Monthly Archives: September 2015

Counseling, football, recovery and triumph

By Bethany Bray September 28, 2015

In a life of ups and downs, football has been a constant for Chris Harris, a 34-year old limited licensed professional counselor (LLPC).

Among the struggles Harris has faced was a battle with severe depression that threatened to derail his life at a young age. Football served as a saving grace for him during some of his darkest periods — times when life didn’t seem worth living.

Chris Harris, LLPC

Harris’ example of how football can change lives for the better was featured in the National Football League’s “Together We Make Football” campaign in 2013. He was one of 10 finalists from across the United States featured in nationally televised video clips on Thanksgiving Day.

In the NFL’s three-minute video, Harris explained how football had been a lifesaver for him, in addition to providing him with an opportunity to become a leader and peer counselor on a newly established club team at Oakland University in Michigan.

When he was younger, “I couldn’t see myself living to even be 20 [years old],” Harris says, citing his struggles with alcohol addiction, depression and fitting in with peers. “Anytime I got really down, football would come knocking. That’s why I love football.”

Harris says football will always be a central part of his life, even though his playing days may be behind him. He graduated from Oakland University this year with a master’s degree in counseling.

Harris wants to build a platform from which he can reach people who are wrestling with some of the issues he has struggled with, including depression, anger, alcoholism, bullying and finding focus and direction in life.

He has established a private practice and hopes to eventually specialize in sports counseling and youth development and mentoring. He would also like to become a public speaker.

“I’ve always had a natural passion for helping people,” he says. “With my personal experience with mental illness and trauma, I know how that impacts people. … I have a passion to be a bridge builder.”

When Harris speaks about the potential for recovery and triumph, it’s personal. Counselors should never underestimate the power of growth and development to change a person’s life, he says.

“Even if a client doesn’t see it in that moment, have the vision of them yourself growing and developing to achieve the life that they want for themselves,” he says. “As a counselor, make sure you maintain that vision of them getting healthy, recovering and achieving the triumph that they would like, because it is possible.”

‘I would have never imagined myself being here’

The 6-foot-5-inch Harris played football as a youngster growing up in Detroit. At age 19, he made the roster of the Motor City Cougars and played semi-professionally for four years.

Playing with the Motor City Cougars pulled him out of a downward spiral he fell into after high school, including a bout of depression, alcohol dependency and grief over the death of his grandfather.

He fell into another dark depression in 2009 when he was six months shy of earning an undergraduate degree in social work at Wayne State University in Detroit.

Although his 2009 mental health crisis was as a breakdown, it also marked a breakthrough for him, Harris says. Since that time, he has been able to rise above his struggles and make a 180-degree turn, he says.

He has completed bachelor’s and master’s degrees at Oakland University, where he also was a leader on the school’s club-level football team.

“At my darkest time, I would have never imagined myself being here,” says Harris, a national certified counselor (NCC). “But guess what? I did the work, I sacrificed, I made the decisions, and it happened. I know it sounds cliché, but if I can do it, anybody can do it.”

Harris is starting a yearlong internship this fall with Michigan College Access Network, an organization that works to boost the percentage of Michigan residents who go to college. The organization places particular focus on students from families with low incomes and students who would be the first in their families to seek postsecondary education. Harris will be working in a local high school, where he will advise students on everything from choosing a college or academic major to applying for financial aid.

James Hansen, a professor and coordinator of the mental health specialization within Oakland University’s counseling department, describes Harris as a bright, warm, accepting and curious person.

“He glows with those qualities, and his clients will certainly benefit from that, as [will] the others in the counseling profession he encounters,” says Hansen, who is a member of the American Counseling Association.

“I admire his courage,” Hansen says of his former student. “His own journey informs his empathy and his ability to be an excellent helper. … He has a sincere desire to help others. I admire what he’s gone through.”

Trust and team building, on and off the field

Much like football, counseling is based on building relationships and trust with those you work with, says Harris. The relational aspect of counseling is what ultimately drew him to the profession, he says.

“[Counseling] has techniques and theories. However, it’s all about the relationship, the therapeutic alliance,” he says. “I feel in my heart that it’s the truth – relational health is central.”

As a counselor, Harris would like to work with athletes – a natural fit with his personal experience and with the profession’s relational approach.

