Tag Archives: Substance Abuse & Addictions

Behind the Book: Q&A with Ford Brooks and Bill McHenry on substance use and addiction 

October 19, 2023

A image of a support group with two younger people facing an older man; beside the image is the cover of the third edition of A Contemporary Approach to Substance Use Disorders and Addiction Counseling

Monkey Business Images/Shutterstock.com

Substance use and drug overdoses have significantly increased since the start of the COVID-19 pandemic. The rising need for mental health and addiction services led co-authors Ford Brooks and Bill McHenry to publish a third edition of A Contemporary Approach to Substance Use Disorders and Addiction Counseling. The revised edition stresses the need for counselors to unlearn their biases regarding substance use and the importance of working from a multicultural framework. It also includes new sections on harm reduction strategies, medication-assisted therapy and the use of telebehavioral health therapy in treatment.  

“One of the main reasons we wrote this text is to encourage readers to more fully engage in the helping process with clients with an SUD [substance use disorder],” say Brooks and McHenry in the first chapter of the book. “We hope to help you avoid our mistakes and to provide you with informative and creative approaches to working with this unique population of clients.” 

Counseling Today spoke to Brooks, a professor of counselor education and director of the Growing Edges Community Clinic at Shippensburg University of Pennsylvania, and McHenry, an associate professor of counseling at St. Edward’s University, to learn more about this revised edition.  

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How did the COVID-19 pandemic affect substance use and mental health treatment in the United States?  

Bill McHenry headshot

Bill McHenry: The pandemic brought on challenging issues related to this field, including online support, ways of coping with boredom (a huge risk factor) and the increase of use by individuals who did not previously meet the criteria of substance use disorder.  

We have also seen an increase in the use of online counseling, support groups and contact with individuals (e.g., sponsors) in this population. These are most likely positive and useful new additions to existing treatment modalities. For example, the increased use of technology allows clients to attend online support groups that may be too far away to travel to in person. 

How can counselors uncover and address their own biases regarding substance use disorders? 

Ford Brooks headshot

Ford Brooks: First, counselors need to explore where these biases may stem from. Over the years, many of my students have been impacted personally by addiction — through their own or their family members’ substance use — and subsequently they have emotional pain that influences how they work with clients with substance use disorders.  

I ask counseling students enrolled in my class to attend support groups for people and families dealing with substance use, such as Alcoholics Anonymous, Narcotics Anonymous and Al-Anon. Doing this helps them see how individuals who struggle with substance use and addiction are living honest, productive and sober/clean lives. It can also help students better understand people who have suffered with and from addiction.  

BM: One of the best ways to challenge one’s biases and prejudices is to immerse oneself into the culture. I suggest students and practitioners attend open meetings and listen closely to the stories of individuals and their family members dealing with these challenges. Furthermore, reading literature that describes and articulates the fact that these clients are human beings first and people who happen to have a substance use disorder or addiction second can help arrest the beliefs inherent in biases against these populations. Finally, some counselors are biased due to personal experiences. I suggest they work on their family/friend history that may be hampering the ability to empathize and understand the challenges of this population.  

What makes your book different from most textbooks on substance use and addiction? 

FB: As with previous editions, this revised version contains real case examples to help readers better understand and apply what we are discussing. I’ve been practicing as a counselor since 1985 and have continued to see clients even after becoming a counselor educator, and the information and experiences in the book are based on my experience as clinician. I have also used the information presented in this book in my own clinical practice. 

Graduate students can use our book in their work for practicum and field internships and beyond. What makes our book different is that I understand what it’s like as a counselor to sit with a person at the absolute lowest point in life and how compassion, presence, support and resources can make such a difference in the healing process.  

What should counselors be aware of when working with people with disabilities with respect to substance misuse? 

BM: People with disabilities can often be an overlooked population by family, friends and/or professionals in terms of both mental health issues and substance use disorders/addictions. I suggest counselors attend to the whole person rather than the disability. Simple awareness of the fact that members of this population can be overlooked in this regard can go a long way in effective assessment and treatment.  

Why is self-care so vital for counselors working with this population? 

FM: Working in the substance use and addiction field is challenging and demanding work, no doubt about it. It takes commitment and creativity, and it stretches our compassion and understanding and often requires us to go to places within ourselves that may be challenging.  

I’d be lying if I said this work doesn’t take a toll on the counselor’s soul, but there is also some good news: This is also rewarding work. Clients get well and make changes, and being present when a client surrenders to the process of recovery or “gets it” and is willing to make changes and take steps to live a different life, one day at a time, makes it all worth it.  

Doing this type of deep work requires counselors to get their own support, including regular clinical supervision as well as their own therapy if needed. I have developed my own self-care practices that help ground me and prevent me from experiencing burnout. I run, do martial arts and go hiking or biking. I’m also an avid guitar player and magician. The support of my family and friends, my own therapy and clinical supervision have all been important in staying in the field and now as a counselor educator. All of these life-giving activities provide me with the needed separation from my work and help to bring joy and pleasure in the face of daily student and clinical challenges. 

What changes do you see happening in substance use and addiction counseling in the next few years? 

BM: The infusion of technology into the assessment and treatment process will continue to grow. Examples here include formal assessments provided online, and telehealth used to conduct initial screenings for client needs. There is also continued emerging discussion and use of harm reduction methods that can work for some individuals in treatment. Whether it’s the reduction of use of a substance (e.g., cutting the amount used daily in half) or needle exchange programs, I think we will see a focus on helping clients engage in changes that ultimately reduce the physical, mental and cognitive impacts of addiction.  

Furthermore, with recent legislation such as overturning the Professional and Amateur Sports Protection Act, which banned sports betting in most states, I fully expect to see process addictions that include gambling addiction and technology addiction continue to increase in the future. Thus, counselors should continue to develop skills in working with process-related addictions as well as stay informed regarding new types of addiction in the coming years. 

 


cover of the third edition of A Contemporary Approach to Substance Use Disorders and Addiction Counseling

 

Order Contemporary Approach to Substance Use Disorders and Addiction Counseling (third edition) from the ACA Store.

 

 


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

SBIRT: Identifying and managing risky substance use

By Mallori DeSalle and Jon Agley September 24, 2015

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 headshotsdependence, 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.

Change_Graphic

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.

