist or whether referral is warranted to another source of services that meet the identified needs.
Each section of the assessment format proposed next is thus linked to one or more of the ASAM dimensions for assessing severity of substance-related problems. The potential for withdrawal or the presence of biomedical conditions (Dimensions 1 and 2) can indicate a higher risk for immediate medical problems and a higher relapse rate (American Psychiatric Association, 1994). Thus, when severity is rated high on ASAM Dimensions 1 or 2, referring the client for a medical consultation is often of paramount importance (Mee-Lee, 2001b; Mee-Lee et al., 2013). Ongoing or later psychological intervention can, in many cases, serve as a useful adjunct to medical attention, especially when problems are also determined on ASAM Dimensions 3 to 6, as is often the case.
In the absence of current concerns regarding intoxication, withdrawal, or medical complications, psychologically oriented treatment to address the emotional, behavioral, or cognitive complications of the client’s substance use (Dimension 3) is typically a pressing need for clients who exhibit a substance use disorder. The assessor, then, should thoroughly investigate the client’s subjective experiences of moods, thought processes, and risky behaviors. The anticipated degree of client cooperation with treatment is estimated in terms of the client’s readiness for change (Dimension 4), encompassing both the client’s awareness of the need for some change and the client’s commitment to changing behavior. The assessor also takes into account the apparent likelihood that the client will be able to abstain from or control future substance use, or that the client will resume or continue problematic consumption (Dimension 5). Using Dimension 6, the assessor further investigates the extent to which the client’s living environment poses barriers to or provides supports for the client’s efforts to stabilize or change.
The template provided next can be used with clients who are new to the therapist or with clients the therapist knows well, but for whom substance use concerns have only recently emerged in session. The template organizes a structure the therapist can use to conduct a thorough substance use assessment, but it is by no means the only format available for this task (see e.g., Donovan & Marlatt, 2008; Lewis, Dana, & Blevins, 2002; McLellan, Luborsky, Woody, & O’Brien, 1980; McLellan et al., 1992; Ott & Tarter, 1998). Donavan and Marlatt’s 2008 edited volume in particular includes extensive information about testing instruments and assessment guidance pertaining to seven categories of psychoactive substances as well as eating, gambling, and sexual behavior disorders and relapse issues. The interview strategy and template presented below emphasizes the value of interpersonal interaction in an ongoing clinical dialogue as a crucial tool for comprehensively assessing complex and individualized substance use information.
Readers are encouraged to use this template flexibly, in accordance with their own experiences and with their places of employment or training. The important point is for assessors to be aware of the broad range of considerations to be addressed in piecing together a picture of the client’s substance use issues. Confidentiality provisions and limitations should be addressed with the client prior to starting the assessment, and these will be discussed in detail later in this section.
Introduction of the Assessment Process.For clients who have never taken part in a substance use assessment before, especially those clients who have attended reluctantly at best, the assessor should make an effort to establish rapport and explain the process about to unfold. Even clients who have been through a prior assessment are more readily engaged in the immediate process if the assessor gives an idea of what will happen in the present session. Neutral terminology at the beginning can facilitate the interview. For example, with clients specifically requesting a substance use assessment, the assessor might say:
We’re meeting today to assess your experience with alcohol and drugs. That means I’m going to ask you a set of standard questions I ask every client whenever we agree to do a substance use assessment. This way I can try to get a broad picture of your own use of drugs or alcohol and any related consequences.
The deliberate reference to “use” rather than “abuse,” and “consequences” rather than “problems” is intended to avoid making presumptions about the client’s reasons for coming and also to prevent triggering resistance in clients who do not consider their substance use either abusive or problematic. Any questions the client might have can be invited and answered up front.
With clients in therapy who did not present with substance use issues or request substance use assessment, the therapist may take a different approach to introduce the in-depth assessment process. First, this includes explaining the reasons, including corresponding observations, for recommending the joint undertaking of assessment of the client’s substance use and related experience. For example:
You’ve made three or four references now to “getting high,” and to me that is sounding like a big enough part of your life that it would be worth talking about more, if you’re willing. I’m interested because I think finding out more about that part of your life would help us decide together if your drug use is related to any of the other concerns we have been talking about.
The therapist using this introduction will also be ready to hear and respond to the client’s reactions to this proposal.
Next, the assessor often describes the assessment process to the client in enough detail so the client knows what to expect. For clients who are agreeable to the assessment, this may be less crucial than with a reluctant client, but it still helps prepare the client and structure the discussion when the therapist describes what will happen. When the client is unconvinced of the need for substance use assessment, the therapist’s description can emphasize taking a nonjudgmental stance to gather information that will be used to determine whether a focus on substance use issues is relevant to plans for continuing therapy. For example, the assessor might say:
I’d like to take at least part of our session this week or next to ask you a series of questions about substance use that may or may not be related to your own history, but will give us a broader picture of your own actual experience, past and present. By learning more about any role substance use may have played in your life and where you stand on the topic, I’m in a better position to either be convinced we don’t need to talk more about your substance use, or to think about other options open to us.
Finally, the therapist invites the client’s questions or other reactions to the assessment proposal, giving them full weight of consideration through discussion as needed. The therapist asks for the client’s agreement to proceed according to a negotiated schedule. If the client is willing and there is time left in the immediate session, the therapist may launch right into the substance use assessment. If this topic arises toward the end of a session or if the client wants time to think about the prospect, an agreement can be formulated to resume the discussion at the beginning of the subsequent session.
With clients who dismiss the need for further assessment of their substance use even after the therapist has made the request and offered a rationale, the therapist can honor the client’s refusal and still explicitly hold open the possibility that the discussion may resurface at another time.
Client History of Substance Use.Once the client asks for or agrees to an assessment, a logical next step is to inquire about the client’s history of involvement with alcohol and other drugs. The diverse backgrounds of clients who use drugs or alcohol necessitate detailed history of each individual client’s substance use.
The assessment history begins with asking the client’s reasons for seeking the assessment (Buelow & Buelow, 1998). The therapist should record the answer in the client’s own words (see Table 1, Section a); if paraphrasing is needed, the therapist is recommended to read the written reason back to the client and negotiate the wording until the client agrees with the reason(s) included in the record. With clients presenting specifically for substance use assessment and with whom the therapist is meeting for the first or second time, much important content is typically revealed by how the client answers this question. For example, a client’s report that his wife threatened divorce indicates the need for attention to relationship issues, a client frightened by frequent blackouts and tremors probably needs referral for medical consultation, and the client who says she was ordered by a judge to get assessed following a DUI incident alerts the therapist that consents for releasing information to third parties will be necessary. In addition, the client’s reasons for seeking assessment often provide some initial information about the client’s attitudes toward personal substance use, toward motivations for changing current habits, and toward engaging in therapy to promote such change. Whether the client’s attitude is compliant, sheepish, defeatist, defiant, dismissive, hostile, or some other variant, the assessor can maximize the client’s cooperation by empathizing with the client’s perspective and reasons. The therapist’s communication of acceptance, understanding, or tolerance of the new client’s fears or frustrations must of course be couched in a firm frame of therapeutic boundaries. In most basic terms, the therapist’s implicit message is, “I hear what you’re telling me and here’s what I have to offer.”