“I understand the mentality of an athlete,” he says. “The same things that make them successful on the field of play can get them in trouble off the field – aggression, being strong, being a leader. It’s difficult for athletes to channel that in the right way. You can’t get rid of it (anger, competitiveness, etc.). It’s what you do when you’re angry that gets these people in trouble. I’d like to use my experience as a platform.”

Athletes are hard-wired to understand the give-and-take, trust and relationships that are part of being a tight-knit team, Harris explains. Counselors can leverage these skills when working with clients who are athletes, he adds.

Athletes will especially understand and respond when given a finite task or job to do, Harris says, because that’s what they’re used to in team sports. For example, athletes are used to having to go home and learn their playbook, he says. In counseling, this could translate to the “homework” assignments that counselors often give to clients, such as journaling or communication exercises.

“In sports, you’re used to a script [or playbook], following directions and doing your job,” Harris says. “If [a counselor] can sit down with an athlete, or anyone, and lay the foundation for the relationship to gain and earn their trust – after that, your counseling skills, the ability to sense patterns, read body language, etc., will benefit.”

“Counselors should listen first. Listen to your client speak about what inspires them, what drives them and what they desire,” he says. “Once you’re comfortable and know the client well enough, then you can begin to engage them from that perspective. Bring their struggle back to their strengths.”

****

Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

From the President: Reaching milestones

By Thelma Duffey September 25, 2015

Thelma Duffey, ACA’s 64th president

The Rolling Stones were a popular group when I attended my first junior high school dance. My memories of the dance are good ones, complete with great music and good friends. I remember spending that day picking out my outfit, listening to music and counting down the hours until my friend, Paul, and his mother arrived (yes, she drove us there!). This is a fairly common recollection of a young girl’s early Wonder Years-esque experience with new friends at a new school. As far as adolescence goes, it was a central developmental milestone in my life.

As counselors, we know such milestones do not arrive easily for every young person, nor do all children get the opportunity to enjoy them. This is sometimes the case for children suffering from serious medical illnesses or who have special needs. And yet, when these opportunities are possible, as they were for Allen, a pretty incredible young man with whom I once worked, they can be impactful for all involved. Allen suffered from a debilitating brain tumor, and reaching the milestone of attending a school dance was exceedingly exciting — for him, for his family and for me.

About 25 years after I attended my own first dance, I was working with Corina, a young girl with spina bifida, who invited me to another truly memorable dance event. This dance was sponsored by a local university and a spina bifida organization. That weekend, I spent time with a group of folks who, in addition to being wonderfully bright, friendly and a whole lot of fun, left an indelible imprint on my mind and in my heart.

I came across pictures of Allen and Corina the other day that brought back so many memories. With a cane in one hand and a date by his side, a dressed-up Allen, complete with suit, tie and boutonniere, was beaming. Corina’s picture also showcased an animated smile, and I can still remember how excited she was when the day of the dance finally arrived.

At this point in our profession’s development, we have made tremendous strides with respect to information and education related to working with children with special needs. Thankfully, our information base continues to grow. Through advocacy and education, the American Counseling Association and its divisions such as the American Rehabilitation Counseling Association do a wonderful job of supporting counselors in their work and empowering people with different abilities. ARCA, a long-established division of ACA, focuses on expanding opportunities in employment, education and leisure activities, while also increasing legislative action and public awareness on these issues. If you are interested in learning more about how to provide effective and skillful rehabilitative counseling services and sharing your own knowledge and experience, ARCA (arcaweb.org) is an excellent resource. You can also read Counseling Today‘s article about counselors who help children and families with special needs.

We all have stories to tell, and today I have shared some of my own. Our stories remind us of the important people who helped shape us. Our stories connect us with the times in our lives when we made important decisions and when our passions were ignited. Our stories can also inform and inspire our next steps. I am excited by the next steps we are taking as a profession. I am inspired by our focus on social action and advocacy. And I am encouraged to know that if we — as counselors coming together — unite and invest, we can make a notable difference in many stories that are yet to be told. Will you join me? I hope so!

Wishing you all the best,

CEO’s Message: Give it up for our unsung heroes

By Richard Yep

Richard Yep, ACA CEO

We need only to open a newspaper, tune in to the nightly news on TV or visit a website highlighting the day’s news to learn about amazing people who consider themselves ordinary but do extraordinary things. I’m not referring to athletes who set new records or titans of business who command salaries in the millions. Nope, I’m talking about those in the helping professions who go to work each and every day and do their best to help clients, students and communities with the challenges of life.