 

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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

 

 

Behind the book: A Contemporary Approach to Substance Use Disorders and Addiction Counseling

By Bethany Bray September 21, 2015

The most important tools a counselor can use to help a client struggling with addiction or substance abuse are genuine compassion and a deep understanding, say Ford Brooks and Bill McHenry, licensed professional counselors (LPCs) and co-authors of the second edition of A Contemporary Approach to Substance Use Disorders and Addiction Counseling, published by the American Counseling Association.

“The amount of shame, guilt, embarrassment and terror that drug-abusing and addicted clients feel Branding-Box_Sunstance-Usecan be beyond description,” McHenry and Brooks write in the book’s first chapter. “Therefore, clients need a sense of safety, understanding and compassionate care in the counseling relationship to change and grow. … A genuine, truthful and in-the-moment relationship allows clients to know, without question, that they are understood and cared for during their emotional pain and time of crisis. The connection that is forged between counselors and clients following a drug and alcohol crisis can be profound.”

A counselor’s empathy and compassion will benefit any client, certainly, but that is even more pronounced for those battling addiction, they write. This perspective comes from Brooks and McHenry’s combined experience of nearly a half-century of counseling clients with substance abuse issues in a variety of settings, from college counseling centers to hospital and rehabilitation programs.

The second edition of their book was published earlier this year; the first edition was published in 2009.

 

Q+A: A Contemporary Approach to Substance Use Disorders and Addiction Counseling

Responses by Ford Brooks

 

What is an important takeaway that you want counselors of all types and specialties to know about addictions and substance abuse?

Working with clients who are addicted is not as scary as most may think. Once a counselor is willing to enter the world of addiction through stories, attendance at open 12-step meetings, exploring the horrendous lives of clients and being educated and trained, it is like no other population to work with in counseling. Not only will counselors see fairly quick progress once recovery begins, counselors will see clients at their very worst. Walking with that person through their hell is an experience like nothing else. We walk the journey with them but not for them. It’s a humbling and powerful experience.

Mainly [we’d like counselors to realize that] addiction is treatable like any other disease, and people do get well.

 

The counselor-client relationship plays a key part in this work. What are some techniques you recommend to strengthen the therapeutic relationship?

Empathic listening is very important, as well as motivational interviewing techniques with the OARS acronym: open-ended questions to explore; affirming responses for support; reflective listening and comments; and accurate summaries. The core conditions outlined by Carl Rogers are so important with a population that needs empathy and support through their shame and embarrassment. A nonjudgmental approach is so important.

 

What prompted you to release a second edition of your book? What’s new and different in this edition?

There were three main areas that we found important to address:

  • Changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), including updating diagnostic criteria. The DSM’s fifth edition, published in 2013, contained a major shift from abuse and dependence to a substance use disorder in the model of a continuum, plus the addition of cravings and gambling addiction.
  • Neurobiology and addiction as well as treatment for opiates. We felt that both areas needed some updating, as both have grown in research since the last edition (2009).
  • And finally, because of [the influx of] returning veterans and trauma throughout this country and in others, the treatment of trauma was included along with attention to suicide and depression.

 

In your opinion, what makes professional counselors a good fit for addictions work? What unique skills do they bring to the table?

Having taught an overview course in addiction since 1987, I have found few books to address the “good fit” aspect of counselors. A person makes a good addictions counselor if they are interested, hopeful, patient, willing to challenge in a therapeutic and caring way, and understanding of the internal process of recovery.

In the course I teach, I want students to experience as much as possible the [client’s] internal struggle to go without and the emotions, thoughts and behaviors that go along with this process. Those who are “good fits” will be open to that struggle, be willing to explore their own biases around addiction and immerse themselves in the journey.

The main area we emphasize in the book is a beginner’s mind — one that is open to dealing with the client anew despite multiple relapses, denial and defensiveness. Also, being patient and having a willingness for the client to make mistakes and also a willingness to confront choices throughout the therapy. If a counselor wants to work with this population in treatment, being able to facilitate groups is, in my mind, a must.

 

Besides your book, what are some resources counselors can turn to for more information — and to stay current — on different types of drugs and their effects?

The main association for alcohol and drug addiction is the National Association for Alcoholism and Drug Abuse Counselors (NAADAC). There is also an American Counseling Association division, the International Association of Addictions and Offender Counselors (IAAOC), and the National Institute on Drug Abuse (NIDA). All three organizations have substantial bodies of information, as well as research in the area of addiction.

 

You and your co-author have been doing counseling work in substance abuse and addictions for more than a decade. How have you seen the field change?

I watched treatment program after program close in the late 1980s due to managed care. With that was the departure of many counselors who were in long-term recovery [programs but] not licensed to provide services. Many of the counselors who were then charged with running programs were licensed but had limited knowledge about addiction. The days of inpatient treatment are now reserved for those with financial resources. Although there is availability for those without the money to enter inpatient treatment, the funding is becoming less and less. Intensive outpatient programs have moved into a significant place in providing services.

Medication-assisted treatment with opiates has continued since the inception of methadone in the 1960s. Properly assigned medication protocols along with structured treatment and tapering is a new area of exploration. As stated before, the increased scientific knowledge of how the brain holds the key to addiction determines and supports [the concept] that addiction happens in the brain.

We also can see that addiction is addiction is addiction. Ultimately, the understanding [needs to be] that to enter recovery, one needs to be in treatment and discontinue addictive, mood-altering chemicals.

Another area of continued growth has to be with addiction and returning veterans and the treatment of co-occurring disorders. Sadly, the gap between treatment services continues. Those who treat mental health only treat mental health [and] those who treat substance use disorders only treat those issues. It is the challenge of the next iteration of counselors to close that gap.

 

What made you personally interested in pursuing addictions and rehabilitation counseling as a specialty?

I have a family history of addiction that extends generations and have experienced the impact of addiction. When I was an undergraduate at the University of Richmond, a graduate student from Virginia Commonwealth University (VCU) came to my psychology class and talked about [VCU’s] alcohol and drug rehabilitation program. I applied after hearing how powerful her experience was in the program. The rest is history.

 

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A Contemporary Approach to Substance Use Disorders and Addiction Counseling is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222.

