Tag Archives: Substance Abuse & Addictions

Integrating addictions counseling into LPC licensing

By Bethany Bray April 10, 2014

The process to become a licensed professional counselor (LPC) qualifies the license-holder to work with clients who present with posttraumatic stress disorder, schizophrenia, eating disorders and other diagnoses listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Why then, would addiction – another DSM-5 diagnosis – be any different?

An extra, state-level certification is often required for counselors to work in addictions. That model complicates things for counselors and is turning graduate students off to the field of addictions counseling, contends Keith Morgen, president of the International Association of Addictions and Offender Counselors (IAAOC), a division of the American Counseling Association.

“You have to find a balance,” says Morgen. “You need to have the training to know how to do addictions work, but to [require additional licensure or certification, depending on the state] becomes less of a benefit and more of a hassle. It’s driving people away.”

IAAOCIAAOC recently formed a task force to focus on this issue. The group plans to present its findings – and suggestions for a possible remedy — at ACA’s 2015 Conference in Orlando, Fla. Morgen says IAAOC is looking for more counselors, both entry-level and established counselors, to get involved in this process (see the “get involved” box at the end of this article for more information).

Morgen, an assistant professor of counseling and psychology at Centenary College in New Jersey, says he often hears from students and young counselors who are frustrated with the extra requirements addictions counselors face.

“I’ve seen it firsthand, over and over and over again,” says Morgen, who is an LPC, national certified counselor and approved clinical supervisor.

Students who are very qualified, including those who have completed internships at addictions facilities, are having to get an additional license or certification beyond their LPC to find work in addictions facilities — despite the fact that the scope of practice of LPCs in their states covers all of the DSM, says Morgen.

“Depending on the state, that’s a lot of extra time and extra money,” he says. “Because of an outdated system, [young counselors] are being driven away. … It’s a whole body of counseling being forced into a burdensome process. It’s fragmenting the entire field.”

Some addictions facilities require counselors to have an extra state-level license before they’ll hire them, explains Morgen. “For example, in New Jersey, an LPC can do addictions work, but LPCs or recent grads [who are] logging hours for licensure are being told by facilities that they’d prefer the applicant to get the addictions license on top of the LPC,” he says.

Morgen says he’s also heard of this happening in Illinois, Ohio and Pennsylvania recently.

This model also creates frustration for many veteran counselors. In some states addictions work is restricted for an LPC, and LPCs must refer any client who presents with an addiction issue in a counseling session to a certified/licensed addictions counselor, says Morgen.

Having to refer a client to another therapist mid-program is disruptive to the client and frustrating for the counselor, he says. It’s also counterintuitive, he adds, because addictions are often coupled with anxiety and other issues that clients typically work through with LPCs.

The IAAOC task force formed in February after receiving approval from the committee’s executive board. Morgen co-chairs the task force with Geri Miller, a professor of human development and psychological counseling at Appalachian State University in North Carolina. Also on the task force are Kristina Depue (University of Florida), IAAOC/CACREP training standards committee chair; Nathaniel Ivers (Wake Forest University); and IAAOC legislation/advocacy committee chairwoman Christine Chasek (University of Nebraska-Kearney).

Over the next year, the task force will consider “recalibrations” that could be made to graduate course work and licensure requirements to make things easier for working and incoming counselors to enter the addictions field with their LPC, Morgen says.

However, Morgen stresses that the aim of the task force is not to eliminate the field of addictions counseling.

“We’re not saying ‘get rid of addictions counseling,’ but [instead] ‘get LPCs into the mix,’” he says. “LPCs need to be more integrated into the work with addictions clients alongside addictions counselors. And, just like any other DSM disorder class, LPCs should not be in any way boxed out and declared not eligible or qualified to work with a population. How much graduate school training do we all really get on any DSM disorder class? For example, how much classroom and practical training do we really get focused entirely on mood disorders? Yet, there are no obstacles for LPCs to work with mood disorders once they graduate. They simply transition into working at a facility with no required extra training for additional licensure/certification besides the work for LPC. This issue fits neatly within [the 20/20: A Vision for the Future of Counseling] initiative, and we’re trying to help ACA link our issue to 20/20.”

“Geri [Miller] and I firmly believe that effective counseling on substance use disorders does require specific and rigorous counselor training,” Morgen says. “But we also believe the current national practice of credentialing and training must change. State by state, outdated and burdensome rules are keeping countless qualified and capable counselors from entering the addictions field.”

“That’s what we believe and why we’re doing this.”




Get involved


To participate in the IAAOC task force, email Keith Morgen at morgenk@centenarycollege.edu by May 12.

The task force welcomes counselors who have experienced frustration with the issues mentioned in this article, such as having to refer a client out of session to an addictions specialist, or being informed of a need for additional addictions licensure/certification, says Morgen.


For more information on IAAOC, see IAAOC.org




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

Follow Counseling Today on Twitter @ACA_CTonline


Online gambling addictions up, despite absence from DSM

Heather Rudow December 5, 2012

(Photo: Wikimedia Commons)

The number of online gamblers who exhibit problem gambling behaviors has increased dramatically in the past decade, according to reports. However, online gambling addiction did not find its way into the soon-to-be published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), and future editions don’t seem to have plans to feature it any time soon — which troubles some addictions counselors and problem gambling specialists.

Julie Hynes, the problem gambling prevention coordinator at Lane County Public Health in Eugene, Ore., believes the reason online gambling has yet to be recognized by DSM-V is because it is still a relatively new problem on the radar of mental health professionals. InterCasino, the first online casino, launched in 1996.

What Hynes says she finds more controversial, however, is actually the classification of problem gambling itself in the DSM-IV.

“Many experts do not consider problem/pathological gambling as an impulse control disorder as it is currently classified,” Hynes says. “Many consider problem gambling to be a behavioral addiction.”

Proposed drafts of the DSM-V would categorize problem gambling as a behavioral addiction instead.

Pathological gambling was officially recognized as a disorder in 1980 when it was included in the DSM-III. The DSM-V, set to publish in May 2013, includes “Munchausen by Internet” and has Internet addiction listed under the category for “future study.”

Hynes is not a member of the American Counseling Association, but she delivered the keynote speech on online gambling at the Midwest Leadership Institute and Nebraska Counseling Association Annual Conference in October.

Doyle Daiss, an alcohol and drug counselor and current president of the Nebraska Counseling Association, believes online gambling addiction should be included as a part of the pathological gambling diagnosis in the DSM.

“I am hopeful that future research will focus on online gambling issues to identify what, if any, differences exist between traditional and online gambling addictions, as well as different interventions that can create a best clinical practice guideline when addressing online gambling behaviors,” says Daiss, a member of ACA.

Daiss has personally noticed an increase in online gambling behavior among his clients over the past five years. “Gambling behavior is an area that has largely been under-assessed during the pretreatment assessment, in my opinion, and yet it is often present in clients whose presenting problems are not gambling in nature.”

Because of this increased awareness of gambling being a possible secondary issue to mental health and substance abuse problems, Daiss began screening for it more earnestly and has found it to be present in many of his clients and in situations that he might previously have missed.

Hynes says gambling addictions in the U.S. have increased substantially due to the increase in online gambling sites.

“In the mid-1990s, there were only about 15 online gambling sites,” she notes. “Today, there are over 2,600 sites and, despite its illegality in the United States until 2012, over $4 billion a year has been spent on online gambling by Americans [according to 2011 statistics by the American Gaming Association]. It is expected that with the recent legalization of online gambling in the U.S., the amount of money spent will rise significantly — global revenue for online gambling in 2010 was $30 billion.”

Hynes has found online gambling to be most prevalent among the young adult population — especially among college students. She cites their tech savviness, newfound freedom from their families and “access to discretionary money” as key factors.

“I’ve seen and heard from many youth and young adults who’ve grown up with online gambling around them, whether it’s seeing ads for online sports books, playing at  ‘free’ online casinos or other ways of engaging, online gambling has become an ingrained part of the Internet culture,” Hynes says. “I’ve talked with kids who play with their parents’ credit cards, often even together, as it’s seen as a way to bond. All too often, parents don’t even realize that online gambling can be very risky.”

Daiss echoes Hynes’ observation. “I have personally noticed online gambling becoming more prevalent among males, 21 to 30, who are also struggling with mental health or substance abuse issues in which isolation is an issue,” Daiss says.  “Those individuals with whom I have worked have isolated themselves in their house with their computer and initially begin participating in online gambling in which token money is utilized. Within a short period of time, however, they begin utilizing sites in which real money is exchanged via a credit or debit card.”

Hynes says counselors often stereotype gambling addicts based upon general risk factors, which can be problematic.

“We need to remember that there are people from all walks of life that can and do develop addictions to electronic forms of gambling,” she says. “For example, the mom who stays at home might escape from her stress with some online games, and she develops a gambling problem. The disabled veteran who finds that gambling online gives him an outlet and connection to the outside world, and he finds himself borrowing money and against his mortgage payments to gamble.  And so on.  Counselors should be aware that gambling addiction can move quickly and can easily be hidden behind other addictions. Counselors need to screen for pathological gambling in their assessments and throughout the therapeutic process —particularly if there are warning signs [such as] suicidal ideation, mentions of debt, bankruptcy, relationship problems, etc.”