In previous columns, I have shared with you the trials, tribulations and successes of your peers. Specifically, I want you to think about your colleagues who do what they do not for notoriety but because they want to help those in distress. Whether it is giving guidance to adults who are navigating career challenges, offering help to LGBTQ teens who just want to live their lives or providing service to returning veterans who are having difficulty adjusting to civilian life, ACA members play critical roles in their communities. And they do so without fanfare.

As ACA past president Sam Gladding has said, these counseling professionals really are “unsung heroes.” I couldn’t agree more. As many of you know, the ACA Foundation annually recognizes someone with the Samuel T. Gladding Unsung Heroes Award. Last year’s recipient, Bob Schmidt of Connecticut, was recognized for his amazing commitment to the survivors of the Sandy Hook Elementary School shooting. Bob has worked tirelessly with the school, the community and other service organizations to ensure that those in the town where the shooting occurred could begin to rebuild their lives.

I am fortunate to work for organizations such as ACA and the ACA Foundation because it allows me to observe and interact with such selfless individuals. Through my work, I am reminded of the tremendous efforts of our members and leaders. I also realize that we need to do more to ensure that there is “care for the caregivers” as well.

As the charitable and supporting arm of ACA, the ACA Foundation has acknowledged that it will continue to develop these resources for professional counselors. An example of this effort is the ACA Foundation’s flagship publication, Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding. This publication, now in its third edition and edited by Jane Webber and J. Barry Mascari, was first released shortly after the 9/11 terrorist attacks. The latest edition reflects the dramatic growth in knowledge and experience within the field. In addition to caring for the caregiver, the publication addresses compassion fatigue, secondary traumatization and debriefing strategies to aid those on the front lines of disaster relief. The resource also offers lessons learned, crisis plans, step-by-step protocols, treatment strategies and insights from experienced professionals.

From my vantage point, we all need to continue supporting the ACA Foundation and the good work it is doing. I know that as many of you begin looking toward the end of the calendar year, you start to think about the charities that have had meaning and impact in your life. For this reason, I will once again be making a contribution to the ACA Foundation. I hope you will join many of your fellow ACA members and do the same. Just think: If each ACA member gave $5 (for the year, not the month — although that would be nice!), we could have an incredible impact on the development of resources that support professional counseling’s unsung heroes.

I encourage you to go to the ACA Foundation website at acafoundation.org and click on the “Donate Now” button. As I said, if we all contribute even a small amount this year, the collective good will be felt throughout the profession.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800.347.6647 ext. 231 or email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.

Attending to tummy troubles

By Lauren Mirkin September 24, 2015

Most of our clients come to us for help with relationship difficulties, work-related stress, persistent anxiety, chronic depression or other well-researched and commonly encountered challenges. Most of us feel that our education and experiences have effectively prepared us to deal with these conditions. Armed with a time-tested array of evidence-based strategies, we confidently set out to help our clients work toward productive relationships, satisfying work experiences and greater equanimity.

But in talking to other counselors, I have found that many of them feel ill equipped to help clients who present with more physically based concerns that are interfering with their quality of life. What about clients who are frequently late to work or don’t feel they can go out with friends because they never know when they will need to find a bathroom immediately? What about the 25-year-old client who has a little-known condition called gastroparesis? How would you help her balance the need to puree or blend all of her food with her desire for an active dating and social life?

The previous examples illustrate a cluster of disorders known as functional gastrointestinal disorders, or FGIDs. These are problems marked by persistent, recurring symptoms — such as gas, bloating or loose stools — that result from abnormal function of the gastrointestinal (GI) tract without any underlying physiological problem such as a growth or hormone imbalances.

How can counselors help? There are several ways.

Clarify and validate: Many clients with FGIDs are sent to a therapist by their medical practitioners when medication, procedural or surgical treatment options have not helped or are not indicated for their condition. The unspoken message is, “I, as your doctor, cannot find anything medically wrong with you, so it must be in your head.” The subtle — or sometimes not-so-subtle — implication is that this person has stomach troubles because she or he is so stressed out and overwhelmed by life.

Medical professionals do not often educate patients about the nature of FGIDs or point out the existence of evidence-based psychological treatments that may help them manage the condition. Mental health professionals, on the other hand, have a different view. Psychologist Barbara Bradley Bolen, author of the book Breaking the Bonds of Irritable Bowel Syndrome, writes, “Despite the prevalence of IBS [irritable bowel syndrome], most people feel fairly alone in their suffering. The effort to cover up symptoms and the corresponding feelings of shame and embarrassment can serve to further exacerbate those very symptoms and the discomfort that goes along with them.”