 

 

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About the authors

Ford Brooks is a professor in the Department of Counseling and College Student Personnel at Shippensburg University of Pennsylvania. A licensed professional counselor, he has been a counselor for more than 30 years, working primarily with clients who suffer from addiction and co-occurring mental disorders.

Bill McHenry is a licensed professional counselor and dean of graduate studies and research at Texas A&M University in Texarkana. His more than 15 years of counseling experience includes working with groups and individuals with substance abuse and addiction issues in schools, universities, rehabilitation programs and mental health agencies.

 

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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

 

Motivation to change

By Stacy Notaras Murphy April 27, 2015

A 40-year-old man enters counseling to deal with “relationship issues.” He says his marriage is failing due to his use of online pornography and that his financial situation is in constant peril because of high gambling debts. He adds that he drinks alcohol daily and fears he is dependent on it to remain functional.

In terms of treatment triage, many clinicians would choose to make his alcohol dependence a top priority because active substance addiction can make other goals impossible to achieve. But Motivation_smallsubstance abuse work is a significant undertaking. It is not unheard of for a treatment plan to include group therapy, family therapy and an inpatient treatment facility. With the focus of treatment squarely on alcohol use, the client’s other issues may linger on the back burner indefinitely.

It could be a mistake to leave addiction to certain behaviors — such as this client’s compulsive gambling or use of online pornography — out of the treatment plan, says American Counseling Association member Mary Crozier, associate professor and coordinator of the substance abuse counseling certificate program at East Carolina University (ECU) in Greenville, North Carolina. “Just as we’ve adapted to the presence of co-occurring disorders, we are adapting to the presence of behavioral addictions with mental illness and other addictions,” she says, although adding that the dearth of prevention research and services that target behavioral addictions is a significant obstacle. But like most paradigm shifts, the connection between substance abuse and behavioral addiction is slowly coming into focus.

A new book that delves into the diagnosis and treatment of behavioral addiction, The Behavioral Addictions, edited by Michael S. Ascher and Petros Levounis, makes the case that certain behaviors can turn into addictions that follow similar paths to substance use disorders. Levounis, chair of the Department of Psychiatry at Rutgers New Jersey Medical School, tells Counseling Today that behavioral addictions should be viewed as a new field of study encompassing “a number of diverse conditions, from the more traditional problems of gambling, sex, Internet, food and shopping to emerging constructs such as work addiction, love addiction and addiction to indoor sun-tanning.”

Although gambling addiction is the only behavioral addiction found in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), clinicians and researchers are noting that the neurobiological responses to behavioral addiction are similar to those of substance abuse. At the same time, treatment options must be more nuanced for behavioral addictions. For example, alcohol abuse may be treated through abstinence, but food addiction and sex addiction are related to typical human activities for which complete self-denial is an unrealistic goal.

It wasn’t until Crozier had already completed her doctorate and taken a teaching position at Medicine Hat College in Alberta, Canada, that she truly saw for herself the relationship between substance and behavioral addictions. “[The college’s] addictions counseling program integrated substance and behavioral addictions into each course,” she says. “Their model allowed students to see the interactions between substances and behaviors and to really learn about well-researched, prevalent behavioral addictions. Examples of this integration were to weave binge eating disorder into the counseling course, pathological gambling into the assessment course and hypersexuality disorder into the prevention course. Needless to say, I learned a lot and saw addictions in a new light.”

Crozier’s research partner, Shari Sias, a member of ACA and its division, the International Association of Addictions and Offender Counselors (IAAOC), also had a postgraduate awakening to the connection between substance abuse and behavioral addiction. While serving as the clinical coordinator of an outpatient substance abuse counseling center, she and her staff noticed that the clients were also struggling with behavioral addictions. “Once the chemical addictions were addressed, their behavioral addictions began to surface,” says Sias, now an associate professor and director of the substance abuse and clinical counseling programs at ECU. “Staff began asking for training in behavior addictions, and we asked [sex addiction expert and author] Patrick Carnes to come and lead a training. This was an eye-opening experience for all of us, and [we] started incorporating behavior addiction information as part of the outpatient program.”

Complex presentation

As is the case with most disorders, clients struggling with behavioral addiction often present to counseling for other reasons. Crozier is careful to note that not everyone who engages in potentially addictive behaviors actually becomes addicted. She explains that some people come to counseling simply for advice about managing those behaviors.

“Other clients are unaware that their compulsive behaviors are causing risks and negative ripple effects for their friends, family, boss, etc.,” she says. “There seems to be a strong correlation between behavioral addictions — especially pathological gambling — and substance abuse. Many clients thus present to counseling with substance, familial, social, financial, health and occupational challenges.” For this reason, Crozier advises counselors to conduct assessments on behavioral addictions with all clients, both as part of a stronger initial screening process and intermittently thereafter.

Sias agrees. “Most of the clients I’ve counseled sought services due to a chemical addiction, and as part of that work … became aware of a process addiction,” she says. “It is important that behavioral addictions be included in the assessment and treatment process. If we as counselors don’t ask about it, clients may not be aware of the need to treat both the chemical and behavioral addiction.” Sias adds that successful treatment may address both the chemical and behavioral addictions as part of a holistic, client-centered plan, including referrals to other support professionals, such as financial counseling for gambling debts or medical care for binge eating disorder.

Levounis thinks the role of the counselor in helping people who struggle with behavioral addiction is two-fold. “On one hand, she or he is in a unique position to recognize the signs of these poorly understood — and, in general, poorly researched — addictions,” he says. “On the other, the counselor may be able to reformulate a person’s problem in terms of an addictive process, beyond the traditional structures of CBT [cognitive behavior therapy] and psychodynamic psychotherapy.” He provides the example of a person reeling from a series of unsuccessful relationships. The client may find it helpful if her or his counselor reconceptualizes the struggle in terms of unrelenting cravings for the euphoria of a new romance.

“In other words, in terms of an addiction to love,” Levounis says.

Motivational interviewing: A collaborative conversation

There is some good news for counselors who want to start assessing and treating for behavioral addictions and who are experienced in working with clients facing substance abuse issues: These counselors likely already possess the required skills. The evidence-based approach used in motivational interviewing can be refocused to help clients deal with behavioral addictions as well as substance abuse. In fact, none of the counselors interviewed for this article think that motivational interviewing is better used to address one kind of addiction over another. Their general consensus was that, because of its Rogerian, person-centered emphasis, motivational interviewing is useful with anyone considering behavior change of any kind. In their book, Ascher and Levounis point out that due in part to the absence of DSM-5 diagnoses for most behavioral addictions, motivational interviewing joins individual and group psychotherapy and self-help groups as one of the few current treatment recommendations for these disorders.