Daiss agrees, saying he believes that gambling behaviors as a whole often go undetected and that addictive gambling behaviors go undiagnosed due to counselors’ personal assumptions or lack of knowledge.

“Good, bad or indifferent, gambling is a prevalent activity in our culture that in recent times has experienced a perception that it is a legitimate form of entertainment,” he says. “Because of this ‘legitimacy,’ I believe counselors may be inclined to overlook online gambling behavior or may fail to educate themselves in the process of online gambling behavior. If the symptoms are missed, the addiction is allowed to continue toward the inevitable outcome that ruins lives.”

 In one specific instance, the wife of a client Daiss treated made note of the manner in which her husband’s online gambling was done “right under her nose. She stated her husband would spend extended episodes of time on the computer gambling,” Daiss recalls, “but she was unaware of it because each time she approached him on the computer he would minimize the window of gambling and maximize a ‘legitimate’ window. She did not find out until several months later — when he was unable to pick up the mail ahead of her to secure the credit card bills — what was actually occurring.”

Hynes says that there are a multitude of side effects from gambling, impacting both the gambler and those close to them:

  •  Suicide attempts and ideation: This is one of the most harmful effects of problem gambling in general. In Oregon, almost half (48 percent) of all problem gamblers entering into treatment reported suicidal ideation within six months of entering treatment; 9 percent actually attempted suicide. (Oregon Health Authority, 2012)
  • Increased withdrawal from family, friends and usual interests as greater amounts of time are spent gambling.
  • Mood changes and swings: The gambler can be excited about wins, dejected and/or angry after losses and exhausted from hours of being engaged in gambling.
  • Debt: The average problem gambler in Oregon owes $30,000 in gambling-related debts. (Oregon Health Authority, 2012)
  • Criminal behavior: It could be crimes of theft but often is “white collar” crime, i.e., writing bad checks, embezzling from employers, etc.
  • Concurrent addictions: Problem gamblers have high rates of co-occurrence with other mental health and addictions issues.

Daiss believes the harmful effects of online gambling are similar to other addictions, “inasmuch as the person becomes preoccupied with the behavior and begins to lose control over the activity and how much is spent,” he says. “Those with whom I have worked state that they did not begin experiencing financial problems immediately due to the nature in which credit cards can be repaid, thus the financial amount that is repaid is a fraction of that which is actually borrowed. Within a short period of time, however, they begin applying for and receiving new credit cards, causing a financial  ‘house of cards.’ Eventually, the financial burden impacts their life and their family’s life, as monies set aside for staples in life have to be used to repay credit cards. Unfortunately, the addiction remains in place and becomes secondary to the financial turmoil, so the cycle continues. Before ‘rock bottom’ eventually occurs, the addict and their family are tens, if not hundreds, of thousands of dollars in debt, with no legal way to repay it.”

Hynes says online gambling and electronic gambling, however, differ from other kinds of gambling because of the time it takes to become addicted.

“Where ‘analog’ problem gambling [such as] sports bets, horse track betting, etc. often takes years from onset to [become] pathological behavior,” she says, “electronic gambling addiction has the tendency to develop rapidly.”

Hynes attributes this to a variety of factors, including:

  • Easy access.
  •  The isolative, anonymous nature of the medium and the ability for individuals to hide their behavior.
  • Rapid rate of play (e.g., casino card games have an average rate of play of about 30 hands per hour, compared to online poker, which can average 60 to 80 hands per hour, and many players play more than one hand at a time).
  • Decreased perception of the value of cash (i.e., players are forgetting that they are spending real money).

“The above factors can all too easily create a perfect storm for addiction,” Hynes continues. “Add in other risk factors, such as ADHD or concurrent substance addiction, and [it] is easy to see how electronic gambling can be highly addictive and very difficult to manage.”

In the clients Daiss treats — primarily people suffering from drug and alcohol addiction — who eventually disclose having an online gambling addiction, many “[indicate] that the primary difference is how the gambling can occur from the safety of the home,” he says, “thereby allowing them to participate in gambling behavior without requiring them to enter the traditional gambling world of casinos or other public venues. Again, this is a lucrative element to those individuals who are struggling with mental health and substance abuse issues in which public interaction is problematic.”

Daiss believes the best approach for professional counselors in helping clients with a gambling addiction is to ensure that pretreatment assessments include a gambling screening instrument and that they continue to screen for gambling behaviors throughout the treatment session. “Once an online or traditional gambling addiction is identified, the best approach is for that therapist to make a referral to a qualified counselor,” he says, if they don’t already specialize in that area.

Hynes says counselors “can and should” screen for problem gambling with a two-question test called the Lie/Bet Questionnaire for Screening Pathological Gamblers. Visit preventionlane.org/lie-bet for more information and to download the screening tool. Hynes says it is also important for counselors to get connected with problem gambling resources and specialists in their region.

“If counselors are unsure about resources, they might start with contacting the National Council on Problem Gambling for information about local resources,” she says. “The council’s website, ncpgambling.org, provides a ‘counselor search’ resource for all states. While there are many similarities between problem gambling and other addiction and mental health disorders, there are also distinct differences in problem gambling that are important to address. Access to money is one example.”

Additionally, the National Council on Problem Gambling operates a 24-hour helpline, 800.522.4700, and Gamblers Anonymous (gamblersanonymous.org) provides information about problem gambling and locations of groups around the country.

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.

Alcohol screening and brief counseling interventions for trauma unit patients

Nathaniel N. Ivers & Laura J. Veach December 1, 2012

Laura Veach offers counseling services to patients in a hospital trauma unit.

As I (Laura) prepare to see another patient, I read the quick details indicating he has an alcohol-related injury. His blood work showed an alcohol level of .16, two times the legal limit of intoxication. He fell off a ladder and has a mild concussion with a nasty cut above his swollen and bruised right eye. He probably won’t be here in the hospital trauma center long. He is in the “day” hospital and represents one of the 1,000 people we have seen for alcohol screening and brief counseling interventions in the past five years at Wake Forest Baptist Medical Center.

So, I walk toward him — toward hope that maybe, just maybe, this will become a memorable, teachable moment for him. And maybe, just maybe, this amazing set of professional counseling skills that I have acquired and honed over 30 years will be there for him in just the right way, at just the right time, to help him as he explores changing his risky drinking patterns. He is not diagnosed as an alcoholic, but he does infrequently overdo drinking and is assessed as a risky drinker.

My route takes me past the waiting area for the intensive care unit (ICU). At least 30 people are here, speaking in hushed tones. I know intuitively why they left their cozy family homes so early on a Saturday morning to assemble here in these sterile concrete hallways where there is nowhere to suffer silently under the harsh lighting. I am struck by the sheer force and heaviness of their worry and pain.

So many young faces are in this waiting area. They are here not for one of their own but for two: two teenagers, ravaged, lying in beds, surrounded by prayers and forever changed, the focal points of all the heroic efforts our highly specialized trauma surgeons and medical team can provide.

The trauma surgeon’s medical notes, written upon her initial exam of the teenage driver, rattle back and forth in my mind, like gravel pinging loudly in a tin can. They are reverberating words that cannot be erased or forgotten: “Skull fracture, severe.” The prognosis is dire.

I can imagine the pure, carefree, wide-open joy this 19-year-old felt the previous night as he entered that twisting curve, the wind in his face, and popped the top as he rode that powerful rocket into the night. Knowing he had such power at his fingertips, heightened oh so sweetly by those liquid kisses from that last ice-cold blue can.

Such total freedom — then.

Now, he and his rider, an 18-year-old friend, lie in tubes and plastic in the ICU. Their connection to this day is tenuous at best. Will this be a teachable time for any of the caring neighbors, the classmates, the church members, the community leaders, the parents? So little is spoken about the drinking.

Both the driver and his passenger had alcohol levels far exceeding the .08 legal limit to operate a vehicle, and both were under the legal drinking age. What do we make of this? Do we keep our silent vigil?

We have learned through extensive research that approximately half of the patients admitted to hospital trauma centers have alcohol-related injuries. Now, as I go to see the man in the day hospital to provide alcohol screening and a brief counseling intervention, what will he see? How willing will he be to see the connection between his injury and his risky drinking? Will he be open to exploring change?

There is an enormous weight attached to my work here at this hospital, teaching many counseling student interns and doing what many say shouldn’t be done by counselors. Naysayers question whether anyone will really make changes to their drinking habits after just one counseling session. Yet quietly, and frequently, we see trauma unit patients making these healthier changes. Our own research, as well as the research of others, confirms that many of these individuals sustain those changes.

So, I walk on. I walk on this Saturday morning, just like many other days, toward this injured person and toward hope that maybe, just maybe, this will be another memorable, teachable moment.