To help clients over these difficult feelings of doubt, counselors can work to validate and normalize clients’ symptoms and experiences, educate them about the nature of FGIDs and suggest strategies to help alleviate their suffering. I have had clients who have broken down in tears of relief during our first session, happy that they have finally found someone who understands what they are going through and who is prepared to offer workable solutions to ease their distress and misery.

Acknowledge the mind-body aspect: In their groundbreaking book Trust Your Gut, physician Gregory Plotnikoff and health psychologist Mark Weisberg write about the new science of psychoneuroimmunology, the study of mind-body interactions. Their work reflects a growing recognition in recent years among medical experts of the interconnectedness of the body and mind. They write, “We approach the treatment of gut issues from the premise that the mind and body are all part of an integrated system. … The most surprising insight is that our brain does not distinguish between what is physical and what is psychological. It creates the same neurohormonal responses either way. This new perspective allows a completely different way of looking at the problems of gastric distress. More important, it makes it possible to find new solutions.”

Many clients and, unfortunately, many medical professionals, think only in a linear and one-dimensional way about FGIDs. Here is a common line of advice offered by doctors: “First, try medication. Then add fiber or a fiber supplement. If that doesn’t work, go to a dietician so she or he can ‘fix the problem’ by providing a regimen of food restrictions.” The flaw in this approach is that a functional disorder always has both physical and psychological components.

In addition to being a licensed clinical professional counselor, I am a clinical nutritionist. In that role, I help patients with supplement or dietary recommendations that may be indicated for their FGIDs. When wearing my counselor hat, however, I have seen firsthand how some clients with FGIDs feel embarrassed about being encouraged to seek out a mental health professional for what they perceive to be a physical problem. Therefore, it is important to help clients understand that FGIDs, like many other health problems, are multifaceted and must be approached from various angles, including the angle of mental health. By looking at the problem in this way, clients ideally will come to understand that the mental health professional may be only part of the solution and that their nutritionist, physician and perhaps other team members might have roles to play as well. In the great majority of cases, a team approach is most effective.

That said, counselors who are trained in empathic listening and who practice Carl Rogers’ unconditional positive regard can be hugely beneficial to clients with FGIDs. Many of these clients have been talked down to, lectured at and even blamed for their gastro distress. Many have been told it is all in their head and that they are simply too stressed or overwhelmed. Many have felt attacked or accused by family members, friends, colleagues or health professionals. A counselor who is paying attention with compassion, seeking to understand the person’s discomfort and attempting to connect both emotionally and cognitively with the distressed client can be a wonderful catalyst, providing the healing space needed to help the client begin to get well.

Teach self-monitoring skills: Within the therapeutic relationship, the counselor can provide information to help destigmatize the FGID, which reaffirms for the client that it is perfectly normal to feel stressed about symptoms that seem unresponsive to medical treatment. Additionally, counselors can play an important role in helping clients establish an effective and personalized style of self-monitoring that will aid them in developing more insight and objectivity related to their condition. This is valuable in helping clients identify factors that increase or decrease their symptoms. Self-monitoring in this way can be analogous to using worksheets or logs to help a client with depression or anxiety. Margaret Wehrenberg, in her book The 10 Best-Ever Depression Management Techniques, recommends identifying triggers as the first technique to use with clients who are struggling with depression. A similar approach, applied in the context of the steps mentioned previously, may be appropriate for FGIDs.

Jeffrey Lackner, a research psychologist at the University of Buffalo Behavioral Medicine Clinic, has written a self-help book called Controlling IBS the Drug-Free Way in which he suggests that clients first track their symptoms in a daily IBS diary. Specifically, he recommends that clients should note when symptoms occur and what triggers them. In addition, he recommends that clients use a daily stress worksheet to write down stressful situations, thoughts related to what was happening during the situation and techniques that were used to cope. He believes it is important for clients to monitor their symptoms for several reasons. “Tracking your symptoms will help you identify more subtle triggers of your symptoms and how you respond to them,” he writes. He then adds, “Monitoring creates a little distance between you and your symptoms so that you can see the big picture more clearly.”

Recommend relaxation training: Another way counselors can support these clients is by introducing, demonstrating and helping to monitor a regular program of relaxation training. Lackner suggests controlled breathing, muscle relaxation and visualization exercises.