“[Motivational interviewing’s] client-centered counseling style for eliciting behavior change and helping clients explore and resolve ambivalence is great for meeting clients where they are in the change process,” Sias says. In her experience, she also has found that motivational interviewing increases client attendance and retention rates. “We know the longer clients remain in treatment, the better the recovery rate,” she adds.

Melanie M. Iarussi, an ACA member and secretary of IAAOC who is also an assistant professor at Auburn University in Alabama, is a trainer with the Motivational Interviewing Network of Trainers (MINT) organization. She has used motivational interviewing in a variety of clinical settings, including substance abuse treatment centers, college counseling centers and a domestic violence intervention center. She defines motivational interviewing as a humanistic, goal-oriented approach designed to help people identify and strengthen their personal motivations to engage in behavior change. “The humanistic underpinnings of the MI [motivational interviewing] approach made complete sense to me, and using MI strategies gave me some tools to promote engagement in counseling and enhance problem awareness with my clients,” she says.

Motivational interviewing encourages the counselor to engage in a collaborative conversation that meets clients where they currently are. The approach avoids imposing beliefs or forcing change on the client. “Instead, MI is grounded in respect and valuing the client with all of his or her experiences and wisdom,” Iarussi says. “MI emphasizes empathy — truly seeing the issues and concerns through the eyes of the client, taking into account his or her worldview, background, resources, etc. — and it requires a unique, responsive approach to each individual.” She adds that MI counselors support client autonomy, affirming the individual strengths and assets that can be a foundation for making positive changes.

When treating behavioral addictions, Iarussi has found that motivational interviewing works well in tandem with other therapeutic approaches. For example, she says, clients with behavioral addictions can benefit from a combination of motivational interviewing and CBT. “MI can help the person cultivate and enhance their motivations to pursue behavior changes, and then CBT can help them develop the skills and tools needed to implement the change,” she explains.

Iarussi cautions, however, that challenges may arise when the client perceives that the behavior provides more benefits than costs or when resources are lacking for the client to implement and sustain change. If the counselor and the client collaboratively explore the possibility of change and the client decides against it, the MI protocol calls for the counselor to honor the client’s autonomy and decisions. “We can express concern in a genuine, compassionate manner, but we do not attempt to coerce or force change upon clients,” Iarussi notes. “In the end, it is truly their choice if they will change their behavior. … The counselor acts as a guide.”

Iarussi goes on to explain that when there is a lack of resources contributing to the inability to change, the MI counselor helps the client manage with whatever resources are available. Creativity is useful here, she says. For example, consider a client who struggles with hypersexual behavior who would benefit from attending a 12-step meeting. If the client lives in a small community without close access to such a meeting, the counselor and client could work together to brainstorm options such as online meetings, committing to travel to a meeting far away at least twice a month and so on, Iarussi says.

Within the community of addictions counselors, motivational interviewing is now a widely accepted tool for working with behavioral or process addictions, according to Paul Toriello, an ACA and IAAOC member and MINT trainer who serves as director of graduate studies in the Department of Addictions and Rehabilitation Studies at ECU. In fact, Toriello says that most of the motivational interviewing trainings he currently runs are outside of the substance abuse arena. “MI was in many ways born in a substance abuse setting, but it has evolved for so many years,” he says, noting that his current work involving motivational interviewing is in career motivation with wounded veterans.

Toriello says motivational interviewing’s strong basis in research also has garnered interest in recent years from organizations that need to incorporate evidence-based practice into their treatment planning for funding reasons. “MI checks the box in terms of evidence-based practice, but it is also very fulfilling to practitioners,” he says. “People get into counseling [work] because they want to build relationships, and if I can do that and, at the same time, meet the demands of funding agencies and insurance companies, it’s hard to lose.”

Specifically, Toriello has found motivational interviewing useful in helping clients with behavioral addictions such as gambling and disordered eating. “You name the target behavior, and MI can be done the same way,” he says. “Now there is a lot of variance within [it] … but the approach to behavior X, Y or Z will essentially be the same, guided by the four processes.”

Finding clients’ humanity 

The four core processes of motivational interviewing are engaging, focusing, evoking and planning. Moving through these four stages, counselors aim to guide their clients toward developing their own motivations to change a behavior. Starting with engagement, counselors work to create the therapeutic alliance that is found in most counseling approaches.

Toriello says the framework offers significant flexibility for counselors to follow their own unique paths. He describes it as almost dancelike: “I am strategically asking questions and making reflections so my client will come to a different decision about the behavior he [or she] wants to change. The word you often see is [that MI counselors use] an ‘evocative’ spirit to draw out of the client [his or her] own natural resources for change. That’s one of the things that makes it so person-centered. The interviewer has a sense that everything the client needs to make the change is already within them. It’s the interviewer’s job to bring that out of them, with skillful questioning.”

Toriello offers the example of an adolescent male he worked with in a residential environment years ago. Conduct disorder, angry outbursts and substance abuse were the norm in the facility, and “Johnny” presented with all the symptoms from day one.

“He came in like a bat out of hell,” Toriello recalls. “He just hit the ground running, throwing, spitting, kicking, you name it. Until one day, some time had passed after he went through a crisis period, and I brought him [into my office] and pulled his record. I talked to him to try to get a sense of where he was coming from. [I used] open-ended questions as opposed to confronting or prescribing, and he didn’t act up and he was actually responding, which was cool to see. This got to a point where he broke down, shed a bunch of tears and we implemented some tools he could take with him. He was not an angel, but once we tried to just listen, as opposed to confront, it was working.”

Toriello says that experience set him on a course to learn more about motivational interviewing. “I came from that other model, where you tear down the defenses first. But [with Johnny] I could see, ‘Wow, there is a human being in there!’ But what got us to see that was to act like human beings [ourselves] rather than like power and control mongers,” he reflects.

Challenges ahead

From Sias’ perspective, the biggest challenge for counselors working with the behavioral addiction population is not the clients’ needs but rather having access to services that actually address these disorders. “We need more programs that focus on behavioral addictions, and I think existing substance abuse treatment programs need to integrate behavioral addictions,” she says.