When the assessment is conducted in the context of substance use concerns raised during the course of therapy with a continuing client, the reasons for the assessment have most likely already been discussed during collaborative decisions to incorporate this in-depth assessment into the treatment strategy. Still asking the client to elaborate on his or her understanding of the reason for assessment at the start provides opportunities for the therapist to hear how the client is approaching the activity and also to clear up any possible confusion.
Table 1. Template for Assessing Client Substance Use History
Once reasons for the assessment are established, the therapist informs the client that a detailed list of commonly used and misused substances will be covered. Table 1, Section b, provides a template for requesting and recording information about the client’s personal substance use history. (The tables have all been compressed here in the interest of space, but a roomier version along with the entire assessment interview questionnaire developed and explained here is compiled in the Appendix.) The therapist may start assessing substance use history by saying something like:
I’m going to go through a list of drugs and other substances that are widely used and misused, and I want to find out if and when you have personally tried any of them. I’ll start with alcohol, because as you probably know, that’s one of the most common recreational substances.
For each category of substances, the assessor then asks if the client has ever used any of them. If the answer is affirmative, the rest of the questions across the top of the grid in Table 1 are relevant as well. The assessor, interested in the frequency, intensity, and severity of any substance use by the client, can ask the following questions for each drug category the client admits using:
At what age or approximate date did the client first try that drug? How has the client’s use increased or decreased over time? When was the period of heaviest use, and what was it like? How much and how often has the client used over the past month? And what was the date and amount of most recent use?
Obviously asking each of these questions for each category of substances can be time-consuming, especially with clients who have lengthy histories or who have used multiple drugs. However, such extensive histories help pinpoint the nature of the client’s issues and the most appropriate treatment options. Assessment may take more than one session. In cases of ongoing assessment during therapy, the client and treatment provider may incorporate plans to allot some time in sessions to spend on continuing substance use assessment and the rest of the time on other topics or goals.
The assessor who shows interest in the client’s full story also helps establish rapport. In circumstances where time is limited, the assessor can express this interest without necessarily hearing the whole story at once. For example, if the client continues at length or brings up important information toward the end of the session, the assessor can let the client know,
What you’re telling me sounds very important, and we will definitely come back to it because I want to hear more about it. (Or, if referral is in order: “. . . and I strongly encourage you to bring it up with the therapist you will be working with.”) But to make sure we cover what we need to get to today, let me first ask you about . . .”
In these instances, the assessor should make note of the topic to ensure that further assessment and discussion are conducted when time permits.
The history assessment starts with alcohol both because it is a legal drug and one consumed by people in virtually every segment of society. Clients are sometimes put at ease by first discussing their experience, if any, with this “safe” substance. The type of alcohol a client drinks (wine coolers, beer, mixed drinks, straight liquor, etc.) should be determined. For each subsequent category, the assessor also inquires about and records information about the form in which the client has used the drug. For cannabis, as an example, the assessor should determine whether the user has ingested the marijuana by means of joints, pipes, bongs, blunts, edibles, hash, chew, or some other form. By the time the assessment reaches the category of central nervous system (CNS) stimulants or “uppers,” the assessor using the template in Table 1, Section b, will note that a few examples of that category (e.g., cocaine, Ritalin, methamphetamine) are included to generate further questioning if the client is unfamiliar with the general category. The categories of sedative (“downer”), opiate (painkiller or analgesic), and hallucinogenic drugs also include examples that can be offered to prompt clients who may not be aware how the drugs they have consumed are classified or how those drugs operate on the brain. For example, a client who took a “roofie” (Rohypnol) pill given to her at a party, in search of a fun “high” at the time, may not know that the so-called “date rape” drug depresses the CNS and creates a sedative effect on the body.
This history-taking phase of assessment also provides opportunities, then, for the therapist to begin educating the client about the nature and biological impact of the drugs the client has ingested, inhaled, injected, or been curious about using. Many therapists discover that the education goes both ways – clients experienced with substance use and effects can help therapists better understand the impetus for and effects of taking drugs in addition to extending a therapist’s list of drugs to be assessed for along with their “street names.”
Walking through the client’s drug history will also yield encounters with signals of issues the therapist will wish to record and pursue if ongoing therapy is recommended. Some clients are quite willing to tell their stories to an attentive, caring therapist, and some end up sharing personal details they had not planned on discussing. Clients’ descriptions of their initiations into drinking or drug use, or of the forces encouraging their continuing use, can uncover links to comorbid symptoms or interpersonal, educational, or occupational concerns. The effective assessor will take careful note of such hints or details and encourage the client to use ongoing therapy as an opportunity to explore these issues more deeply. Even at this early stage, the therapist can offer recognition of a difficulty and hope of finding a better way to deal with it.
Once the substance use history is completed, the assessor often already has some diagnostic impressions. At the least, the assessor can narrow the focus from generalized substance-related disorders to consideration of disorder(s) associated with a particular class of substances. Distinguishing diagnoses depends on not only the drug that has been used, but also on the conditions under which the drug was used and the consequences of use. Thus, the rest of the assessment template offered here explores the physical, psychological, interpersonal, educational, vocational, financial, and legal factors linked to the client’s drug or alcohol use.
Physical Symptoms of Substance Use Disorders. The importance of first addressing or ruling out any need for medical attention has already been mentioned. Thus, the next section of the assessment template corresponds to ASAM Dimension 1 (Acute Intoxication/Withdrawal Potential) and helps determine whether the client meets the DSM-5 criteria for tolerance or withdrawal. Because each drug has its own particular effects on the brain and the body, the criteria that identify intoxication or withdrawal for cocaine, for example, are different from those indicating marijuana intoxication or alcohol withdrawal. Table 2 includes lists of numerous physical consequences and psychological symptoms associated with problematic substance use. The table further incorporates all the indicators of withdrawal summarized in the DSM-5 for each class of substances with which withdrawal symptoms have been demonstrated. Compulsive use of alcohol, opioids, sedatives, hypnotics, or anxiolytics (anti-anxiety drugs) each produces significant and measurable withdrawal symptoms, whereas stimulants like cocaine or phencyclidine (PCP) elicit less obvious but still evident signs of withdrawal, and hallucinogens and inhalants have no established withdrawal syndrome (American Psychiatric Association, 2013). Withdrawal potential is also determined in part based on the client’s replies to the earlier history questions about most recent use and amounts of use in the past month.