The purpose of this article is to introduce counselors to a community context — the hospital trauma unit — in which counselors historically have not been represented. We believe, however, that counselors, because of their unique set of skills, can provide an invaluable service in these units. The individuals depicted in this account are based on composites rather than on any actual cases.

Negative effects of alcohol

According to statistics from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), approximately 65 percent of U.S. adults drink alcohol. An estimated 9 percent of U.S. adults drink in an addictive or abusive pattern, while an additional 19 percent drink in risky patterns, often involving binge drinking; 72 percent of U.S. adults either do not drink alcohol or do not exceed the NIAAA risk limits when drinking.

NIAAA has indicated that males younger than 65 who drink more than four standard drinks in one day and 14 or more standard drinks in one week are more susceptible to alcohol-related harm, such as violence, accidents and alcohol dependence. (A standard drink equates to one 12-ounce beer or one 5-ounce glass of wine.) For females, NIAAA has indicated that more than three standard drinks in one day or more than seven standard drinks in one week constitutes “risky drinking” behavior that may lead to alcohol-related harm. NIAAA also has a resource for those exploring changes to their drinking habits, called Rethinking Drinking, which outlines a number of negative effects from alcohol.

According to NIAAA, alcohol is a contributing factor in 60 percent of deaths resulting from burns, drowning or violence; 50 percent of severe physical traumas and rapes; and at least 40 percent of fatal car crashes, suicides and deadly concussions from falls. In addition, heavy drinkers often have a greater risk of physical deterioration such as cirrhotic liver failures, heart attacks, vascular strokes, insomnia, depressive disorders, gastric bleeding, numerous cancers and sexually transmitted diseases. Additional alcohol-related complications thwart effective management of diabetes, hypertension and anxiety. Drinking by pregnant women can cause serious brain damage and other complications to the unborn infant.

In summary, negative effects from alcohol use are seen throughout the spectrum but particularly among the 28 percent of individuals who drink excessively or addictively. Our alcohol screenings and counseling interventions are focused on these individuals.

The teachable moment

A Level I accredited hospital trauma center provides the best in trauma care and is required to provide alcohol screening and brief intervention to patients when clinically indicated, such as when patients enter the unit inebriated. (Note: Given the context of this article and the language used by hospital staff, we will most often be referring to “patients” rather than to “clients.”) In many hospitals, nurses and other staff complete these screenings and interventions. Our particular hospital is one of a very few in the nation engaging counselors to provide this service. We thought that counselors would be effective in this role because of their training in active listening, rapport building and empathy, their attention to multicultural considerations and their skills pertaining to alcohol and substance abuse.

The motive behind providing this service in trauma units is simple. Faced with a crisis (in this case, the realization of being seriously injured and in a hospital as a result of alcohol use), patients may be more amenable to the idea of making healthy changes regarding their consumption of alcohol. Counselors can help patients explore their alcohol use and connect the dots between their alcohol use and their health risks. Without the screening and brief interventions, however, many patients may not consider the connection between their alcohol consumption and the injury that brought them to the hospital.

Our Teachable Moment research study was funded by the Robert Wood Johnson Foundation. The research team, led by physician Mary Claire O’Brien, also included co-investigators Beth Reboussin, Laura Veach and Preston Miller. The primary goal of the project was to analyze the effects of two brief counseling interventions on patients’ alcohol consumption: a quantity/frequency intervention and a qualitative intervention. An auxiliary goal was to determine the potential role counselors could play in providing brief alcohol screenings and interventions to patients in hospital trauma units.

The quantity/frequency intervention consists of counselors focusing on how much alcohol patients consume (quantity) and how often they consume it (frequency) in a typical day and week. A key element of this intervention is providing education about risky drinking behavior based on research conducted by NIAAA.

The qualitative intervention consists of counselors eliciting information about instances when patients have “drunk too much” or have “overdone” their drinking. Patients are also asked what they believe might have contributed to these instances of overdoing it or drinking too much.

With both interventions, counselors provide patients with screening results, explore patient perspectives regarding their drinking behaviors, help patients to formulate goals for changing their alcohol behaviors (when desired) and emphasize the patient’s options in making changes, if any. Screenings and brief interventions, which generally last between 20 and 40 minutes, are done in the patient’s hospital room, usually at the patient’s bedside. Patients with more serious or advanced problems associated with alcohol, such as alcohol dependence, are encouraged to seek additional help and are given referrals to licensed counselors who specialize in alcohol dependence.

Cultural considerations

Multicultural considerations are key in our hospital trauma center, which serves a vast geographical area and a diverse patient population. For example, one patient might be airlifted from rural Appalachia with severe stab wounds; another patient might be a gang member severely injured in a car wreck who is transferred from an urban hospital; yet another patient may be a college sophomore from a local private university who was admitted through the Emergency Department after a serious fall. Each will have sustained life-threatening, alcohol-related injuries, and each will be offered alcohol screening and brief counseling interventions, with emphasis placed on cultural considerations to enhance each patient encounter. Cultural considerations are particularly emphasized when our patients speak a language other than English. In our region of North Carolina, this commonly involves Spanish-speaking patients.

We have had the opportunity to serve a diverse group of English- and Spanish-speaking trauma center patients. These opportunities have provided us with some insights into cultural factors that potentially influence alcohol screenings and brief interventions. Particularly, we have recognized that patients’ worldviews, or the way they make sense of the world, play an important role in how we assess and intervene with these individuals. Specific elements of worldview we have found helpful to consider include internal versus external locus of control, rugged individualism versus collectivism, high- versus low-context communication styles and personalismo.

Locus of control refers to an individual’s sense of control over and responsibility for circumstances in her or his life. Individuals with a strong internal locus of control believe they are the masters of their destiny and that their choices determine their circumstances. In the 1994 film Renaissance Man, Danny DeVito’s character expressed his internal locus of control orientation when he stated, “The choices we make dictate the life we lead.”

Conversely, an external locus of control — sometimes referred to as fatalism or fatalismo — refers to a person’s belief that life events or circumstances are attributable to external forces such as destiny, luck or God and are, therefore, beyond one’s control. Individuals with a high external locus of control may not respond well to interventions that emphasize a future orientation and goal setting as a priority.

Both the quantity/frequency and qualitative interventions described earlier are goal- and future-oriented in that patients are prompted to set goals for improving their drinking behaviors. This focus works well with patients who espouse an internal locus of control, but patients with an external locus of control may struggle with this approach.

To further illustrate this point, I (Nathaniel) will share an instance from a few years ago when I was providing individual counseling services to a middle-aged Latino male. During one session, I was attempting to help this client create a therapeutic goal that was both measurable and realistic. Nonverbally, he demonstrated a lot of hesitation to formulating a goal. I was puzzled by this reaction, so I mentioned to him the nonverbals I was noticing and asked for clarification. He said he was uncomfortable setting goals because it made him feel like he was “playing God,” which, to him, was inappropriate and unreasonable.

To be sensitive to his perspective, I decided that, rather than couching our work together in terms of goals, I would present it in terms of his values, which happened to be religion and family. Thus, instead of asking him to set goals, I asked what he believed his family or God would want for him and how he thought he could accomplish it. That approach seemed to work for him.

In a similar vein, the values of individualism and collectivism influence our work with trauma unit patients. Rugged individualism places value on the individual; one’s sense of meaning and worth comes from one’s individual accomplishments. A common phrase used in the United States that illustrates the value placed on individual responsibility is “He needs to pull himself up by his bootstraps.” Thus, in individualistic cultures, the smallest unit of society is the individual.

Collectivism, on the other hand, places value and responsibility on the collective, or group. In many cultures, the group is synonymous with the family. One’s value and worth comes from honoring one’s group or family. Familismo, a strong bond within a family, is common in Latino cultures. In a collective society, the smallest unit is the group, because individual values cannot be extricated from those of the group.

Most counseling theories and interventions have been developed by and for people who espouse an individualistic worldview. Thus, when working with trauma unit patients who valued collectivism, we had to modify our approach slightly. Rather than discuss individual goals in isolation, we would help patients tailor their goals to fit those of their family or group. We also asked all patients if they had people on whom they could count to support them in their goals.

I (Nathaniel) speak Spanish and provided alcohol screenings and brief interventions to Spanish-speaking patients. However, fluency in Spanish was not enough to be effective with these patients. It also was important to take into account high- versus low-context communication styles. In Beyond Culture, Edward T. Hall postulated that White Americans engage more frequently in lower-context communication than do ethnic minorities in the United States. In other words, White Americans often focus on what is being stated verbally and less on nonverbals and context. High-context communicators, on the other hand, place less emphasis on words and more on the context of the conversation, the paralanguage and the nonverbals being used.

Latino immigrants, who made up the majority of the patients I served, often communicate from a high-context perspective. Thus, it was very important for me to assess the nonverbals, the tacit messages and the nuances these patients used in addition to the actual words being spoken. For example, it is considered rude in many Latino cultures to say no to a request or to refuse something outright. Because we were running a study as well as providing a service, we had to describe the study in detail and ask patients if they would consent to participate. In a few instances, patients verbally consented but, when presented with the informed consent form, decided they “weren’t feeling well” or “would prefer to look over it and get back to me later.” In one case, a patient chose not to participate after giving verbal consent because he was not comfortable placing his signature on a white piece of paper (the informed consent form). Having lived in a Spanish-speaking country and having experienced high-context communication firsthand, I recognized that these comments, especially when coupled with the paralanguage and nonverbals, were polite ways for the patients to express they were not interested in participating in the study.