Despite the challenges, she adds that there are many rewards in working with this population. “Counselors trained to address both chemical and behavioral addictions are providing holistic care that makes a big difference in the lives of the clients we serve,” Sias says. “Being part of the change process with clients is an amazing experience.”

Crozier was a member of the IAAOC Process Addictions Committee when it conducted research on the topic of counselor readiness for working with behavioral addictions. The findings from the 2014 nationwide survey of counseling students, faculty and professionals suggest that few counselors are formally trained in process or behavioral addictions; scant research is readily available; and the empirical studies that are available aren’t being widely utilized. Given those findings, Crozier recommends that all counselors join IAAOC’s Process Addictions Committee and read its newsletter.

On a more personal level, Toriello can foresee challenges for new clinicians as they face behavioral addictions in their offices. “You can’t go through a counselor education program and not be steeped in Carl Rogers and the person-centered approach, so these new counselors have the knowledge,” he says. “[But] I am concerned about their strength to implement that knowledge and stay true to person-centered approaches as opposed to succumbing to the pressure … of prescriptive techniques, where they start giving unwanted or unrequested advice, or they start problem-solving and not counseling.”

Toriello fears that counselors have taken too much control of the change process. He believes they would do well to use various techniques, including motivational interviewing, to return that control to their clients, thus allowing them to be the experts on their own issues.

 

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Additional guidance

The International Association of Addictions and Offender Counselors, a division of the American Counseling Association, was chartered in 1972. Members of IAAOC advocate for the development of effective counseling and rehabilitation programs for people with addictions. For more information, visit iaaoc.org.

Robert L. Smith’s book, Treatment Strategies for Substance and Process Addictions, published earlier this year by ACA, features sections by various authors on pathological gambling, sexual addiction, disordered eating, work addiction, exercise addiction, compulsive buying/shopping addiction and Internet addiction. For more information, visit counseling.org/bookstore or call 800.422.2648 ext. 222.

A podcast on “Gambling Addiction,” delivered by Pete Pennington, is available on the ACA website.

 

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Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.

Letters to the editor: ct@counseling.org

Hidden in plain sight

By Laurie Meyers January 23, 2015

Drunk. Junkie. Loser. These are just some of the ugly labels that get thrown around when people talk about addiction. Labels that reinforce the belief that addiction happens to “other” people — or other counselors’ clients.

Counselors know that addiction is a disease, of course. But it’s a disease with a particularly bad reputation, and many counselors may associate it with resistant clients and low rates of successful treatment. For some counselors, it might even seem easier to avoid working with clients who are Branding-Box-flaskstruggling with addiction. The problem is, that’s not possible.

“I think I’ve heard more often than not [from counseling students], ‘You know, I really don’t want to work with alcoholics and addicts,’” says Ford Brooks, an addictions specialist and counselor educator at Shippensburg University in Pennsylvania. “And I’m thinking, ‘Well, unless you work on the moon, most of your caseload is going to have some impact through [the client’s substance use] or someone else’s use.’”

Gerald Juhnke, an American Counseling Association member who has been involved with addictions counseling since 1995, confirms that thought. “I didn’t really want to go into addictions counseling,” he says. “I mean, who would talk to a counselor whose name is Juhnke? I wanted to go into marriage and family therapy, but what I found is that so many of the couples and families I saw came in with issues related to addiction.”

According to the 2012 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 20.7 million Americans have a substance use disorder. The survey data is based on face-to-face interviews with a representative portion of the population. However, because of the strong stigma attached to acknowledging addiction, many experts believe that estimate is low.

Many of these underreported and undiagnosed cases will end up in counselors’ offices — though not necessarily with addiction as the presenting cause. Myriad issues that bring clients to counseling, such as marital and family discord, problems at work and especially mental health complaints such as depression and anxiety, are frequently connected to substance abuse and addiction.

To genuinely help these clients — who may or may not recognize their substance use problems — counselors of all stripes and specialties need to educate themselves about addiction. This knowledge includes the various types of addiction, how to spot addiction, how to help treat it and when to refer clients for more intense or specialized help.

Counselors should begin by examining their own beliefs about addiction, says Brooks, who was a practicing addictions counselor for 14 years and is the co-author, with Bill McHenry, of A Contemporary Approach to Substance Use Disorders and Addiction Counseling, the second edition of which ACA published this month.

“I want people to be aware of their own biases and preconceived notions about people who use drugs and alcohol,” Brooks explains. “For students, it may be, ‘An alcoholic is my Uncle Joe’ or ‘Drug addicts are worthless and don’t work.’”

Brooks makes a point of discussing with all of his counseling students their perceptions of what addiction is and looks like. “If you have the attitude of ‘I’m better than you’ or you think, ‘Oh, you dope. You shot up drugs and got pregnant and are still using,’ these biases are going to get in the way,” he notes.

To help banish such stereotypes, Brooks has students go to Alcoholics Anonymous and Al-Anon meetings. He says they are almost always surprised by what they see, including that the individuals struggling with alcoholism and addiction seem so “normal.” More than that, the students are often able to recognize reflections of themselves or their families in members of the recovery groups.

Julie Bates, an ACA member and former addictions counselor, would like to see all counselors-in-training given opportunities early on to interact with people who have substance abuse problems. She notes that education and exposure have been shown to reduce stigma.

Even when counselors haven’t been exposed to issues surrounding addiction in training or early in their careers, they can strive to understand the person struggling with these issues, just as they would with any other client.

“We need to train our counselors to be curious — curious about the complexity of addiction,” says Bates, who is now a counselor educator at the University of Wisconsin-Stout, where she teaches classes on addiction. “The ‘why’ questions, such as ‘Why do you use?’ and ‘Why don’t you just stop?’ are not inherently bad questions. In fact, if asked in curiosity and not judgment, [they] are actually exceptionally valuable. We should be very interested and invested in the answers to those questions.”

In fact, asking “why,” along with other questions, has become an essential part of addiction therapy. Counselors and other helping professionals have largely abandoned the confrontational addiction therapy model previously used for decades and exchanged it for more collaborative and client-centered techniques.