Working with a format like the template in Table 2, Section c, the assessor first tells the client,
I am going to read through a list of physical consequences that some people experience when they are using drugs or alcohol or coming down from an episode or a “high,” and I want you to let me know if you’ve ever experienced any of these consequences in the past or present associated with your own use.
Table 2. Template for Assessing Client Substance Use Symptoms
Superscripts indicate the class of substance with which
each symptom is associated in the DSM-5:
The assessor should certainly ask about all the criteria associated with the substances the client has reported using, but it is also useful to inquire about symptoms associated with the disordered use of other drugs in case the client’s self-report has underestimated actual use. The assessor can use the “past” and “present” columns to record a “Y” for the client’s response of “yes” and “N” for “no.” At times, the therapist will need to prompt the client to clarify or add information about whether the experience was in the past, present, or both. Sometimes the therapist will need to reword the criteria in language that makes sense to the client. For example, the therapist may need to explain that tolerance means “using more and more often, or in larger and larger amounts, to try to get the same high,” or that lacrimation refers to watery eyes and rhinorrhea to a runny nose. Taking notes on any details the client shares about experience of symptoms is also important for future treatment planning. Such comprehensive assessment reduces the chances that significant or serious problems will go undetected.
Psychological Consequences of Substance Use Disorders. Like many other assessment protocols, the template offered here includes a list of psychological and behavioral as well as physical symptoms of intoxication and withdrawal, also compiled from the criterion sets for each substance classified in the DSM-5. This section of the assessment template in the right-hand column (d) of Table 2 corresponds to the assessment of ASAM Dimension 3 (Emotional, Behavioral, or Cognitive Conditions). The assessor informs the client, “Now I have another list of symptoms, but the set we just discussed were more physical and this next set is more psychological – about thoughts, feelings, and behaviors.” Again, the assessor asks clients whether they have ever experienced these consequences, in either the past or the present, and records any relevant detail clients provide. Using the present template, affirmative responses are followed with the therapist’s question about whether the clients perceive that symptom as caused by alcohol or other drug (AOD) use, and “yes” and “no” responses are documented in the columns provided in the template.
The assessor can begin formulating a diagnosis by checking the extent to which the symptoms, both physical and psychological, reported by the client overlap with those indicating a disorder of use for the client’s drug(s) of choice. The review of consequences can also be utilized as a chance to educate the client about risks associated with continuing substance use. The therapist’s inquiries about psychological distress or dysfunction often yield information that will guide ongoing assessment and treatment planning. A detailed substance use assessment frequently takes sufficient time to preclude a complete diagnostic assessment of possible comorbid disorders or other concerns of clinical significance, at least in the same session. However, the assessor’s broad scope – touching on questions about depression, anxiety, irritability, memory, concentration, and the like – will help focus attention on setting treatment goals and objectives, including plans for further assessment in subsequent sessions if needed. Psychological inventories – such as instruments assessing for depression, anxiety, and other psychological complications – can also be useful in this context. Donovan and Marlatt (2008) as well as Ott and Tarter (1998) provide reviews of instruments with well-established psychometric properties and utility for assessing substance use disorders.
Client’s Risk of Endangering Self or Others. For some clients with substance-related disorders, the anger, depression, or anxiety they experience due to consequences or losses associated with their substance use lead to defeatist thoughts and/or destructive behaviors. The items embedded in Table 2, Section d, to assess for psychological conditions and complications include estimation of the client’s level of risk for danger to self or others. Violent behavior sometimes occurs in concert with excessive drug or alcohol use, probably attributable to both the mind-altering, disinhibiting properties of psychoactive substances as well as to the illegal status accorded to most drugs of abuse and to the use of alcohol under specified conditions (e.g., underage drinking, driving while intoxicated, etc.). As with any client, the admission of suicidal or homicidal ideation requires the therapist to immediately and sensitively determine whether the client has a plan of action and, if so, has the means and intent to carry out that plan. Thorough assessment of suicidality or homicidality cannot be postponed. If the therapist considers the risk to be high or a threat to be significant, the therapist is obligated to take appropriate action, advisably in consultation with a colleague or supervisor. If, on further questioning, the client actively denies intent, means, or plan to harm self or others, the therapist can still express empathy for the suicidal or homicidal thoughts the client is reporting and the feelings underlying them.
It is also worth asking whether the client’s thoughts or impulses toward hurting self or others tend to increase, decrease, or stay the same when the client is using psychoactive substances. The therapist can offer the client opportunities to learn to better cope with violent thoughts and potentially dangerous behaviors as part of the therapy and recovery processes. Confidentiality considerations in risk assessment implanted in a substance use assessment will be further discussed later. As with other aspects of the assessment, thorough documentation of risk assessment discussions is good and recommended practice.
Client Intoxication at the Time of Assessment. On occasion, substance use assessors and therapists will encounter clients who are under the influence of a drug or alcohol at the time of the interview. To detect and appropriately respond to intoxicated clients, the therapist should be familiar with the different criterion sets indicating states of disordered intoxication with each category of substances. Buelow and Buelow (1998) provided a comprehensive list of indicators of intoxication with various substances. If the client’s behavior, appearance, or odor suggests intoxication at the time of the interview, the assessor should directly inquire whether the client has used substances that day. The assessor can explain that a thorough assessment is difficult, if not impossible, while the client’s thought processes are compromised. (The assessor needs to be prepared to discuss this position with a client who counters that his faculties are not affected or are, in fact, even enhanced by substance use.) If the client denies use, the assessor may request a biological screening test. If the client admits to use, the therapist can ask that a follow-up session be scheduled at a time when the client is clean and sober (Doweiko, 2002).
If the client is too intoxicated to participate in an assessment interview, the therapist can suggest not only rescheduling assessment for a time when the client is clean and sober, but also may decide to refer the client for medical intervention or detoxification. Based on the client’s behavior, appearance, and answers to questions about physical and psychological symptoms, the therapist will need to make a judgment about whether immediate medical attention is needed. If so, the therapist can arrange for the client to contact someone the client knows to transport the client to a detox center. If that option is not available, the therapist may call a crisis center or the police to assist with transportation. Buelow and Buelow (1998) underscored the wisdom of never offering a ride to a client unless the treatment provider is trained and employed for such services. The assessor should be aware of state laws and employer policies regarding professional responsibilities when a client appears intoxicated.