Personalismo, the valuing and cultivation of an interpersonal relationship, also influenced our work with Latino patients. Personalismo often is developed through mutual sharing. Thus, a good way for counselors to foster personalismo is to open up and share aspects of their lives with clients. This is important because, regardless of the context, one’s alcohol use is usually not a subject that people feel readily comfortable discussing. To help patients feel more comfortable discussing private, intimate and guilt-laden topics, we found it helpful to take a few minutes to connect with them by asking patients about themselves. With our Latino patients, that oftentimes meant sharing things about ourselves with which we felt comfortable, such as where we were from, where we learned Spanish, hobbies we might have in common with the patient and so on. Those few minutes were very helpful in breaking the ice and creating a sense of connectedness and trust that encouraged patients to discuss their drinking habits.


In providing this service to more than 1,000 individuals in an intense medical setting, it has become clear that offering alcohol screening and brief counseling interventions has substantial benefit to the recipients and to their loved ones. There is also benefit to the health care system in the form of reduced medical costs and reduced rehospitalizations for alcohol-related injuries. Then there is the benefit to society. Studies spanning several different trauma centers show a 50 percent reduction in subsequent DWIs when alcohol screening and brief interventions are provided.

The majority of those receiving our bedside alcohol screenings and brief counseling interventions have never spoken with a counselor previously, yet they overwhelmingly rate these sessions as positive and beneficial. Further, in our six-month follow-up phone calls, former patients report substantial improvement in their quality of life (this result corresponds to other screening and brief intervention studies). The majority of individuals also report a substantial reduction in drinking, showing trends of drinking below at-risk levels or abstaining.

We continue to increase our counseling services in a medical setting, placing emphasis on cultural competence, while also providing research, exemplary professional counseling and counselor education training opportunities.

“Knowledge Share” articles are based on sessions presented at American Counseling Association Conferences.

Nathaniel N. Ivers is a licensed professional counselor, national certified counselor, human services board certified practitioner and assistant professor in the Department of Counseling at Wake Forest University. Contact him at iversnn@wfu.edu

Laura J. Veach is a licensed professional counselor, licensed clinical addiction specialist, certified clinical supervisor and associate professor in the Department of Counseling at the University of North Carolina at Charlotte and in the Department of Surgery at the Wake Forest School of Medicine.

Letters to the editor: ct@counseling.org.

Working through ambivalence with adolescent substance abusers

Matthew Snyder & Lynn Zubernis April 1, 2012

As practicing counselors, we all have clients who are “easier” than others. The easy clients are motivated toward change, take action on established goals and internalize feedback readily. The other side of that coin is that we also have clients who are more difficult. They are not motivated toward change, do not perceive the need for change and are ambivalent toward counseling. We have all encountered the person who has experienced a heart attack but continues to smoke, or the person who keeps abusing alcohol despite DUIs, failed relationships and repeated hangovers. Why do some people change, while others continue to engage in self-destructive behaviors?

In many settings and with many populations, ambivalence is more the rule than the exception. Clients who are mandated for treatment by an administrator or judge, who are “forced” into counseling by concerned parents or loved ones, or who are simply “going through the motions” may exhibit high levels of ambivalence, and this can be a major impediment to positive change. So how, as counselors, do we best help these clients?

If we look at James Prochaska and Carlo DiClemente’s “stages of change” model, many of these ambivalent clients are in the precontemplation stage. In other words, they are not at the point in the change process in which they are able to make insightful conclusions. They do not see their behaviors as problematic, or if they do, they are most likely blaming an external entity or third party for their problems. When we have clients who are at an early stage of the change process, we want to help them begin to feel or think that they are ready, willing and able to make a positive change. To achieve this, clients must recognize that their current behavior is a concern, think that they will be better off if they change and believe they are able to change.

So, how do we get them from this initial defensive stance to a place in which they are internally goal driven and actively seeking solutions? William Miller and Stephen Rollnick (1991) and Thomas Bied, William Miller and J. Scott Tonigan (1993) established that certain critical conditions must be present for change to occur. These conditions include empathy, feedback regarding personal risk associated with current behaviors, emphasis on personal responsibility for change, clear goal options and the facilitation of client self-efficacy. Following this work, Robert Stephens and Roger Roffman (1996) found that brief treatments can be effective for substance use clients and can establish these critical conditions for change.

Building on these areas of critical research, which have been continued and expanded through the past two decades, this article will briefly discuss how to work effectively with ambivalent clients and provide some useful techniques and strategies for doing so. Because most of us work within the constraints of managed care, organizational constraints or merely the financial realities of the current economy, we will focus on brief treatments that empirical studies have demonstrated to be effective. The framework and interventions we present feature eclectic ideas from a variety of theoretical approaches to counseling, including humanistic, cognitive behavior, solution-focused and motivational interviewing paradigms.

Substance abuse is a serious problem among adolescents, who face significant stressors in competition for academic and job success, a lack of support from overstressed parents and school systems, and the challenges posed by formal operational thinking and rampant social comparison (including cyberbullying). It is widely accepted that both risk taking and resistance are developmentally appropriate parts of individuation. Thus, the approach outlined here can be particularly effective in helping teens and young adults to accomplish positive change.

The initial sessions

The first counseling session is always important. Ideally, it establishes rapport and sets the groundwork for client change. With ambivalent or unmotivated clients, the initial session is even more critical.

The goals of such a session are first to express empathy, then to develop discrepancies between what the clients want and the behaviors they are engaging in and, finally, to support the belief that clients can make positive change. Rapport is critical and hinges on the counselor’s expression of real interest in clients’ views. This means not being dismissive or making assumptions based on one’s own beliefs about what is “best” for clients.

We often tell our graduate students that counseling is not like putting together a barbecue grill — there are no printed instructions or one-size-fits-all approaches. Instead, a counselor has to listen, long enough and hard enough to “get it.” But how can counselors really know that we get it? When we do, clients’ behaviors and coping strategies will make sense — not in a general way perhaps, but in the context of their specific circumstances. Their behaviors may be kicking them in the backside, but somewhere, a reinforcement contingency is present that is keeping them dependent on this behavior. Oftentimes, clients also have a realistic fear of giving up the only coping strategy they have been able to find.

One important caveat is to avoid increasing the client’s resistance, which will result in the client tuning you out — and very little actual change. Try to steer clear of taking any kind of argumentative stance. This will help you avoid power struggles, including adolescents’ typically knee-jerk response to anything that sounds as if an adult is telling them what to do. Drawing from what humanistic psychology teaches us, the counselor should listen and reflect rather than judging or telling clients what to do. From a motivational perspective, it is important for all clients — but especially for adolescent clients — to make choices for themselves and to experience that choice as being internally motivated.

During the initial session(s), it is expected that adolescents will be ambivalent regarding change. Start from this premise and try not to expect otherwise. After the counselor accepts this and listens closely enough to understand the context of the client’s behavior, the next step is to develop discrepancies. These usually involve a client’s behaviors not matching his or her verbalized goals or affective expression. No matter how ingrained the coping behavior, even the most defended clients are aware on some level that there are costs to the behaviors they have adopted.

However, it is just as critical for the counselor to remember that clients likewise perceive benefits to their behavior. If the behavior is continuing, something is reinforcing it, and the perception of the client is that the reinforcements are currently outweighing the costs. As we often emphasize to our graduate students, every behavior has a reason — you just need to keep digging to figure out what that reason is. Beginning counselors commonly fear acknowledging the “positives” that clients associate with their addictive behavior, whether it be substance abuse, an eating disorder or self-harm. But the counselor gains credibility and the client feels as though the counselor “gets it” when both costs and benefits are discussed openly.

Having acknowledged the positives, we then want to examine the negative outcomes and make concrete comparisons between the two. We follow this with a systematic exploration of the feelings associated with these behaviors and outcomes. Change does not happen in an intellectual, rational vacuum. If the emotional costs of change are perceived as too high, clients will remain where they are — this makes perfect sense, because no one wants to incur emotional suffering.

The next step is to move forward to the future, examining how these behaviors affect the client’s long-range goals. The reinforcing impact of many coping behaviors such as substance abuse are limited to short-term pain reduction, and clients avoid awareness of long-term negative impact. It is human nature to prioritize stopping immediate pain over some future deferred benefit. Change will occur only if adolescents perceive a discrepancy between where they are and where they actually want to be, while also having the emotional regulation skills and substitute coping strategies to tolerate some discomfort in getting there. In other words, it makes sense to change only when the client (not the counselor) comes to believe that the good things about the problem behavior are outweighed by its adverse consequences.