New perspectives on addiction

These newer techniques and perspectives on addiction and substance abuse are driven in part by research that has upheld what counselors and other helping professionals have long contended: Addiction is a disease, not a moral failing.

In 2011, after years of research, including an extensive focus on the chemistry and wiring of the brain, the American Society of Addiction Medicine officially defined addiction as a disease of the brain — specifically, a “primary, chronic disease of brain reward, motivation, memory and related circuitry.” Brooks believes this definition, with its emphasis on physical changes that cause behavioral impairment, helps ease some of the stigma attached to addiction and substance abuse disorders.

Of course, in addiction, as with any other mental health disorder, the brain does not hold the full story — not physically, at least. Although addiction has a strong genetic component, psychological, environmental and social factors also play essential roles. Probing these elements is a critical part of addiction therapy and recovery.

When Brooks began working with clients struggling with addiction in the mid-1980s, the recovery field was dominated by helpers who had been formerly addicted themselves. These individuals didn’t necessarily have training in mental health disorders or counseling but instead drew upon their personal experiences in recovery.

This was a seemingly practical approach, based in both the 12-step process and directly confronting clients with their problems by saying things such as, “This is your sixth DUI. Time to make a change!” Brooks says. This approach came from a place of compassion, he notes, but tended to increase defensiveness in a client base that was already on guard and often in denial.

By the late 1980s, treatment was no longer routinely dispensed by formerly addicted helpers in recovery. Instead, it became the realm of counselors and other trained professionals. However, until the past decade or so, the confrontational model still dominated treatment, notes Juhnke, a former president of the International Association of Addictions and Offender Counselors, a division of ACA, and a counselor educator at the University of Texas at San Antonio. Now, in addition to the 12-step process, which many professionals still consider an essential part of recovery, Juhnke, Brooks and other counselors have increasingly been turning to more collaborative, person-centered methods such as motivational interviewing. Brooks and McHenry note in their book that motivational interviewing can be particularly helpful for evaluating the existence and extent of a client’s addiction.

“MI [motivational interviewing] … has the counselor or group work side by side with the client,” Brooks explains. “I’m helping you side by side, versus me sitting across from you telling you all that your disease has done.”

When the counselor and the client collaborate, it allows them not only to identify the problem but also to more clearly understand the triggers, behaviors and negative consequences associated with the addictive behavior, Juhnke notes.

“MI allows me to ask simple questions to help them figure out what might be causing their problems,” he says. For instance, Juhnke might ask the client a question or make a statement such as, “Help me understand what you are doing when you have trouble getting into work in the morning.”

With this process, Juhnke is probing for — and simultaneously opening the client’s eyes to — the addictive behavior that caused a particular negative outcome. This line of questioning might reveal that the client drank several beers before work, allowing Juhnke to call attention to the damage that the client’s overconsumption of alcohol is doing.

In Juhnke’s experience, clients don’t usually come to counseling looking for help with addiction but rather for assistance with work problems, family troubles or some other issue. But if substance abuse is a contributing or precipitating factor to the client’s problems, careful probing through the technique of motivational interviewing can reveal a pattern, he says.

“You might say, ‘Are you using any substances?’” Juhnke explains. “And they might say, ‘Yeah, I’m drinking a little bit.’ And then you ask, ‘How’s that going?’ ‘Well, it’s going pretty good — I have no problems.’ But then, as you begin to talk with them, you find out that it is a problem — that they’re losing money because they drink so much, and they just got terminated from their job because of their drinking on the job or before going into work.”

Even after this revelation, Juhnke doesn’t confront the client. Instead he might say, “Hey, I’m a little confused. You say you’re not having problems with your alcohol consumption, yet you tell me you got terminated from your job [and] that you’re abusive toward your spouse or partner when you drink. Help me understand that.”

Juhnke explains that if he were using the “old school” approach to treatment, he would be in the client’s face, determined to show the person that he or she has an addiction.whatarewetreating

“But with MI, if they don’t admit it, no problem,” he says. “I just keep asking questions, and my goal is to help them gain insight by their answers. And hopefully they’ll begin to realize, ‘Hey, I do have a problem here.’”

Once a client recognizes that he or she has a problem, Juhnke will continue to use motivational interviewing in conjunction with family or couples therapy, if possible, and have the client attend 12-step meetings.

ACA member W.Bryce Hagedorn, an addictions counselor in Orlando, Florida, and an associate professor and coordinator of the Department of Child, Family and Community Sciences at the University of Central Florida, frames his addiction counseling around the Stages of Change Model.

“Research has shown that no matter what kind of change they are seeking,” Hagedorn says, “clients go through six stages: precontemplation, contemplation, planning, action, maintenance and termination.”

Hagedorn tailors his approach according to what stage the client is in. He notes that motivational interviewing is particularly helpful in tackling the denial that is entrenched in the precontemplation and contemplation stages. He also likes to use “heart-centered” therapies such as Gestalt or art therapy in the contemplation stage. He thinks this provides a way for clients to bypass the mental blocks of denial and resistance by connecting directly with their emotions. Once a client reaches the stages of planning, action, maintenance and termination, Hagedorn advises using a behavioral method such as cognitive behavior therapy, dialectical behavior therapy or acceptance and commitment therapy.

Juhnke says motivational interviewing is also particularly effective in helping clients identify circumstances that might trigger an episode of substance abuse or, for those in recovery, a relapse.

“The hard part with addiction is that everyone always thinks that they have their addiction beat,” he says. “I just had a client recently who thought he had his addiction beat. He had been sober for seven years and, suddenly, at the department Christmas party, he has a drink. And then he thinks, ‘Well, I’ve already had one drink and it didn’t hurt me. I bet I could have two.’ And then by the end of the night, he’s got a fifth of vodka down and he’s saying inappropriate things to his boss and subordinates.”

Afterward, the client was embarrassed and ashamed, but Juhnke helped him work through the issue by examining what had happened. He asked the client why he suddenly took a drink after so long in recovery. What specifically was happening when he made that decision? What were the triggers? And how could he learn from that?

“Because in recovery, it’s all about learning from your relapses,” Juhnke emphasizes. “Anyone in recovery is going to have relapses, but it’s learning from each time you relapse, learning what happened. How did that happen? What kind of things can I do to insulate myself from that same situation or having those feelings again?”   