Unless the client is obviously incapacitated, however, it is advisable for the therapist to spend some time talking to the client who has made the effort to come to the appointment. By engaging the client who has already shown up in the assessor’s office, the therapist can began to establish a base of information about the client, emphasize the importance of coming to future sessions sober, and educate the client about available professional services. The block of time spent in the interview also allows the client to “sober up” or “come down” before leaving the assessor’s office. It is recommended that the assessor not only schedule a second appointment for the client, but also to ask for the client’s commitment to abstain from drug or alcohol use for 24 hours prior to the next and any future appointments. This stipulation can be combined with the request that the client cancel the session if the client becomes intoxicated the day of a session. The expectation of sobriety during sessions should be reiterated and discussed at the next contact with the client.
Table 3. Template for Assessing Client Medical Concerns
e. Medical concerns
f. Treatment history
Inpatient treatment/hospitalization (incidence/outcomes)
Concurrent Medical Concerns and Treatment History. As demonstrated earlier, the client’s potential for acute intoxication and/or withdrawal (ASAM Dimension 1) can be determined from the types of questions posed in Table 2 plus the recent use questions in Table 1. Assessment of psychological complications of substance use (ASAM Dimension 3) begins with items like those in Table 2, Section d. ASAM Dimension 2, Biomedical conditions and complications, can be assessed using formats like Sections e and f of Table 3. The client’s past and current medical problems, medications, and instances of outpatient interventions or inpatient hospitalizations are all important for assessing the degree to which health issues and treatment history are likely to complicate any current substance use and treatment.
A good example is the case of Tatlyn’s pregnancy, outlined at the beginning of the section, involving multiple instances of substance use in the two months following conception. Any medical conditions that may be relevant to the conceptualization and treatment of the substance-related disorder should be noted along with the DSM-5 code in a diagnostic summary. This promotes thorough evaluation of the client’s situation and improves communication with other providers of care to the client. Assessors should facilitate appropriate referrals when the client’s health concerns or medical symptoms are outside the assessor’s own area of expertise.
Note in Section f of Table 3 that past treatment episodes may include interventions for substance use and/or mental health disorders, or for other medical concerns. It is useful to assess the client’s relationships with or impressions of doctors or treatment providers with whom the client has worked. For example, did the client inform any health care providers of alcohol or other drug use? Does the client have an established medical provider? To what extent has the client been satisfied with services received? To what extent and on what criteria does the client consider those treatment episodes to have been successful? Such exploration of the outcomes as well as the incidence of past treatment helps gauge not only the need to refer the client for medical consultation if biomedical concerns appear to be exacerbating substance use problems (or vice versa); it also helps locate starting places for planning a client’s treatment.
A substance using client who reports no past treatment interventions will require different treatment plans than one who reports successful past interventions, but is now experiencing depression or impulse control problems when faced with consequences of a past alcohol or drug use disorder. Still other motivational treatment strategies are needed when the client reports any history of unsatisfactory interventions for either substance use disorders or mental health issues, or when the client reveals current use of prescription drugs suspected by the therapist to have potentially dangerous interactions with recreational substances the client is also using. For For those readers who want more detail, formulating treatment plans is the focus of Chapter 6 in the Glidden-Tracey book on which this course is based, and of the companion course, Might as Well Face It, There's Addiction Among Your Clients: Treatment Planning, on this website, ContinuingEdCourses.Net. The point here is the importance of thorough assessment of medical and psychological history in driving subsequent decisions about treatment strategies.
In addition to biomedical concerns, the assessment of the client’s symptoms and treatment history is also intended to elaborate on psychological difficulties the client may be facing. The checklist of psychological symptoms in Section d of Table 2 has already been discussed for assessing severity on ASAM Dimension 3, but Section f of Table 3 and Section g of Table 4 also cover information relevant to psychological functioning.
Clients’ responses to Section f on treatment history, especially regarding any past mental health therapies, can augment information clients have already provided on psychological symptoms or may uncover information clients have not yet revealed, or suggest hypotheses for the assessor to pursue. Examples include clients who admit few if any psychological symptoms in the past or present, but acknowledge fairly extensive treatment histories, or clients who say that past treatment was successful yet report current psychological distress or dysfunction.
Environmental Factors Associated With Substance Use. Section g of the assessment template, in Table 4, on the environmental milieu in which the client’s substance use is occurring, provides a context in which the assessor can test or further develop hypotheses and diagnostic impressions. After introducing the topic of environmental issues, the assessor specifically questions the client about her or his residential situation, social supports, family/developmental/cultural history, educational and/or vocational status, financial factors, transportation issues, and legal concerns. Assessment of each of these areas helps target the situations and factors (a) that the client subjectively considers problematic, (b) around which the symptoms occur most intensely, and (c) which can become a focus of treatment planning and intervention. In other words, any client who indicates environmental difficulties – for example, beliefs that one’s residence is unsafe, or limited social supports, or family members with substance use diagnoses or problem behaviors – could understandably be reporting or demonstrating emotional, cognitive, or behavioral problems during the assessment. A client with a history of educational failures, financial difficulties, job losses, or legal troubles is also likely to be assessed as more severe on ASAM Dimension 3.
TABLE 4. Assessing Contextual Factors Linked to a Client’s Substance Use
g. Environmental Factors
Social support system
Family and developmental history and cultural factors
Client Motivations for Treatment and for Behavior Change. Assessment of the client’s readiness to change (ASAM Dimension 4) is saved for the end of the interview using the present template (see Table 5) because logic and experience indicate that it is most effective to gather as much standard information as possible before asking clients loaded questions like whether they believe they have substance use problems or whether they think they need help addressing problematic substance use. Two related reasons for this approach are that questions about the client’s motivation for change carry the potential to trigger client resistance, which can limit further information gathering and, more importantly, that the interview process provides opportunity to develop rapport and establish a basis of trust with the client. The demonstration of genuine interest and positive regard while gathering relevant information helps the assessor elicit less defensive responses from the client once the time has come to assess readiness to change. Therefore, assessment of relapse potential (ASAM Dimension 5) and recovery living environment (ASAM Dimension 6) is discussed as part of this assessment protocol prior to ASAM Dimension 4.
Client Relapse Potential. Despite many good intentions, once the client has presented for an assessment or is committed to therapy, relapse into old habits or former problems remains a thorny barrier for many with substance use disorders. Chapter 8 of the Glidden-Tracey book on which this course is based addresses in detail the problem of relapse and means of intervention that help clients prevent and cope with relapse. For now, assessment, both initially and ongoing, can be used to estimate how the potential for relapse is likely to be manifest for a particular client. For some clients, relapse is defined in terms of continuing substance use with its associated problems. For many others, even current abstinence from substance use does not erase the difficulties caused by their prior use, and the continuation of associated problems often begs for therapeutic intervention. In the second edition of their Placement Criteria, ASAM revised the title of Dimension 5 (Potential for Relapse, Continued Use, or Continuing Problems) from its original title of Relapse/Continued Use Potential to reflect an expanded conception of the term relapse (Mee-Lee, 2001b).