A good way to get clients to express their ambivalence, as well as their awareness of some of the potential costs of their behavior, is through reflective listening. For example, a client who talks about feeling less anxious and more sociable when using marijuana but is also motivated to do well in school and concerned about the cognitive impact of use is expressing both positive and negative aspects of using. A typical reflective statement that points out one of these discrepancies would be “So, you are saying that you really enjoy the feeling of getting high, but at the same time you are afraid of losing brain cells.” If a client says, “Maybe I should start cutting down on my marijuana use a little bit before I lose my job or get suspended from school,” the counselor could follow with “So you see a connection between your drug use and problems you are having at school and work.” In making such a statement, the counselor is acknowledging and reinforcing the client’s insight, which naturally leads into more directive goal setting.

It may sound counterintuitive, but we want clients to become more distressed about their usage. People are motivated to change something when they’re in distress, so clients need to experience that distress. By first understanding and then challenging their defense mechanisms and pointing out the discrepancies, counselors can use this distress as a motivating factor toward change.

The early sessions should also be designed both to increase client motivation to address issues of concern and to empower clients for change by educating them about cognitive behavior approaches and the triggers to their substance abuse. It is important in these initial sessions for clients to start expressing motivational statements. These statements can be in the cognitive, affective or behavioral realms. For example, a client might say, “I guess maybe this is more serious than I thought” (cognitive recognition of the problem) or “I’m really worried about what’s happening to me” (affective expression). Motivational statements also include implied or stated intention to make changes, such as “I’ve got to do something!” or “I know I can do it if I put my mind to it.”

Later sessions

After the initial session(s), in which counselors have highlighted some discrepancies and clients have been able to verbalize some motivation statements, there are many techniques you can use to help clients progress toward goal setting and positive change.

Often, young adults who are abusing substances have a limited repertoire of alternative coping skills, so they are understandably reluctant to give up the ones they do have. Skill deficits should be explored and remedied, and new behaviors should be taught and practiced. This can be achieved through role-play, scripting or cognitive restructuring.

A functional analysis can also be very helpful at this point in the process. It will help clients explore and understand that there are antecedents and consequences that influence their usage patterns, and that their responses to these environmental contingencies are entirely understandable. Change the antecedents and consequences, and the behavior changes.

An understanding of the way in which their use is influenced by external factors, in combination with an emphasis on the client’s ability to change these, can be motivating and empowering. This approach also avoids pathologizing clients. Self-efficacy is an important component to later sessions. From this point, you can help clients come up with alternative behaviors and cognitions that will in turn alter their ultimate consequences.

Once clients have gained an understanding of how their behaviors are negatively affecting multiple aspects of their lives and have gained motivation toward change, the next step is goal setting.

Warning signals and how to navigate around them

Resistance is common when working with ambivalent clients. It should be expected but not ignored. Resistance might take the form of a client contesting some factual information or something the counselor has said. It might take the form of frequent interruptions to change the subject or be of the “yes, but …” variety. These should serve as red flags for the counselor, indications that you’re pushing too hard or trying to go too fast. Clients didn’t develop this coping strategy overnight, and it’s unrealistic to think they’ll discard it quickly either.

When you sense resistance, drop back and “roll with the resistance.” Repeat clients’ statements in a neutral, nonjudgmental tone, letting them know that you’re hearing them and that you realize what they’re saying is important. Express empathy with their statements, perhaps by reframing them toward the positive. Emphasize what clients are already doing that’s helping them move toward positive change. Shift focus away from obstacles that seem immovable to barriers that these clients have already been able to surpass.

Rather than arguing with clients, it can be helpful to try a paradoxical approach, siding with the problem instead of challenging it. Exaggerating what clients have said can sometimes help them to see the downsides of their coping strategies more clearly. For example, if a client has said that alcohol makes him or her more sociable, you can take that side by expanding the statement: “You can only talk to people and get to know them if you’re drinking, and it’s really helping you get to know people better and form some close relationships.”

Other motivational interviewing techniques are also useful in minimizing resistance. Asking open-ended questions (“What do you think about your alcohol use?” instead of “Do you know what drinking does to you?”), using reflective listening and validating the client’s worldview are all good approaches to use in helping the counselor to “get it” and helping the client to feel “gotten.”

Clients are more likely to attempt change and to persevere after relapse if the counselor has taken the time to get to know them and shared positive affirmations with them. Engaging in the helping process when dependent on a coping strategy that will be challenged takes a tremendous amount of courage. Reflecting that courage back to the client can be the starting point for real change.

“Knowledge Share” articles are adapted from sessions presented at past ACA Annual Conferences.

Matthew Snyder is an assistant professor and graduate coordinator in the Department of Counselor Education at West Chester University. Contact him at msnyder@wcupa.edu.

Lynn Zubernis is an assistant professor in the Department of Counselor Education at West Chester University.

Letters to the editor: ct@counseling.org

Don’t turn away

Lynne Shallcross June 1, 2011

Julie Bates offers a sobering thought to anyone who assumes that certain individuals choose a life of addiction. Bates, a doctoral candidate in counselor education at Penn State University, worked for three years at a methadone clinic in Massachusetts. One of her clients, a 23-year-old woman who exhibited track marks running from her shoulder down to her knuckles, had already been addicted to heroine and cocaine for a decade.

How had she gotten so far off track by the tender age of 13? Because her mother had injected her.

Bates, a member of the American Counseling Association, says that story stays with her wherever she goes, reminding her very clearly that clients with addictions need empathy and help, not judgment. While in treatment with Bates, the woman’s most difficult struggle involved rebuilding herself, redefining who she was after a decade of addiction and learning how to function as an adult without the addiction component.

In working with the woman for three years, Bates learned that addictions counseling is a long-term process. “Be patient,” she advises. “It’s not something that changes overnight or even over a couple months.” Although her client was able to stop using heroine after only about two months, it took closer to 10 months before there was any decrease in her cocaine use.

What helped the client finally make inroads in beating her addiction was writing letters to her mom, even though the letters were never mailed. In the beginning, the letters were positive, with the woman thanking her mom for her sacrifices and love. But as time went on, the letters became more “real,” Bates says, expressing such thoughts as, “Mom, you said you loved me, but you injected me when I was 13. What chance did I have?”

Through the process of writing the letters, the client realized she had been brought up to believe that when you love someone, you lessen their pain through drugs. Through counseling, she was able to tweak that worldview, learning that drugs do not equal love and that she was worthy of being loved on the basis of who she was, not what drugs she used or gave to others.

Counselors who don’t work in addiction clinics might not experience situations quite this extreme, but experts in the field warn that addictive behavior is often intertwined with many of the problems for which clients seek counseling. The realization that a client has addiction issues is daunting to many counselors who don’t specialize in that area. But Bates encourages those counselors not to turn away. “Don’t be afraid to talk to the client,” she says. “A big disservice would be ignoring [the addiction].”

Gerald Juhnke, professor and doctoral program director in the Department of Counseling at the University of Texas at San Antonio, says many clinical mental health counselors start their careers not wanting to work with anyone who has an addiction. In fact, Juhnke admits, when he set out in marriage and family counseling, he was one of those counselors who wanted to avoid addiction issues. But the reality is, when it comes to fairly common issues such as depression, anxiety or career and family problems, there is often an overlap with addictions, Juhnke says. Existing problems might compel a person to begin using drugs or alcohol or to engage in some other addictive behavior as a coping mechanism, or the problems the person presents with might be the result of a preexisting addiction. “Even though you don’t plan on seeing people with addictions, it will happen,” says Juhnke, a past president of the International Association of Addictions and Offender Counselors, a division of ACA, and former editor of theJournal of Addictions & Offender Counseling. “People rarely come in saying, ‘I have an addiction problem.’ They come in saying I lost my job, have problems in my family, etc.”

Sticking with an addicted client

Even when counselors don’t think they are skilled enough to work with addicted clients, Juhnke says automatically making a referral isn’t the best idea. Accredited master’s-level counseling programs include training in addictions work, so most counselors possess at least some knowledge in this area. Juhnke strongly recommends that counselors consult with a supervisor and then attempt to continue working with addicted clients. “The client might have a good relationship with you as the counselor,” he says. “If the counselor panics and says, ‘I can’t work with you anymore,’ then the client feels abandoned. They feel like, ‘I won’t tell anyone again that I have an addictions problem.’ If you’ve already got a good counseling relationship, don’t abandon the client. Get someone who can give you ideas and direction, and follow what they have to say,” advises Juhnke, who coauthored Counseling Addicted Families: An Integrated Assessment and Treatment Model with W. Bryce Hagedorn.

Kerrie Fineran, an assistant professor of counseling at the University of North Texas (UNT), offers similar advice to counselors who don’t specialize in addictions. She recommends that counselors seek supervision, educate themselves on the resources available in the community for addicted clients and refrain from automatically referring or including language in intake paperwork that indicates they won’t work with clients who are using. A referral may be necessary if a client needs help beyond what you’re able to provide, especially in cases in which outpatient therapy might not be enough, says Fineran, a member of ACA and IAAOC. “But the process of referral should be something that promotes hope and your belief in their ability to change and doesn’t destroy the trust they’ve built with you.”