Juhnke finds it is helpful to teach all of his clients — but particularly those battling addiction — the acronym H.A.L.T.: hungry, angry, lonesome, tired. He says these feelings often represent precipitating events for substance abuse, and if clients can learn to recognize those feelings as they’re happening, they can address the situation without reaching for a substance.

Intervening on campus

Addiction treatment isn’t the only thing that has changed in the field; the diagnosis of substance abuse has changed as well. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has combined the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe. As a fact sheet published by the American Psychiatric Association notes, “In DSM-IV, the distinction between abuse and dependence was based on the concept of abuse as a mild or early phase and dependence as the more severe manifestation. In practice, the abuse criteria were sometimes quite severe. The revised substance use disorder, a single diagnosis, will better match the symptoms that patients experience.”

This new diagnosis range fits nicely with what ACA member Rick Gressard is trying to do at the College of William & Mary with the New Leaf Clinic. Gressard and his colleague Sara Scott created the student substance abuse clinic to provide counseling services to students and a place for counselors-in-training to get hands-on experience with addiction treatment. Gressard, Scott and the college view the clinic as playing a crucial role in the prevention of future, more serious substance abuse problems.

New Leaf Clinic operates in conjunction with the Office of Student Affairs and is part of the disciplinary system at the college. The clinic is open to any student who wants to come in voluntarily for counseling, but all students at the college who incur an alcohol or substance use infraction, such as being drunk in public, destroying property, or possessing marijuana or another illicit substance, are required to visit the clinic. Depending on the infraction, the student faces three different levels of intervention, all of which are nonconfrontational, nonjudgmental and focused on harm reduction, Gressard says.

The first level consists of required attendance at a single psychoeducational session. “We take the approach that people are seeking a high from alcohol, and they think more is better,” Gressard says. “But we try to help them see that high levels really bring problems, and you actually don’t feel better but worse.”

The session covers topics such as binge drinking and the increased likelihood that students will experience negative consequences such as being arrested, passing out, getting injured, getting into fights, having a sexual experience they regret, being sexually assaulted or otherwise harmed, or ending up in the hospital because of an overdose the more frequently they engage in the behavior. “It’s become a cliché — college students falling off balconies — but we see a lot of those kinds of accidents,” Gressard says. “These are the kinds of problems we are hoping to help them avoid.”

The second level of intervention consists of two sessions. In the first, students fill out a survey on their patterns of drinking and substance use, receive additional psychoeducation and are asked to track their use over the course of the next week. During the second session, students receive an assessment of their drinking or substance use habits based on the survey they completed in session one. The survey was designed specifically for William & Mary and uses data provided by the school’s students so that respondents can compare their drinking and substance use habits against the habits of peers. The student and the counselor-in-training then discuss the assessment, the student’s feelings about the assessment and any concerns or questions.   

The third level of intervention involves a minimum of six individual sessions. Students at this level also take an initial assessment during the first session. The remaining sessions are dedicated to individual counseling using motivational interviewing.

According to Gressard, the intervention program has been surprisingly successful in reducing harm to students and helping those who are grappling with more serious forms of substance abuse.

Intertwining issues

One of the most substantial complicating factors in addiction treatment is the prevalence of comorbid or co-occurring disorders. According to the SAMHSA survey estimates, out of the more than 20 million Americans with a substance abuse problem and the nearly 44 million Americans who have some form of mental illness, 8.4 million people have both. Many professionals who treat addiction believe the incidence of comorbidity is actually much higher. Brooks thinks the comorbidity rate continues to rise with the field’s increasing awareness of co-occurring disorders. In other words, addiction and other mental health issues have always been intertwined; professionals in the field are just getting better at recognizing it.

In Gressard’s experience, where there is substance abuse, there are often other mental health problems. He notes that the epidemiology has shown that those with substance abuse disorders are twice as likely to have other mental health problems and vice versa.

Hagedorn might peg the rate of comorbidity even higher. He says he rarely sees a client who presents solely with a substance abuse problem such as alcoholism or solely with a mental health disorder such as depression.

“I subscribe to a self-medicating hypothesis, which is something of a chicken-and-egg situation,” says Hagedorn, president of the Association for Spiritual, Ethical and Religious Values in Counseling, a division of ACA. “Are they using substances to medicate mental health concerns? Or is the psychological pain or wounding that is contributing to the mental health disorder also contributing to the substance disorder?”

In the past, substance abuse counseling and mental health counseling were often separated, which meant that clients frequently missed receiving all the treatment they needed. “I think we are doing a real disservice to clients by only treating just what makes the most noise. We tend to listen to what clients say hurts the most and not look for what is underlying the pain,” Hagedorn says.

However, he believes that counselors should not try to address both co-occurring disorders simultaneously. “You don’t start digging into why the client [with addiction] struggles in the first six months,” he asserts. “Don’t dig until you know how the client will cope with this understanding. A lot of clients want to understand why, and some counselors take them there way too early. I have
seen the bad results of understanding why too soon.”

Hagedorn explains his line of thinking with a hypothetical situation. “Say someone comes in and says, ‘I just don’t understand why I keep drinking. I want to know why,’” he says. As the counselor digs, he or she discovers that the client had a neglectful father and feelings of inadequacy. The client suddenly realizes this is why he or she drinks, Hagedorn says, but what then?

“How does the client deal with this without drinking again?” he asks. “You keep clients locked in pain without having [another method] to deal with the pain.”

Hagedorn believes the addiction should be treated first so that when the client experiences the pain of understanding the underlying cause, he or she will have learned not to automatically turn to the addictive substance to cope.

Juhnke takes a different perspective. He thinks that once disorders co-occur, they’re all but inextricable. “It’s kind of like Jell-O,” he says. “You have the granules, and then water is added, and then they’re all just fused together.”

In addition, Juhnke asserts that clients with comorbidity are often experiencing such severe problems that there’s little time to separate disorders and treat them independently.

Brooks agrees that co-occurring disorders must be treated simultaneously. He points out that people with co-occurring disorders sometimes start their substance abuse as a way to self-medicate, so if counselors treat the addiction but not the mental health problem, the cycle will start all over again. Comorbidity greatly increases the chances that a client in recovery will relapse, he asserts. To guard against that, a counselor must consider both disorders at the same time. If the client is on medication, a counselor should be working with a psychiatrist who specializes in both substance abuse and mental health disorders, Brooks notes. Similarly, any treatment program (whether inpatient or outpatient) should specialize in both substance abuse and mental illness, he says.