In the assessment template developed here, relapse potential is assessed in terms of substance use history (Table 1, Section b), presence of tolerance and withdrawal symptoms (Table 2, Sections c and d), treatment history (Table 3, Section f), and plans and confidence regarding future reduction of substance use (Table 5, Section h). Higher relapse potential is indicated by longer histories and greater frequencies and intensities of use, by greater recency of use, by lesser amounts or lesser success of past treatment interventions, and by lower motivations and intentions to reduce substance use.
The Client’s Recovery Environment. The client’s environment for recovery and living (ASAM Dimension 6) is a crucial factor in terms of the forces that support or inhibit any efforts the client makes to change problematic behaviors. Environmental assessment using a format like that presented in Table 4, Section g, allows the therapist to identify any aspects of the client’s situation that may threaten the client’s safety, well-being, sobriety, or efforts toward change, and to make treatment recommendations accordingly. In addition, the assessor can determine strengths inherent in the client’s environment that can be utilized to promote recovery. Discussion of both bolstering and limiting factors in the client’s environment also helps establish rapport and hope, as well as further setting the stage for treatment planning.
For example, consider a cocaine dependent client who has reported reasonable social supports and no residential or legal problems, but is facing extreme debt due to his expensive drug habit, complicated by the threat of job loss. The assessor can segue into treatment recommendations by saying something like,
It seems that improving your situation would involve addressing not only your cocaine use, but also the financial problems it’s caused, and maybe also the problems at work. Luckily, you feel you can count on some family and friends to support you, but I can also offer the option of working in therapy on how to cope with the complications in your life. In fact, the next time you come in could be used to flesh out a plan for using your time in therapy to deal with the things you see as problems.
Table 5. Assessing a Client’s Treatment Readiness
h. Motivation for Treatment
More on Assessing Treatment Readiness and Offering Recommendations. By the time assessors reach this point in the assessment, they have learned a great deal about their clients and are in the position of offering some suggestions about how therapy could be useful to the client. However, the potential utility of therapy depends, to a large extent, on the client’s willingness to partake. This movement in session from assessment of the client’s situation to presentation of treatment recommendations nicely parallels the estimation of the client’s motivation for change (ASAM Dimension 4), assessed in the present template by items in Section h of Table 5.
To increase chances that the client will choose to take advantage of the therapy option, the assessor needs to assess the client’s readiness to change and be prepared to fashion recommendations that correspond to the client’s level of motivation. Few people are willing to change a behavior they do not consider problematic, so the first question the assessor asks regarding readiness to change is whether the client perceives a personal problem with the use of drugs or alcohol. Asking the client about intentions to modify substance use behavior as well as about confidence in one’s ability to actually change behavior is also part of assessing readiness to change. Using open-ended questions with neutral wording is important. Miller and Rollnick (2002) recommended assessing the client’s perceptions of the importance of making a change and of confidence in one’s ability to do so.
Some people who perceive a substance use problem and indicate readiness to make a change believe they can do it themselves, whereas others are convinced they need external help. Some other people who do not consider their drug or alcohol consumption to be a problem may still agree that their efforts to deal with other issues in their lives could benefit from therapy. The client may see no connection between those other difficulties and the client’s substance use even though the assessor suspects a link. Still other clients will inform the assessor in no uncertain terms that they see no need for or have no interest in therapy. In each case, it is important to ascertain whether the client believes behavior change is desirable or needed, and whether clients see themselves as seeking therapy voluntarily or pressured into it by some third party. The assessor may at times concur that further intervention is unnecessary for certain clients. Yet when the assessor decides to recommend therapy, the client is more likely to be receptive when the assessor has carefully and accurately determined the client’s level of motivation for change. Motivational interviewing strategies (Miller & Rollnick, 2002) are useful in this context.
The questions posed in Section h of Table 5 help assess motivations for seeking help and for change during the initial contact with a client, and shape the form in which the assessor will present therapy recommendations to the client. The assessment of motivation for change continues to be a relevant concern beyond the beginning of treatment as the therapist plans and evaluates the course of treatment to fit the client’s expectations and efforts as the work proceeds. The art of piecing the assessment findings into the client’s treatment plan is sketched out in both Glidden-Tracey’s (2005) chapter 6 and the corresponding ContinuingEdCourses.Net course, incorporating the stage model of change (Prochaska & Norcross, 1994). This influential, transtheoretical model is elaborated below, too, because unless the assessor responds appropriately to the client’s level of readiness for change as assessed on ASAM Dimension 4, the client may not return to allow any therapist a chance to plan further treatment.
Prochaska and Norcross (1994) summarized the literature on behavior change as a process that occurs as a person moves through a series of stages from Precontemplation, in which the person is unable or unwilling to see a need for change, to Contemplation of the possibility of change, Preparation to take Action, followed by further steps for Maintenance of the change. The template presented in this section can be used as a rough assessment of the client’s stage. The assessor can then offer recommendations the assessor believes the client is likely to accept given the stage of change at which the client currently operates.
A client who denies a drug or alcohol problem or the need for change, especially in the face of contradictory evidence, is probably in the Precontemplation stage, and the assessor will need to present recommendations with this in mind. The assessor might say,
I hear you saying you don’t see a problem, and I respect your viewpoint. I also heard you say some other things that don’t quite match up with that perspective, and here’s what they are. [Assessor names any evidence suggesting a problem without yet labeling it as a problem.] So I’m not saying there is or is not a problem, but I am saying there’s a lot going on here and it seems worth coming in for one or two more sessions to talk about this some more and decide what to do about the situation. Even if we end up deciding together that there is no problem with your alcohol (or drug) use, it still sounds like (this person or that situation) is a hassle for you, and we could use our time together to figure out what you can do to make it better. Would you be willing to talk to me or to someone about this for a couple more sessions?
This “foot-in-the-door” approach validates the client’s opinion, but also offers an alternative for the client to consider as well as a limited time frame for additional contact that encourages the client to keep thinking about the alternatives without making an indefinite commitment to an unknown process.
The client in the Contemplation stage of change at the time of initial assessment is identified by affirmative answers to questions about an alcohol or drug problem and the need for change, but negative replies to questions about intentions and confidence to actually make the change occur. To this client, the assessor could say something like,
What I’m hearing is there’s one part of you that wants to change your habits and solve this problem, but there’s another side to you that isn’t convinced you can or even want to. I recognize and accept the aspect of you that doesn’t want to change, but I also encourage you to give fair consideration to the aspect that wants to improve your situation, because I believe you can. Therapy could help you sort that out. How would you feel about coming talk to me, or to someone else if you prefer, for a few weeks to weigh your options and then you will have a fuller set of information to help you decide if you want to take further action at this point?
Again, the assessor attempts to obtain a short-term commitment from the client that will permit decision-making about next steps. For clients at this stage, the decision is about whether to move toward action on an identified problem rather than about whether a problem even exists.