Many clients with FGIDs have a chronically activated fight-or-flight stress response. As Lackner writes, “Diaphragmatic breathing … activates the part of the nervous system that puts a brake on the fight-or-flight response. It’s impossible to be physically relaxed and stressed at the same time, so that by controlling your breathing patterns you override the physical part of stress that can aggravate bowel symptoms.”

The authors of Trust Your Gut also include relaxation in their programs and recommend that patients work on getting grounded, a term they define as “being calm, centered, relaxed and focused.”

Offer or recommend hypnosis: Counselors can also assist clients with FGIDs through the use of hypnosis. Clinical psychologist Olafur Palsson, an expert in hypnosis for gastrointestinal disorders, writes, “Clinical hypnosis is a method of inducing and making use of a special mental state where the mind is unusually narrowly and intensely focused and receptive. In such a state, verbal suggestions and imagery can have a greater impact on a person’s physical and mental functioning than otherwise is possible.”

Palsson also states that during the past 15 years, research has shown that hypnosis can influence gastrointestinal functioning in powerful ways and is particularly effective in helping patients with IBS. In a study at the University of Sweden, for example, researchers found a 40 percent reduction in symptoms of IBS and observed long-term relief even for the most severe symptoms. What intrigued the researchers was not only the high percentage of patients who got relief but also the cost-effectiveness of the intervention. The hypnosis sessions took place in a regular health center, so there was no need for patients to attend a specialized treatment center.

Palsson offers an encouraging outlook on hypnosis for gastrointestinal functioning: “This benign and comfortable form of treatment will hopefully become a more popular treatment option for GI patients — especially for those who have not received much relief from standard medical management.”

Offer cognitive behavior therapy: Charles Burnett, nationally known for his work with patients suffering from chronic illness, says, “Cognitive behavioral therapy [CBT] is not a cure for functional gastrointestinal disorders, but the tools and skills developed during therapy can dramatically reduce the stress of coping with a chronic condition.” Importantly, Burnett points out, “CBT helps to shift functional GI symptoms to the background, so patients can experience decreased depression, reduced anxiety and improved quality of life.”

Furthermore, in a 2013 review study published in the World Journal of Gastroenterology, the researchers concluded, “There is increasing evidence for the efficacy of CBT in alleviating the physical and psychological symptoms of IBS, and it has been recommended that it should be considered as a treatment option for the syndrome.”

Note that studies have found not only psychological benefits from CBT but physical ones too. Again, the mind-body connection is paramount. Here’s an example of how this can play out: Many people who suffer from FGIDs worry about finding a bathroom in time to avoid an embarrassing accident in public. CBT can give these clients tools to help lessen their stress, which in turn may ease their actual physical symptoms.

In particular, CBT is often used in cases of IBS — one of the most common forms of FGIDs — because it enables clients to overcome cognitive distortions related to their symptoms. To help clinicians recognize all-or-nothing or absolutistic thinking, Bolen offers the example of a client who maintains the irrational thought that her symptoms are completely unpredictable and unmanageable. Bolen suggests that once this person learns to identify triggers, she will better understand when and how her IBS is likely to manifest, and she will be better equipped to deal with the unpleasant symptoms.

Most counselors are trained in the basic tenets of CBT and should be able to effectively help FGID sufferers with this therapy. In recognition of this, a 2007 review article in Psychosomatics emphasized the “great need” for FGID behavioral specialists.

Conclusion

My hope is that as a result of this article, counselors will feel more confident in helping clients with FGIDs by drawing upon evidence-based therapies ranging from relaxation training to CBT. It is gratifying to know that we possess the knowledge, training and skill to help alleviate the suffering of those coping with this debilitating and frequently misunderstood health condition.

****

Lauren Mirkin is a licensed clinical professional counselor and licensed dietitian/nutritionist. Contact her at laurenmirkin@gmail.com.

Letters to the editor: ct@counseling.org

SBIRT: Identifying and managing risky substance use

By Mallori DeSalle and Jon Agley

The mental health workforce in the United States is a leader in mental health and substance abuse treatment innovation. Currently, the vast majority of treatment focus is on the relatively small portion of the population that is substance dependent, but those with an “at-risk” level of use may go untreated. Only 5 percent of the U.S. population meets the requirement for alcohol and drug dependence, while more than 20 percent of the population fits into the “risky” or “harmful” drinking or substance use category.