If counselors are unsure about whether a client is exhibiting addictive behaviors, IAAOC President Juleen Buser says research often references the three C’s of addiction as a way to conceptualize some of the core characteristics. “Counselors can be on the lookout for these three C’s as they work with clients as a preliminary way to assess the presence of addiction: loss of control over addictive behaviors, despite the client’s aim to stop; compulsive use; and continued use regardless of negative consequences,” says Buser, assistant professor in the Department of Graduate Education, Leadership and Counseling at Rider University in Lawrenceville, N.J.

The addictions counseling field has made a significant transition over the past few decades, according to Juhnke. It used to be that most addictions counselors were former addicts in recovery, whereas now, Juhnke says, there is a movement of mental health professionals heading into the field with master’s-level degrees and a specialization in addictions work.

Juhnke notes the licensure situation regarding work with addicted clients can be complex. Requirements vary state to state, meaning that any licensed counselor might be permitted to practice addictions counseling in one state, while in another state, the counselor must also be licensed as a chemical dependency counselor to perform the same work. This can be frustrating and confusing, Juhnke acknowledges, especially for counselors with advanced degrees who are then informed they need yet another license to practice addictions counseling. On the positive side, he says, the effort to make the field more professional with licensed caregivers is laudable.

Although master’s counseling programs touch on addictions, Fineran says counselors who want to specialize in addictions work should seek additional training and continuing education opportunities such as conference presentations, workshops and specialty certification programs.

Addictions can come in the form of process or substance addictions, but regardless of form, addiction is still addiction, Juhnke says. “All addictions are very difficult. One isn’t more difficult than another. In general, substance disorders revolve around ingesting, inhaling, huffing, injecting or taking some type of substance. Process disorders generally revolve around ‘doing behaviors,’ such as gambling, shopping, eating, sex, pornography, running, weightlifting, etc. The No. 1 thing in treating addicted clients is respecting them and treating them as if they were your mother, father, sister or brother. Failure to treat persons with addictive disorders as a loved one first often results in misperceiving the client’s addictive behaviors as [being representative of] the person.”

Understanding the struggle

Students who enroll in Fineran’s drug and alcohol counseling class at UNT are going to feel deprived — and that’s just the way she wants it. Each semester, Fineran asks her students to commit to giving up a substance or a process for the duration of the course. The goal of the exercise is for the students to understand the process of addiction and develop empathy for the addicted clients with whom they’ll someday work.

“Many of them think that people with addictions should just stop, quit it and pull themselves up by the bootstraps,” says Fineran, who likewise commits to giving something up each semester. “It seems like a simple thing to stop something, but [with this exercise], they understand what the body goes through and what the mind goes through. They really struggle with it. They start to understand what individuals with these problems go through and gain an increased sense of empathy that they can tap into when working with individuals from this population.”

At the beginning of the course, about half of the students are excited to accept the challenge because they’ve been wanting to give something up but needed a nudge to follow through, Fineran says, while the other half are terrified and don’t see how the exercise will help them learn anything. By the end of the course, roughly 95 percent of the students say the exercise was an excellent tool that taught them about the process of addiction and about themselves.

Many of the students give up something that has a physical impact, such as cigarettes or caffeine, so it doesn’t take long for them to experience symptoms of withdrawal. Most of the students relapse at least once during the semester, so Fineran addresses that topic in class. Some of the students acknowledge that they simply no longer felt like abstaining, whereas others slip up without thinking, such as by ordering a Coke at a restaurant. Regardless of the reason, Fineran says, the students learn about the shame and guilt that accompany a relapse and, more important, learn about the process that led to their relapse. Fineran works with the students to create plans to recognize warning signs of a possible relapse and to head it off before it happens. The project is particularly worthwhile because these counselors-in-training may one day create similar plans with clients who have addictions, Fineran says.

The class also discusses how life presents continuing challenges in the recovery process. For instance, Fineran says, students who commit to giving up beer for the fall semester might not realize until later how this decision affects their football watching. Or perhaps they give up sweets only to realize what a challenge that will pose during the holidays. “They go home for Thanksgiving and find out what it’s like to live in a world where everyone else isn’t trying to give up what they’re trying to give up,” Fineran says.

In addition to giving up a substance or a process, Fineran asks her students to attend at least two recovery meetings in the community, followed by writing a personal reflection to share with their peers. The meetings are as impactful as the attempt to abstain from something, she says, because they show the students that real people — often those similar to themselves or even people they know — are struggling. In addition, students are often impressed and humbled by the sense of community and hope that they witness at the recovery meetings.

“People with addictions are often maligned,” says Juhnke, who requires students in his addictions classes to give up both a process and a substance for the semester in addition to attending multiple 12-step meetings. “We think they’re old drunks or old addicts and we shouldn’t pay attention to them. But if we think of them as moms, sisters, dads, etc., we see them as people, not as the behaviors.”

It can be easy to focus on the behaviors that often accompany an addiction — such as stealing, lying or cheating to secure another hit — without realizing that those behaviors take place as a result of a physical or psychological dependency, Juhnke says. “Take, for instance, an addict who steals his mom’s silverware or credit cards. We might say, ‘What a bad son.’ But those are the components of the addiction, not the person behind the addiction.” Putting his students in the shoes of an addicted person is an effective way of building empathy, Juhnke says.

Empathy is one of Carl Rogers’ core conditions of counseling, along with congruence and unconditional positive regard, but those conditions have a tendency of disappearing when the client has an addiction, Fineran says. “We often look at people and think, ‘Just quit! You lost your home, you lost your job, so just quit this.’ But empathy helps counselors see that clients with addictions aren’t really any different than other counseling clients.”

After their own struggles to give up a substance or a process, Fineran says most students realize that people with addictions are simply people with problems — just like everyone else. “It becomes less scary for them and less of a mystery about what addiction is about,” she says. “It’s really about people trying to make changes in their lives, which is the same as every other client who comes in who might not be addicted.”

“Without that empathy and understanding and care for our clients, I don’t understand how they could ever imagine that we believe in them,” Fineran says. “We need to believe in them. We need to believe that these people are worth the change.”

Motivation for change

Historically, treatment for clients with addictions has often been directive, confrontational and harsh, Fineran says, but the trend is moving toward a model that is more supportive and inclusive of Rogers’ core conditions. That’s good news, she says, because research shows people do better when they are encouraged and when someone helps them elicit their own motivation for change instead of simply “throwing the book at them.”

“One movement that has gained steam over the past two decades is a shift to treatment models such as motivational interviewing, which differ from earlier models that focused on more intensive confrontation of clients,” Buser says. “Motivational interviewing works from the premise that clients come to counseling at various levels of motivation. A counselor’s role is to meet the clients at their current level of motivation — not presuppose a client is ready for action when, in fact, [he or she] may only be contemplating the need for change.”

Buser says a counselor might first assess a client’s level of motivation and then work toward increasing that motivation. “Authors have discussed the use of scaling questions to assess readiness to change at the start of counseling. If a client is ambivalent about treatment, gentle questions and door openers can be used by the counselor to help the client explore this ambivalence. For example, a counselor might acknowledge the client’s tentativeness about change, while also pointing out the client’s dissatisfaction with at least certain elements of the addictive behavior.”

Empathy is a critical component of motivational interviewing, Buser says. “For example, clients who struggle with eating disorders, termed a process addiction, often hide their behaviors and experience a sense of embarrassment about … binge eating and purging behaviors. Empathy is critical in this sense, as clients will be more likely to open up and disclose their disordered eating practices if they feel accepted and understood by a counselor.”

Juhnke is also a proponent of motivational interviewing with addicted clients. Through the process of a counselor asking questions about which parts of a client’s life are going well and which parts are not, the client can reach a clearer understanding of what is going on in his or her life, he says. For instance, a client might present with marital problems, trouble holding a job or failing grades before the counselor figures out that an addiction is intertwined, Juhnke says. Although the client at first might deny that an addiction is part of the problem, as the counselor asks questions and the client continues to want a solution to the problem, he or she may begin thinking about the impact that addictive behaviors have on the situation. Motivational interviewing helps move clients from a precontemplative stage to a contemplative stage, Juhnke says, and often encourages them to “bite into the whole treatment process.”

If motivational interviewing doesn’t prove helpful, Juhnke next tries a solution-focused approach, which creates a target the client wishes to aim for. Instead of focusing on the problem and how bad it is, which can be overwhelming for the client, Juhnke says solution-focused techniques urge the client to think about what an improved life would look like and what changes need to take place to get there. “Clients can tell you what they need if you listen to them, and this allows them to have influence on the kind of treatment they need,” he says.

If a solution-focused technique isn’t the right fit for an addicted client, Juhnke recommends trying a cognitive behavioral approach in which the counselor helps the client gain insight into his or her addiction triggers and how to respond once those triggers hit. For example, with a client who comes home from work to an empty house, feels lonely and reaches for a beer, Juhnke might ask the individual for alternative ideas of how that void could be filled. Keep in mind, he cautions counselors, that the same solutions won’t work for every client.