The Preparation stage is identified in the client who reports intentions to change, but has not yet taken active steps and may lack confidence in doing so. In such cases, the assessor’s recommendations could take a form similar to the following:
It sounds like you’re motivated to make a positive change in your behavior, and I’m glad to hear it! I also know it can be a hard thing to do at times, and I give you a lot of credit for coming this far already. Even when you feel ready and you’re starting to plan your strategy, it’s still important to have some support and a sounding board as you prepare to take those steps. Therapy can help with that. If you decide to come in for a few sessions, you and I (or your therapist) can put together a plan of action and track your progress over time.
Here the assessor offers therapy as a potential context in which the client can work on deciding how to take action.
Some clients during initial assessment report already taking direct Action toward the process of change. They will readily admit some problem associated with drug or alcohol use, and when asked if they plan to stop or reduce use, they will say they have already begun to do so. Clients just starting the Action stage are sometimes discouraged that change is even more difficult and progress more slow than they had hoped, and signs of actual improvement or success may still be minimal at best. Fears of relapse into old habits or problems are common among clients who present at this stage of the change process. With such clients, the assessor can recommend:
Therapy can provide a secure place where you can keep actively working on the changes you’re already starting to make. Yes, I can see that it’s frustrating when change is slow and not yet obvious, and the pulls back to old familiar tendencies are strong. But you decided to make this change and you’re already doing some of the things you need to do, and I’m confident that if you stick with this you will see the payoff in the long run. You can do it! How about coming in once a week to support your efforts, check up on your progress, and tighten up plans as you get clearer on what works for you?
The last stage in the transtheoretical stages of change model is Maintenance. A client in this stage presenting for assessment has not only made efforts to change, but has experienced some success and is working on keeping the momentum going and holding onto the improvements already accomplished. An example would be a client who kicked a long-standing drug habit during a period of incarceration, has not used for a few years, and is fairly confident that he will not return to drug use, but is still mandated to obtain an assessment and possible therapy by terms of his parole, and who reports to his assessor that he still struggles with managing the anger he used to blot out by using drugs. Or another who is not sure how to handle contacts with old friends who still use drugs and occasionally offer her the opportunity to do so, too. For a client at the Maintenance stage, the assessor can validate and reinforce progress achieved by the client, and can offer therapy as a means of keeping on track with goals the client has set and is continuing to refine for oneself during the long course of remission from a substance use disorder.
For each client, then, the assessor carefully conceptualizes the client’s readiness for change and willingness to engage in therapy. Accurate conceptualization depends on the assessor’s attention to the client’s present reaction to the assessment process, including discussion of immediate and longer-term needs. With clients who misuse psychoactive substances, the assessor’s determination and recommendations should account for some special factors that are likely to arise in assessment.
CONSIDERATIONS FOR ASSESSMENT GIVEN CHARACTERISTICS OF SUBSTANCE USE DISORDERS
Some clients are not honest with themselves about their behavior, whereas others intentionally downplay their substance use to avoid expected sanctions. Because many forms of substance use are illegal, because misuse of psychoactive substances is widely stigmatized, and because many with substance use disorders are ambivalent at best about giving up an inherently pleasurable habit, many clients minimize their actual use or consequences when talking to an assessor. Especially if the client is meeting the assessor for the first time at the assessment interview, or if the client feels coerced by a third party to be assessed, the client may not trust the assessor to use the information in a manner that is favorable to the client. Clients often suspect that the assessor may report them, shame them, or try to make them quit using drugs or alcohol. Many will test the therapist by feeding false information to see how the therapist handles it, or even by confronting the therapist with questions like, “Why should I tell you anything? You won’t believe me anyway” or “How do you know I’m not lying to you?”
Many substance use professionals take the stance of assuming information given by substance using clients is not entirely accurate (e.g., Doweiko, 2002). It is also crucial for the assessor to strike a balance between validating the client and entertaining reasonable doubt. Validation in this context does not entail blind or absolute acceptance of the client’s word as truth. Rather, it means letting the client know that the assessor takes what the client says seriously and respectfully, and remains open to the possibility that the client’s information is true even as competing and possibly contradictory information is being simultaneously considered. The assessor who tells the client overtly or otherwise, with no benefit of doubt, that the assessor believes the client is trying to deceive the assessor runs the risk of alienating the client. Even if that client returns for therapy to satisfy some third-party obligation, real progress in therapy will be difficult if the client does not think the therapist believes or respects the client. Likewise, if clients believe they have successfully duped a gullible therapist, those clients will probably view the therapist as incompetent.
Thus, the recommended, balanced message for the therapist to give is:
I trust you to be straightforward with me, and I also take into account any other information that’s coming to me along the way. So I believe what you tell me unless I have substantial reason to do otherwise. And then we can talk about that.
This approach tells the client that the therapist will listen carefully and try to fairly evaluate the situation, rather than jump to a snap judgment. Thus, the therapist can encourage the client to return for future sessions. This approach also buys the therapist time both to demonstrate expertise and trustworthiness to the client and in that context to glean more information to help verify or refute the therapist’s hypotheses about what is actually going on with the client.
The problem of client deception or distortion in assessment interviews points to the next two considerations in substance use assessment – the utility of multiple data sources and the necessity of data privacy considerations.
The Utility of Multiple Data Sources
The assessor sometimes has access to sources of information about the client in addition to the client’s self-report. These may include discussions with family members or friends who accompany the client to the assessment site, documents such as referrals or releases brought to session by the client or requested by the therapist, or consultations with involved parties such as medical, social service, or law enforcement personnel. Any such information should be collected with the client’s knowledge and consent. This is because a therapist is obliged to avoid revealing that an individual is a substance use client to anyone else unless certain conditions are met, as elaborated shortly.
Incorporating data from outside sources into the assessment can help verify a client’s position, or it can provide alternative interpretations of the client’s situation that help the therapist establish a base of evidence with which to confront the client if needed. Either way, using sources of information external to the client where available allows therapists to expand their conceptualizations of intervention needs and options. Attention to multiple data sources can also help identify potential barriers and resources potentially influencing the client’s progress toward meaningful change.
The Necessity of Data Privacy Considerations
The protection of confidentiality and provision of clear advice to clients on its limits are paramount in any therapy, but professionals working with substance use disorders should be aware that records on drug and alcohol treatment are held to an even higher standard of confidentiality than other mental health and medical records (Lopez, 1999). Title 42, Part 2 of the Code of Federal Regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records specifies that, to permit clients with substance use problems to address their drug or alcohol concerns in counseling or therapy without fear of legal recrimination or public disclosure, federally funded treatment programs and their therapists are prohibited from disclosing that any individual is, ever has been, or has plans to become a client for treatment of a substance use disorder except under specified exceptions. Generally, this means that a provider of assessment, therapy, or other relevant services is obligated to withhold knowledge of contact between a client and the treatment provider from any third party unless one of the following conditions applies (Lopez, 1999).