Screening, brief intervention and referral to treatment (SBIRT) is an emerging clinical practice in which health care or mental health care providers can intervene with patients/clients who exhibit problem alcohol or drug use that does not fit into dependence categories. To provide these services and interventions, individuals and organizations utilizing SBIRT attempt to cast a wide net around 100 percent of their target population using a universal screening process that is appropriate for everyone. SBIRT does not replace treatment; instead it uses clinically tested questions to determine individuals’ level of substance use and then matches them with the appropriate amount of care. For example, individuals who use alcohol at a risky, but not dependent, level might undergo a “brief intervention,” a process involving a five- to 15-minute conversation that guides a person toward the reduction of risky or harmful alcohol use. Individuals who use alcohol at a dependent level might be referred to inpatient treatment instead.

The primary focus of this article is to provide exposure to the process of SBIRT and to inform clinicians on their role in this preventive process.

Historically, high-risk substance use has been associated exclusively with dependence and addiction. In other words, it was believed that only individuals who were dependent on substances experienced harm as a result of their use. Terms such as “alcohol and drug problems” are associated with extreme consequences of substance use, including addiction. Stereotypical images, such as the homeless man drinking out of a bottle contained in a paper bag, have also been attached to long-term substance abuse.

Not all risks associated with substance use are extreme, however. Furthermore, problem substance use cannot be identified simply by looking at a person, and it isn’t limited to individuals with long-standing addictions. Harm from substance use can occur in a much wider spectrum.

Contrary to the historical unitary view of addiction, the range view on substance use suggests that all substance use has a level of risk and that harm or consequences can occur even before a person is dependent. For instance, hangovers, arguments with friends or family, or even overspending are some of the small consequences that may result from problematic substance use. These consequences are often related to the frequency and amount of use.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has formally defined level of risk based on the number of drinks consumed on each occasion and week. Men who consume more than four drinks and women who have more than three drinks in a single occasion are drinking at an at-risk level. Binge drinking is only one of many behaviors that can capture a risky or harmful level of drinking or drug use. Although not every person meets the criterion for dependence, he or she may still benefit from exploring the meaning of at-risk use.

SBIRT is a process that can be used to increase client awareness and normalize the process of examining how alcohol and substances are incorporated into each person’s life. SBIRT often involves a conversation intended to review the level of risk associated with an individual’s frequency and amount of use. The process involves a short screening that suggests the level of treatment or intervention the clinician should provide. In some ways, the screening component of SBIRT serves as a filter that quickly points out the client’s needs (based on level of risk) and gives counselors an access point to start discussing change from the beginning of the relationship.

Tier 1: Screening

SBIRT features three distinct tiers. As with most mental health services, screening is the first tier because this aspect of the process is universal (meaning for everyone). Mental health professionals have been highly trained in client/patient evaluation for the purpose of diagnosis. Every graduate program accredited by the Council for Accreditation of Counseling and Related Educational Programs includes several classes that help build a clinician’s skills for using screening tools to assist in determining a client’s diagnosis. On-the-job training adds to clinical skills in using biopsychosocial assessment tools during the intake process. All of these assessment experiences are geared toward diagnosis.

SBIRT provides opportunities for clinicians to extend this traditional practice of assessment by using short, nondiagnostic screening tools as an introduction to a specific conversation. Whereas the outcome of the screening in traditional assessment is a diagnosis, the goal of screening in SBIRT is to identify each individual’s level of risk and explore how this knowledge may inform future change.

A wide variety of tools are available to assess risk levels for alcohol and substance use. The Substance Abuse and Mental Health Services Administration (SAMHSA) currently recommends two tools that are commonly used to screen for risky and harmful alcohol and drug use: the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test-10 (DAST-10).

The AUDIT, a 10-question screening tool created by the World Health Organization, is both brief and highly sensitive to the level of risk stemming from alcohol use. Topics covered in this tool include frequency of drinking, amount of use, level of difficulty stopping, concerns about the individual’s use as mentioned by friends or family members, and other consequences of drinking. This tool offers an opportunity to look back at specific behaviors that cause concern when an individual’s score indicates a harmful level of drinking. The DAST-10 is another flexible screening tool that is easy to administer. It can be used to screen for any substance use other than alcohol, including nonmedical prescription drug use.