Buser mentions additional therapies that are sometimes referred to as the “third wave” of addiction treatment, including narrative therapy. “Counseling strategies associated with this theory include externalizing the problem, which often involves naming the problem,” she says. “Counselors work to separate the addiction from the client, often by giving the addiction a name, such as ‘bulimia’ or ‘alcoholism.’ The idea is that, through this process of externalizing, clients will no longer internally connect with the addiction. Clients may come into counseling with the view that addiction is a part of them. In this narrative therapy technique, however, the addiction is cast as an external force, and the client takes on the role of actively working to fight against this addiction. Optimally, this reduces self-blame and inspires efforts to combat the addiction.”

A different kind of referral

Clients with addictions won’t always come through a counselor’s door by their own volition. Instead they arrive because they are mandated to counseling by the court system. Although that circumstance might appear to create an entirely different counseling situation, Rochelle Cade says much of the counseling process mirrors that used with other addicted clients. Another similarity is that empathy and unconditional positive regard remain crucial to the process, she says.

Cade, a visiting assistant professor at the University of Houston-Victoria who worked with court-mandated clients for five years, often allowed these clients to use the first or second session to “get things off their chest,” she says. Many clients are upset about why and how they were arrested, the court process, their punishment or their perceived treatment by a parole officer, among other things, Cade says. “In my experience, just listening with unconditional positive regard and empathy early in the counseling process is probably the single most effective intervention for establishing the counseling relationship with these clients. I have been told over and over again that no one else — not the arresting officer, attorney, judge, probation officer, family members, friends or bosses — just listens.”

Some people contend that clients who enter counseling of their own free will are more motivated or ready for the counseling process, says Cade, a member of ACA and IAAOC who serves on the editorial board for the Journal of Addictions & Offender Counseling. “Some would prefer that clients enter the counseling process with some insight into the problem or issue or at least have identified the issue for themselves. Court-mandated clients by title and referral do not usually meet these prerequisites for entering counseling.”

Although she uses the phrase “court-mandated,” Cade prefers to think of clients on a continuum of voluntarism rather than of dichotomies such as voluntary/involuntary or mandated/nonmandated. Many clients, not just those who are court-mandated, first come to counseling on the involuntary side of the continuum, she points out. For example, there is the client who goes to counseling because his wife threatens to divorce him or because his boss threatens to fire him if he doesn’t.

Although much of the counseling process is the same, Cade does acknowledge a few unique challenges in working with mandated clients. One is defining the identity of the counselor’s “client.” This most definitely includes the person in the room engaging in the counseling process but might also include the referral source, such as a judge, parole officer or case manager, or other elements of the community. Issues of confidentiality can also arise, she says. “Counselors, with a signed release of information from the client, complete progress reports and submit them to a probation officer, parole officer or case manager, report them to a drug or mental health court, or submit them to an attorney or judge,” Cade explains. “The counselor may abide by the ethical and/or legal parameters of confidentiality in providing these documents, but the recipient of the documents may not.”

Client autonomy can be another sticking point, Cade says, because when clients are referred through the legal system, typically, their “problem” has already been defined for them and the goals of their therapy have been predetermined. Many of Cade’s clients are ordered to participate in substance abuse counseling as a condition of probation for drug-related offenses. “The problem has been defined: marijuana use,” she says. “The goals have been established by the conditions of probation: Submit to urine analyses and have clean results, participate and complete counseling, and abstain from drug use.”

But if clients don’t agree that marijuana use is the problem or decide they’d simply like to decrease their use, that can be out of line with the court’s goals. “I have had several clients who smoked marijuana all day every day decide to cut their use to one joint at night before bed,” Cade says. “Is this reduction in marijuana use [considered] progress? According to the court, it is not. If the results of a urine analysis are positive for TCH, indicating the client is still using, [the court deems this a] lack of progress or failure to abstain from drug use.”

Termination often poses a final hurdle. Cade has had clients participate in counseling for several weeks or even months and then suddenly stop showing up, oftentimes because they’ve been sent to jail for probation violations, new offenses or other reasons. “When the client is incarcerated, the counselor does not have the opportunity to process the closure of counseling and ethically terminate the counseling process with the client,” she says.

Connecting the dots

Considering that people are complex, complicated beings, counselors say it’s not surprising that addictions often coexist with other issues. Certain personality disorders, including antisocial, borderline, narcissistic and dependent personality disorders, seem to have a “robust” connection with addictions, Juhnke says. Anxiety, depression and trauma also commonly accompany addictions, he says.

“Unresolved trauma can be common with many diagnostic subpopulations,” Juhnke says, “For example, I have often found my clients who fulfill Axis II borderline personality disorder have unresolved trauma resulting from sexual abuse or incest, or feelings — real or imagined — of abandonment by significant others. Drinking and drugging behaviors were common ways of attempting to cope with such unresolved or experienced trauma. Thus, asking clients about their history and paying close attention to potential traumatic unresolved issues is important.”

One client told Juhnke that drinking and using drugs were her way of dealing with feelings of abandonment after her ex-husband ran off with a younger woman. “She was able to clearly articulate why and how this unresolved trauma led to her addictive behaviors,” he says. “Removing her addictive behaviors without addressing the underlying trauma would have left her extremely vulnerable. Therefore, it is important to concurrently address any unresolved trauma and addictive behaviors.”

Grief and loss are also significantly interwoven with many addictions, Bates says, whether the losses occurred prior to the addiction beginning, were incurred as a direct result of the addiction or took place during the person’s recovery and set the client back. In circumstances in which clients were using when they experienced a loss, they may not have processed the loss properly and can come to counseling with built-up grief, Bates adds.

Common losses resulting from addictions are wide ranging, Bates says, and can include family, friendships, jobs/careers, freedom, health, finances and educational opportunities. Even in recovery, she says, addicted clients face the likelihood of loss, particularly as it relates to their friends and social identity because, in many cases, those things were tied to the person’s addiction. In losing the old support system, even if it was an unhealthy one, the person faces the daunting task of starting from scratch, Bates says.

“If you take the substance away, you have to reconstruct the identity,” Bates says. “When you have someone who hasn’t really had to form relationships without the presence of a substance, it can be hard to do. You have to relate to the new friends through personality, not through the substance. Sometimes it’s really difficult for people to do. They forget how to behave socially without the drug.”

Other losses that occur while the person is going through recovery, such as the death of a family member or a friend, can trigger a relapse, Bates cautions. Counselors should work with clients on the area of prevention, talking about how they can rebound from losses that might take place while they’re working through recovery.

Grief can also stem from giving up the addiction itself, Fineran says. “The addiction has been their best friend and their coping mechanism. When they give that up, there’s a process of grief they go through [in] reorienting to their lives without it.” Although counselors can focus on many positive aspects of recovery with clients, Fineran says it’s also imperative to recognize what clients might be giving up, such as the sense of comfort the addiction provided them when things weren’t going well and the people, places and things they fondly associate with the addiction.

Working through the grief

No matter what type of loss or when it occurs, Bates says the best thing counselors can do is to address it with addicted clients. Counselors don’t intentionally skip over grief work, she says, but sometimes more pressing concerns pop up in the context of addictions work, such as immediate health, safety and shelter concerns. But whenever possible, Bates suggests, counselors should remember to address losses the client has experienced along the way because those losses might be contributing to or sustaining the addiction. In many cases, she says, grief work enables the client to make better progress in recovery.

Bates says the focus of these interventions should be on recognizing both the positives and the negatives of the losses that addicted clients have experienced. One intervention Bates recommends is writing, whether it involves clients keeping a journal of their feelings and thoughts or writing letters. For instance, clients can write letters to the addictive substance, both ending the relationship and grieving the loss. Or they can write letters to their “using self,” such as “Dear using self, this is why I don’t want to be with you, this is what you took away from me, and this is what I’ll miss about you,” Bates says. A client in early recovery might write to his or her “recovering self,” explaining what he or she is looking forward to in the future.

“It’s really having them acknowledge what things they’re going to miss about the addiction, whether it’s numbing their feelings or feeling high when they need a pick-me-up,” Bates says. “It’s also remembering why we need to get rid of it and why it’s not useful.”

Whereas writing letters encourages clients to take the time to acknowledge both the positives and the negatives of their losses, journaling can help them create a log of their thought processes. Seeing their thoughts on paper aids addicted clients in identifying triggers and patterns they may have been unaware of previously, Bates says — for instance, how having a fight with a parent led to the client using afterward. The client’s journaling can also alert the counselor to grief and loss issues that had not come to light previously.

Another intervention Bates suggests is the creation of memory books, which can take either a positive or a negative focus. A client might make a positive memory book about a loved one who died, including what the client loved about that person, photos of the client and the loved one together and words or pictures cut out of magazines to describe the relationship. Creating the book can help the client process and acknowledge the loss, while memorializing the good things the person contributed to the client’s life.

On the other hand, Bates says, a negative memory book works well for addicted clients who are having a hard time ending their use. These clients might make a book about their addiction, including pictures of doctors or scars or any other bad memories associated with the addiction. “It’s a reminder of why I shouldn’t be using this, even if my body’s telling me I should,” Bates says.