Informed Consent by Client. First, disclosure is permitted when the client has explicitly by signature waived the right to privacy through written, informed consent, in which case the release should specify precisely what information is to be disclosed, to whom, by whom, and for what purpose. Clients should be informed that they may revoke their consent at any time, by oral or written form, and a date of expiration of the release is to be included. This allows the therapist to assure the client that no information will be revealed to family members who contact the therapist with questions about the client without the client’s permission, and no authorities will be contacted if the client admits to illegal substance use unless the client wants a report to be made (e.g., to a probation or parole officer or to a judge). Confidentiality of the information disclosed remains protected by federal law, and the person making the disclosure is required to include a written notice warning the recipient against redisclosure of the information disclosed (Lopez, 1999). In cases where the client is mandated to seek therapy by court order or as a condition of probation, the client is often required by the person(s) issuing the mandate to consent to communication between the therapist and designated third parties about the client’s treatment, or to be considered in violation of the mandate (a practice that raises some ethical questions about the actual nature of consent).
Confidentiality Rights of Minors. None of the United States of America explicitly requires parental consent or notification for a minor to obtain substance abuse treatment, and 44 states plus the District of Columbia have passed legislation specifically authorizing minors to consent to confidential counseling, therapy, and medical care for substance abuse (Boonstra & Nash, 2000). Such regulations reflect established opinion that minors engaged in behaviors that put them at risk of physical or mental health complications may resist seeking care if their parents must be involved. The six states without relevant laws or policies found at the time Boonstra and Nash (2000) published their report include Alaska, Arkansas, New Mexico, South Carolina, Utah, and Wyoming.
The questions of whether a minor has the right to keep her treatment records confidential from her parents or to authorize access to her records without parental knowledge are less clear. Recent changes in privacy rules have “sever[ed] the existing link between minors’ right to consent to health care and their ability to keep their medical records private” (Dailard, 2003, p. 7). Federal regulations cited by Dailard (2003) permit minors to control their records only when states have legislated authorization for them to do so, and most states are currently mute on the subject. Under these circumstances, it is up to the provider of care to determine whether to disclose information a minor client reveals about substance use to the client’s parent(s).
Disclosure to Authorized Treatment Providers. Disclosure of client-identifying information is allowed when the recipient of the disclosure is either part of the organizational unit providing services to treat substance use disorders, or employed by a qualified service organization having a written agreement with the treatment program to refrain from re-disclosure and abide by Federal confidentiality regulations (Lopez, 1999). In either case, the information to be disclosed must be necessary to the provision of services to the client. For qualifying service organizations, the services provided should be those not available internally to the treatment program (such as laboratory analyses, accounting, legal, medical, or other professional services). All parties receiving confidential client information under such conditions are bound by confidentiality regulations to refrain from further disclosure unless allowed exceptions are in effect.
Additional Conditions Permitting Limited Disclosure. Other specific sets of conditions allow disclosure to designated persons. These include when a crime has been committed on program premises or against program staff, in cases of medical emergency (including suicide threat, drug overdose, or immediate threat of the client’s behavior to the health of another individual), or when child abuse or neglect is suspected. Such situations permit disclosure only to relevant authorities or medical personnel, and not to other third parties including family members. In the event of reporting child abuse, the discloser of a suspicion against a particular client must continue to protect the client’s drug or alcohol treatment records from further disclosure unless the client consents to or the court orders their review in child abuse proceedings against the client.
A court can order a treatment provider to disclose in court confidential records regarding treatment for substance use disorders, but only when certain conditions specified in the regulations are met. A subpoena or search warrant alone is not enough to justify identifying an individual as a client with a substance use disorder or receiving related treatment. The provider and client must be given notice of and time to respond to the application for a court order, except for the party to a crime the information sought will be used to investigate or prosecute. A court must determine that the need for disclosure in the public interest is greater than any potential harm that may accrue to the client. Even when such “good cause” for the disclosure has been established, the information to be disclosed and the persons to receive it must remain limited to that required by the stated purpose of the court order. Disclosure of confidential communication can be ordered by a court only when the information is necessary to protect against a threat to life or of serious bodily injury, is necessary to investigate or prosecute an extremely serious crime [the list of which does not contain the sale or possession of illegal drugs], or is connected with a proceeding in which the patient has already presented evidence concerning the confidential communication. In all other situations, not even a court can order disclosure of a confidential communication (Lopez, 1999, p. 6).
Disclosure of client-identifying information may also be permitted for purposes of research, program audits, or evaluations. Those who receive confidential information for any of these purposes must have established qualifications as well as plans for protection and use of the information, including obligations to avoid unauthorized redisclosure. Research uses require independent approval by a committee for the protection of human subjects.
Informing Clients about Confidentiality Protections and Limitations. The confidentiality regulations summarized earlier emphasize the sensitivity of participation in treatment for substance use disorders and the need to protect the rights of those who seek help for drug and alcohol concerns. Assessors and treatment providers are advised to let clients know up front about the provisions and limitations of confidentiality, and to find out early in the first interview whether the client plans to request disclosure of information about the assessment to any third party.
If the client says yes, the assessor should complete and explain a consent form authorizing the release of information, and discuss with the client the purpose of the disclosure, the nature of information to be disclosed, and any questions the client has about the terms and procedures of disclosure. If the client says no or expresses uncertainty, the assessor can still inform the client that if situations arise where the client or some third party requests a disclosure, the request and next steps will be discussed with the client to the extent required by law before any disclosure will be made. Some clients are not sure or even aware at the time of assessment that third-party disclosure could be requested or required, so a straightforward discussion of confidentiality issues is important with all clients for legal, ethical, and therapeutic reasons.
Client Occupational and Interpersonal Problems
Aside from frank mental health disorders, substance-misusing clients frequently present with problems in their social and vocational transactions. Excessive substance use can diminish a person’s development of, implementation of, or motivation for effective interpersonal or occupational skills. Whether the client reports using substances to cope with skills deficits or admits that substance use is contributing to an interpersonal or occupational problem, the assessor will better conceptualize and engage the client by acknowledging problems mentioned in addition to the substance use.
The assessor needs to ask questions to tease out how, if at all, the client perceives substance use to be related to problems at work, school, home, or with friends. If the therapist learns that the client is trying to blunt feelings about, or avoid dealing with, socioenvironmental difficulties by using drugs or alcohol, the client can be offered help in finding more effective coping strategies. If the assessment indicates that the client’s job or relationships are in jeopardy because of the client’s refusal to admit or inability to reduce substance use, the assessor can suggest future use of therapy as a venue to work through the vocational or relationship issues. Among other approaches, this might include looking at the extent to which the client’s substance use is in fact contributing to the acknowledged problem.