Juhnke thinks it’s best to double or even triple down on treatments and interventions when it comes to comorbidity. “It’s kind of like a big spider web. The more sticky substance we can put down, the better off the client will be,” he says. “Twelve-step programs once a month, that’s not going to be very helpful. But if we have them doing family counseling, if we have them attending 12-step meetings several times a week and if we’ve got them doing homework related to their panic disorder, putting that all together can be really helpful.”

A different kind of addiction

To complicate the picture even further, addictions don’t always involve substances such as drugs or alcohol. Certain behaviors can become addictive, and equally as problematic, as well. Known as process addictions, these behaviors are most commonly connected to sex, gambling, shopping, exercise, eating, Internet use and, some even speculate, work. Process addictions can cause just as much damage as substances, but the behaviors involve common activities, making them more difficult to recognize. But both substance and process addictions follow similar patterns.

“When people are in pain, they find something to ease it,” says Summer Reiner, an ACA member who researches addiction and serves as an associate professor and school counseling program coordinator at the State University of New York at Brockport. That “something” might be alcohol or a substance, but it could also be a behavior such as sex, gambling or shopping, she explains.

As described in the upcoming book Treatment Strategies for Substance and Process Addictions (published by ACA and available in March), process addictions occur when a person experiences a high from a continued activity or behavior. The person’s pleasure causes a rush that he or she is unable to get from other everyday activities. The DSM-5 has a new section on behavioral addiction, but the only diagnosis included is for gambling. However, Internet gaming is listed in a separate section of the manual that includes diagnoses that need more research. Many addiction researchers and professionals believe that other processes or behaviors such as sex, exercise, shopping, eating and even work also qualify as behavioral or process addictions, despite their omission from the DSM-5.

Juhnke says process addictions often co-occur with substance addictions and are actually a harder type of addiction to treat. The traditional addiction treatment model is based on abstinence. However, this approach will not work with people who have process addictions, Juhnke notes. After all, people naturally need to eat, work, exercise, buy things and have sex. So treatment for most process disorders needs to focus on finding a balance between use and abuse.

“With sex [addiction], it isn’t about abstinence for life,” Hagedorn says, citing an example. “It’s how to have a healthy sexual relationship [and] have sex be a connecting experience, not sex being an endpoint.”

But what happens when someone’s process addiction is viewed by most others as a positive instead of a negative? That is the question Reiner asked herself when she started researching work addiction.

“[Work addiction] is something that is rewarded in society and is not seen as a problem,” she says. “You make more money, are professionally rewarded, and when you work hard, your employer and co-workers benefit.”

People with work addictions are often admired by their peers, so the behavior actually receives positive reinforcement, unlike most addictions, says Reiner, the author of a chapter on work addiction in Treatment Strategies for Substance and Process Addictions.

The family of someone with a work addiction is also more likely to make excuses, Reiner notes. “If you had an alcohol addiction and didn’t come to a family party, that would be bad, but people see work as OK,” she notes.

But like any other form of addiction, overwork will eventually result in negative consequences, Reiner says, so counselors should listen carefully for clues indicating that the client’s approach to work is causing problems. For example, clients might mention that their spouse complains that they work too much or brag that they work 60 hours a week.

The client’s co-workers may also start to notice negative consequences, Reiner says. For instance, people with work addictions are happy to do the extra work but often resent that others aren’t putting in those 60 hours or working weekends. Over time, it becomes difficult to work with someone like that, she notes.

In addition, all of the work will eventually take its toll on the person with the addiction because it’s often impossible to sustain that level of performance. Instead, the client is likely to develop health problems or experience total burnout, Reiner concludes.

Recovery from work addiction, as with other process addictions, is about moderation — learning to work, not overwork. “You need to be able to say, ‘OK, I’m going to leave work at 8, and I’m not going to bring my laptop home,’” Reiner says.

Clients with process addictions also need to find other outlets, says Juhnke. “It never works when you just try to remove something,” he says. “If you take one [substance or behavior] away, they will move to another. You want to not just create a void by removal, but help people find out what brings them joy, makes them happy, and fill their lives with that.”

Knowing your limits

“I think counselors should know that they will work with addiction,” Bates says. “Counselors should know that their own perceptions of what addiction is and what it is not may be one of the biggest impediments to providing successful treatment.” She urges counselors at all stages and in all practice settings to work through any biases with education, supervision, additional training and even personal counseling as needed.

Other experienced addictions counselors echo those comments, saying all practitioners should seek more education, training and supervision in this area because the limited courses on addiction in a typical graduate program aren’t sufficient to teach counselors all they need to know. Equally important is that counselors who don’t specialize in addictions treatment know when to ask for help because there inevitably will be times when they feel out of their depth or simply aren’t qualified to provide what a client struggling with addiction needs.

After all, these experts point out, experienced addictions counselors don’t go it alone either. They send clients to 12-step programs, collaborate with or refer to other professionals such as psychiatrists who specialize in substance abuse and mental health disorders and, in some cases, arrange for clients to enter an inpatient or outpatient clinic.

Brooks advises practitioners to make a habit of meeting regularly with peers and more experienced professionals. These meetings can be helpful not only for counselors in session, but also for their own state of mind, especially given the stressful and sometimes tragic circumstances that can accompany working with this client population.

“There is a higher incidence of mortality in this population,” Brooks explains. “So you will have more clients pass away.”

Clients dealing with addiction are also more likely to call in crisis, and that can take a toll, Brooks notes. Talking and sharing with other counselors who have navigated similar circumstances is an essential part of self-care.

But Bates doesn’t want one truth to get lost in all the potential challenges of engaging in addiction work: “Counselors should know that clients with addiction are tremendously resilient people and that they deserve a lot of respect for their efforts to make such a major life change.”

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To contact the individuals interviewed for this article, email:

Julie Bates at batesjul@uwstout.edu

Ford Brooks at cwbroo@ship.edu

Rick Gressard at cfgres@wm.edu

W. Bryce Hagedorn at Bryce.Hagedorn@ucf.edu

Gerald Juhnke at gajuhnkemi@yahoo.com

Summer Reiner at sreiner@brockport.edu

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org