The intent of these tools is not to reach a diagnosis but rather to start a conversation. The screening tools inform how the clinician will proceed with the client in discussing potential future behavior change. When a client’s screening results indicate low-risk behavior, the outcome is a “negative” screening. This means the client is not in need of ongoing services to address the level of risk. The clinician would affirm these clients and encourage them to continue with their positive behaviors or provide them with additional information to support their ongoing success.

A screening that results in a “positive” score is indicative of risky/harmful or dependent levels of use. Each range of positive scores directs the next step in SBIRT. A score in the moderate range on the AUDIT indicates that a brief intervention is appropriate, whereas a higher score may indicate the need for referral to treatment. Low DAST-10 scores indicate the need for a brief intervention, whereas moderate and high scores indicate the need for referral to treatment. In general, positive scores on either the AUDIT or the DAST-10 lead to a short conversation between the clinician and the client about the results. The screening results determine the intensity of the conversation.

Tier 2: Brief intervention

Brief intervention is the second tier of SBIRT. Typically, it is used only with individuals who have a positive screening. Each brief intervention is a five- to 15-minute conversation, ideally held at the time of the screening, that guides the person toward the reduction of risky or harmful alcohol or drug use.

Brief interventions are used to address only the targeted behavior change. In other words, the intervention is geared only toward lowering the risks related to alcohol or drug use. Rather than being a full treatment plan on its own, a brief intervention offers an opportunity to begin a conversation about change that then could be added to the treatment plan or monitored periodically without being a formal part of a treatment plan. Motivational interviewing is the key component of each brief intervention.

Motivational interviewing is a person-centered style of communication that addresses the common issue of ambivalence about change. The following general guidelines for motivational interviewing will increase success with brief interventions.

Use reflective listening skills. Use open-ended questions, affirmations, reflections and summaries to support your client’s discussion with you. Reflective listening is a helpful tool to support client autonomy and reduce ambivalence.

Resist the “righting reflex.” We must fight our reflex as clinicians to support only the “right” change. Supporting clients as they work toward change is important.

Understand and explore the client’s motivations. Through active listening and guidance, you will hear what values and desires your client has for his or her existing behavior and future changes.

Listen with acceptance. Acceptance includes empathy, autonomy, affirmation and absolute worth. Our clients feel understood when we can demonstrate that we understand their perspective.

Empower the client. Using a judgment-free perspective that partners with your client will support change. Partnership is key.

Brief interventions are composed of several specific steps:

1) Establish rapport

2) Elicit thoughts and provide feedback

3) Enhance motivation

4) Negotiate a plan

Step 1: Establish rapport

Counselors will find this step relatively simple. Most clinicians have been trained to build rapport with their clients.

Ask permission to raise the subject of drugs and alcohol. Giving your clients personal autonomy to respond to the questions is powerful. This often leads to increased trust and honesty.
Remain nonjudgmental and accepting. Your clients may share a range of topics with you, and providing the right level of empathy can help them feel comfortable.

Step 2: Elicit thoughts and provide feedback

Clients’ values and considerations about their personal alcohol and substance use can be elicited by looking at the pros and cons of use.

Ask clients how they feel about their current level of use and how drugs or alcohol fit into their life.

a) Elicit things that they like about their use.

b) Invite clients to talk about things that they don’t enjoy or like less about their level of use.

c) Summarize the pro and cons in the client’s own words. Be sure to capture everything.

Next, give feedback that is specific to your client’s thoughts and values, and add some information in the form of feedback. Many clients have never considered the ranges of use, other than addiction, that could result in harm. Though often overlooked by clients, small problems such as headaches, sleep disturbances or being late to work may be a result of substance use. Your conversation about the range view of alcohol use may be the first time that a client has heard about low-, moderate- and high-risk drinking.

Request permission to provide feedback.

a) Look at the responses and the low-risk guidelines together. Compare how your client’s level of use looks compared with the low-risk guidelines. (NIAAA offers this information for alcohol at niaaa.nih.gov.)

b) Link the level of risk, and present concerns that may be related.

c) Ask your client for his or her thoughts about this information.

d) Use photos or images to make this comparison easier.

Step 3: Enhance motivation

In the third step of the brief intervention process, clinicians support the building of clients’ readiness and motivation for change. It is likely that clinicians have heard many reasons that change would be possible for clients (change talk) and other reasons that would make change difficult for clients (sustain talk). Focusing on a client’s change talk while accentuating the positive may soften the sustain talk and increase the frequency with which a client expresses thoughts and ideas that are in line with some movement toward positive change.