The essential point is that goals of assessment – establishing an initial diagnosis and recommending treatment – should not be conducted as if substance use is isolated from the client’s other personal or occupational concerns. When using the DSM-5 format for diagnosis, such concerns can be discussed and recorded to help document the severity of the disorder. A recommendation for therapy to address substance use disorders can certainly encompass plans to deal with interpersonal tensions or vocational problems in concert with substance use behavior. Even when the client does not acknowledge a substance use problem, the astute assessor who has just collected information about a client’s substantial history of substance use can recommend that the client think about using therapy to tackle other concerns the client has identified. The assessor can focus efforts on engaging the client through appeals to problems the client has named, trusting that if the past or present substance use is relevant, it will emerge in subsequent therapy sessions. In other words, offering therapy to address concerns other than substance use to a client who has used substances with high frequency and intensity is still a form of substance use therapy.
Appropriate assessment, diagnosis, and treatment recommendations for clients who use psychoactive substances to the point of a disorder depend on a skilled therapist or service provider. Essential skills include being sensitive to the client’s perspective and receptivity, tolerant of ambiguity and possible resistance, open to both alternative interpretations of the data at hand and to the impact of future information, and skilled at complementing various clients’ interpersonal styles. Therapists who conduct substance abuse assessments need to be aware of their own values, strengths, and limitations. Making use of supervision, consultation, and introspection, therapists learn to detect and address their own barriers to effective assessment.
A therapist who has difficulties interacting with defiant, combative, or noncompliant personalities can explore the feelings and reactions that such people elicit in the therapist and can learn to implement more productive responses to resistant client behaviors. Those with the tendency to jump to conclusions about a client’s dishonesty or lack of motivation to change can practice communicating to clients, supervisors, colleagues, and self that, although the therapist is formulating a knowledgeable opinion, the therapist is also amenable to the possibility that new information or changing circumstances can call for a revision of that opinion. Therapists who feel overwhelmed by the complexities of working with clients who exhibit substance use disorders can consider how to empower themselves to take steps to sufficiently serve those clients who do present with substance use concerns, whether that means learning more about how to conduct competent services or how to provide suitable referrals.
As therapists face up to barriers such as these, they frequently find they have capacities for dealing with hard situations and complex transactions beyond what they realized they possessed. They also encounter lessons in using self-care to prevent burnout. Learning to assess for substance use and related disorders teaches therapists much about themselves in addition to putting them in positions to make meaningful differences in the lives of their clients.
In summary, assessing clients for drug and alcohol problems involves initial screening based on hints of a possible concern, and then further assessment for persons who do not filter through the screen. Assessment involves collecting detailed personal history and environmental information to detect and properly diagnose a disorder where one is evident. If warranted, the assessor formulates recommendations about the appropriate type and level of treatment to be offered and tries to motivate the client to consider and, hopefully, accept the treatment recommendations. Continuing assessment over a course of therapy is also relevant to planning intervention and evaluating client response and progress. The utilities of the frameworks provided by the DSM-5 diagnostic criterion sets, by the ASAM Criteria, and by the transtheoretical model of change have all been demonstrated and further incorporated in this section into a template to guide therapists through the assessment interview. A continuous version of the assessment template is provided in the Appendix.
Thorough assessment and accurate diagnosis drive the development of a treatment plan customized to the client’s particular interests and needs. In the Glidden-Tracey book from which this course is derived, the link is drawn from assessed history, current symptoms, and environmental context to specific goals, objectives, and strategies to be pursued in therapy. Treatment planning is similarly covered in Might as well plan treatment: There’s addiction among your clients, .the online companion course at ContinuingEdCourses.Net.
Human use and misuse of chemical substances is a hot topic, full of controversies, with impact on numerous sectors of society. The intractable complications linked to addictive and risky misuse of drugs and alcohol make substance users a difficult population with which societies must deal. American society is increasingly turning to variations of “treatment” and “therapy” in hopes of remedying problems attributed to psychoactive substance abuse. Although, historically, treatment of substance use disorders has been isolated from other mental health therapies, increasing recognition of the utility of integrated approaches is evident. In conducting research for developing this course, I have been impressed and inspired by the number of recent publications, conferences, and clinical programs that are contributing to advancement of the field and development of more effective services.
As mental health therapists rise to meet the demand for integrated treatments for substance use disorders and co-occurring conditions, they learn to tease out their own opinions and emotions about substance use issues. They also develop an understanding of how to apply therapeutic interventions to facilitate desirable change in a substance user’s troublesome behavior. Throughout this course, I have tried to emphasize that concerns about clients’ substance use can emerge and recur in countless ways across therapy process, creating numerous choice points that therapists will need to carefully address. I have highlighted the prevalence of substance use disorders and their co-occurrence with many problems brought to therapy in hopes of convincing more therapists and trainees that capacities to assess and treat substance misuse, abuse, and addiction are essential skills. I have also concentrated on how therapists can use their understandings of the tasks and processes of assessment to encourage clients who misuse psychoactive substances to make better-informed choices about their own future behavior, including whether or not to consume drugs or alcohol.
Based on my own experience and philosophy, I have emphasized the importance of collaborating with the client to negotiate goals for therapy and strategies for moving toward them. Collaboration can be quite difficult with clients who are ambivalent at best (and hostile at worst) toward suggestions that their substance use habits may need to change in order to resolve the difficulties that brought them to therapy. Thus, attention to the interpersonal dynamics expressed in professional transactions is a crucial component of genuine collaborative efforts.
Changing problematic substance use habits is typically a challenging and lengthy process; but dedicated, consistent, and well-conceptualized therapeutic approaches utilizing thorough assessment, flexible structure, and sincere interpersonal responsiveness can make a significant contribution toward dealing with the difficult personal and social problems associated with risky substance use. I hope the reader will share in the reciprocal impact of working with these important issues as the opportunities arise.
This template can be used with clients who are new to the therapist, or with clients the therapist knows well yet for whom substance use concerns have only recently emerged in session. The template organizes a structure the therapist can use to conduct a thorough substance use assessment, but it is by no means the only format available for this task (see e.g., Donovan & Marlatt, 2008; Lewis, Dana, & Blevins, 2002; McLellan, Luborsky, Woody, & O’Brien, 1980; McLellan et al., 1992; Ott & Tarter, 1998). Readers are encouraged to use this template flexibly, in accordance with their own experiences and with their places of employment or training. The important point is for assessors to be aware of the broad range of considerations to be addressed in piecing together a picture of the client’s substance use issues. Confidentiality provisions and limitations should be addressed with the client prior to starting the assessment, and these are discussed in detail in the previous section.
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