Use a readiness ruler (see image below) to discuss readiness, importance and confidence.
Elicit additional reasons for change.
Identify client strengths and supports.
Ask why a change (even a small change) would be important to the client.
Offer affirmations.

Giving an affirmation of your client’s intention and effort can be an important tool to build confidence at this stage of the conversation. When an individual starts to shift his or her thoughts and statements toward positive change, a clinician can shift focus and begin to discuss what steps to take toward behavior change.

Step 4: Negotiate a plan

Goal setting is the final part of the brief intervention. Setting small, realistic and measurable goals is important in order for our clients to find success in any change process.

Identify high-risk situations for drinking or drug use, as well as possible coping strategies.
Ask for specific steps.
Write the steps down (ask clients to do the writing).
Summarize all of the ideas and the specific steps.
Arrange for follow-up as needed.

Some individuals who receive brief interventions may also be examining plans for accessing additional services. These individuals may not be able to address their substance use changes without the support of specialized treatment.

Tier 3: Referral to treatment

Referral to treatment, the third tier of SBIRT, is designed specifically for individuals who would benefit from more specialized services for alcohol and drug treatment. Individuals who score in the high-risk categories typically need additional services beyond brief interventions. Although brief interventions are shown to be effective for minimizing risk, current evidence indicates that individuals whose screening scores are at the higher end of the continuum for either alcohol or substance use may need additional services to facilitate behavior change. These individuals often would meet the diagnostic criteria for dependence and can be referred to appropriate services as a result of receiving this screening process.

Settings and structure for SBIRT

It is recommended that the full SBIRT process, from screening through clinical intervention and referral to treatment, take place annually with clients. Whether individuals have a low level of risk or report higher levels of use, examining this information on a periodic basis gives clients an opportunity to consistently understand how substance use plays a role in their lives.

Annual screening may seem infrequent to those of us in the counseling profession, but it is important to remember that SBIRT is designed to be implemented and utilized in locations that are not explicitly designed to address substance use (for example, primary care offices). In fact, this process is highly adaptable and can be formatted to fit a variety of settings for mental health professionals. SBIRT has been used in health care, mental health, substance abuse treatment, judicial, employment, education and welfare settings, among others.

Because the premise of SBIRT is to provide universal screening to identify and assist with risky, harmful or heavy/dependent alcohol or substance use, it is sensible to use SBIRT in “opportunistic” settings where individuals are already present. At the same time, the personnel who can be trained to effectively deliver SBIRT or assist with its implementation vary widely and include physicians, nurses, social workers, counselors, police/probation officers, clergy and teachers.

Mental health and substance abuse treatment professionals are most likely to be exposed to or be a part of the SBIRT process in two primary instances. The first is when SBIRT services are implemented in a nearby referral source (for example, a health care organization or other community service organization). In this circumstance, SBIRT services within a community may increase referrals to community mental health and addiction treatment services.

The second instance involves the implementation of SBIRT within mental health and substance abuse treatment itself. SBIRT could take place in a variety of existing intake or treatment review processes. Intake and assessment are natural places for SBIRT to be added. If a client screens positive for risky alcohol or drug use, it would give the clinician an opportunity to add objectives and goals to the treatment plan to lower the level of risk. Treatment plan reviews or the completion of annual paperwork offer other opportunities to check in with clients about substance use.

Taking steps toward SBIRT

SBIRT works to lower risks associated with alcohol and substance use. Adding SBIRT to existing programs could strengthen the reach of clinical and preventive services for all clients. This process can be integrated seamlessly into any existing assessment and treatment process. But, as with any change asked of our clients, SBIRT means changing your organization’s procedures too. Discuss this opportunity with your clinical and administrative supervisor to determine if SBIRT is a good fit for your organization. Training and support materials for organizations and clinicians ready to implement SBIRT are available through SAMHSA.

For more information about how to get started with SBIRT, visit indianasbirt.org.

****

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Mallori DeSalle is a research associate in the School of Public Health at Indiana University-Bloomington, a licensed clinical mental health counselor, a member of the Motivational Interviewing Network of Trainers and the outreach coordinator for Indiana SBIRT. Contact her at mdesalle@indiana.edu.

Jon Agley is an assistant scientist in the School of Public Health at Indiana University-Bloomington and the project evaluator for Indiana SBIRT.

Letters to the editor: ct@counseling.org