Bates suggests additional techniques that can be helpful to clients dealing with addictions and grief, or addictions alone. Bibliotherapy is effective, she says, as is role-playing in groups, where clients can practice saying no to the addiction or work on new social interactions. Bates also recommends using music to help clients relax and having them draw or paint as a way of sketching out what their lives might look like with or without the addiction. Depending on the individual client’s coping skills, techniques such as guided imagery, meditation and progressive muscle relaxation can offer the client a tangible way of relaxing and regulating his or her body without a substance, Bates says.

Bates also points to Robert Helgoe’s book Hierarchy of Recovery: From Abstinence to Self-Actualization as a good resource for counselors working with addicted clients. Helgoe proposes two phases in recovery: the pull and the push. In the push phase, Bates says, addicts are pushed to remain sober to avoid the consequences of their addiction, such as jail time or liver failure. In the pull phase, the addict is pulled toward a new way of being and enjoying the rewards of recovery. Helgoe’s theory, Bates says, is that to move into the pull phase, a client must first fully grieve the addiction and all the losses associated with it.

Bates says counselors may find it worthwhile to talk with clients about the two phases and what will help them want to stay sober. “Consequences get you [the client] into treatment, but will they keep you here? We have to find something more valuable, and that’s [the client as a person],” she says. “If we can focus on the client as a thing of value, that’s worth working on.”

The spiritual side of addiction

Throughout history, spirituality and addictions have been linked, says Keith Morgen, assistant professor at Centenary College in Hackettstown, N.J., and a member of ACA. Using alcohol as an example, Morgen says that leading up to Prohibition, it was thought that alcoholics didn’t possess any morals, spirituality or godliness. “Addictions were considered as being immoral,” says Morgen, secretary-elect of IAAOC and chair of its Spirituality Committee. “[The thinking was], ‘Because they’re drinking or doing drugs, they’ve turned their backs on society or God.'”

But when Alcoholics Anonymous and the 12-step approach came into being in the 1930s, Morgen says spirituality became a source of strength and comfort for addicted individuals, a way to build themselves back up. “It’s a model for how [those with addictions] can spiritually exist in the world,” he says. The spirituality or higher power invoked in 12-step programs can be a traditional god or any other kind of spiritual, philosophical idea that guides one’s life, Morgen says. “When you do reach that last step, you’re said to have had a spiritual awakening. It’s at the end of the 12 steps, not the start. It helps you get to the point where you’re a spiritual, living member of the world around you.”

Reconnecting spiritually with family, friends, society and oneself is a key piece of the 12-step recovery, Morgen says. “The idea is that your addiction isolates you from the rest of the world. The 12 steps are a road map to get back to the world, the community, the people in your life and also yourself.”

Outside 12-step programs, spirituality can still be a crucial ingredient in the work that counselors do with addicted clients, Morgen says. Tackling spirituality is intimidating to many counselors, so Morgen recommends looking at it from the perspective of how clients see their place in the world — what they value and believe in, what gives them strength and what makes them feel full inside.

Counselors used to try to find out if clients had spirituality as a strength or coping mechanism and then wouldn’t delve any deeper, but they need to do more than simply “check the box” after asking the question, Morgen says. “If you conceptualize it as how [clients] have fulfillment, courage, strength, how they see the world — if all that stuff rolls into spirituality, you almost have to talk about that because that’s who the person is. To try to talk to [clients] about their issues, fears, addictions and trials without talking about values, beliefs, where it comes from, how it has meaning, how it shapes them, it’s almost impossible to do.”

Morgen’s advice to his fellow counselors is to understand that everyone has a different definition of spirituality, and each definition is right for that particular person. Even if clients don’t believe in a god or a higher power, just talking about their philosophical sense of what makes the world spin can be helpful to them, Morgen says.

What benefit can spirituality offer to addicted clients? For one thing, Morgen answers, it provides a point of reference. Many times, he says, in living with an addiction, what addicted individuals do, whom they hurt and what they lose become a blur to them. Spirituality provides these individuals a sense of foundation that they didn’t possess when they were in the throes of the addiction, Morgen says. “It gives you a way to look around and make sense of what’s gained, what’s lost, where you’ve come from, where you’re going and how you fit in to all of that. It gives you an ability to find some kind of meaning, direction and an anchor point.”

Recovery communities

Although popular among many people recovering from addiction, 12-step programs aren’t a perfect fit for everyone, says Gerald Juhnke, professor and doctoral program director in the Department of Counseling at the University of Texas at San Antonio. For clients who don’t connect with the spiritual emphasis of 12-step programs, Juhnke says a number of alternatives exist, including Rational Recovery and Secular Organizations for Sobriety.

Some clients might not be comfortable with the personal interactions that 12-step programs require throughout the various stages of recovery. “If that is the situation, the counselor needs to understand how to get the client the necessary environmental supports without 12-step programs,” says Juhnke, a past president of the International Association of Addictions and Offender Counselors, a division of ACA. “I must say, however, that it is exceptionally difficult to try to recover without changing one’s interactions with current ‘using’ friends. Twelve-step programing immediately provides a group of interpersonal supporters and a social environment where all are in recovery and most, if not all, are very supportive of the client’s personal recovery.”

Although the 12-step approach won’t work for every addicted client, Juhnke says one significant benefit of these programs is that they offer a good mix of people just beginning the recovery process with those who are further down the road. For those just starting out, he says, it can be vital to gain support from more experienced peers, while also being able to look to others for advice and wisdom when relapses occur.

— Lynne Shallcross

ACA addiction resources

The following books can be ordered directly through the ACA online bookstore at counseling.org/publications or by calling 800.422.2648 ext. 222.

  • Developing Clinical Skills for Substance Abuse Counseling (order #72895) by Daniel Yalisove provides a framework for understanding substance abuse and teaches the basic concepts and skills necessary for effective counseling ($29.95 for ACA members; $44.95 for nonmembers).
  • A Contemporary Approach to Substance Abuse and Addiction Counseling: A Counselor’s Guide to Application and Understanding (order #72888) by Ford Brooks and Bill McHenry offers a basic understanding of the nature of substance abuse and addiction, its progression and clinical interventions for college/university, school, and community/mental health agency settings ($35.95 for ACA members; $49.95 for nonmembers).
  • Critical Incidents in Addictions Counseling (order #78058) edited by Virginia A. Kelly and Gerald A. Juhnke explores the opportunities and challenges of working with clients struggling with addiction ($19.95 for ACA members; $24.95 for nonmembers).

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.
Letters to the editor: ct@counseling.org

Spotlight on eating disorders

As an assistant professor in the Department of Graduate Education, Leadership & Counseling at Rider University, Juleen Buser’s work focuses on process addictions and, more specifically, eating disorders. Counseling Today asked Buser, president of the International Association of Addictions and Offender Counselors, a division of the American Counseling Association, for her thoughts on the circumstances surrounding eating disorders and possible effective treatments.

Tell us a little about clients with eating disorders. What are they struggling with?

Clients who struggle with eating disorder symptomatology may be struggling with either clinical or subclinical levels of eating disorders. Two major clinical eating disorders include anorexia nervosa and bulimia nervosa.

Anorexia nervosa involves self-starvation behavior, and diagnostic criteria include weight below normal standards and a flawed view of one’s body as overweight. Bulimia nervosa involves binge eating, which is characterized by consuming a large amount of calories in a relatively short time period, a sense of loss of control regarding this food consumption and subsequent compensatory behaviors, such as self-induced vomiting or laxative use. In the new DSM-5 revision, binge eating disorder is planned to be included as a clinical diagnosis. This disorder involves the binge eating behavior of bulimia nervosa but does not include the subsequent compensatory behaviors.

Prevalence rates for clinical eating disorders have been documented to range from approximately 1 percent to 3.5 percent and, overall, are more common among females than males. However, researchers have documented that many more women struggle with subclinical levels of eating disorders — that is, behaviors and attitudes that would not necessarily conform to the criteria for a clinical diagnosis but are nonetheless concerning. Clients struggling with subclinical forms of eatingdisorders may diet frequently, vomit after meals twice a month and engage in a range of other problematic behaviors. Evidence also suggests that subclinical eating disorders can progress to clinical eating disorders. Thus, early intervention efforts on the part of counselors are vital.

Clients who struggle with eating disorder symptoms may engage in their behaviors as a coping strategy. They may utilize, for example, binge eating and purging as a way to manage a range of stressors in their lives — including their distress about their bodies. Interestingly, some research has noted that binge eating and purging behaviors are, in some ways, effective coping strategies, as certain negative emotions have been found to decrease after a binge-purge episode. Yet, other negative emotions, such as shame, have been found to increase after binging and purging. This could be a point of intervention for counselors, who perhaps work from a motivational interviewing perspective and seek to help clients explore ambivalence about treatment.

What techniques are especially helpful?

The field has recommended a multidisciplinary treatment model when working withclients who struggle with eating disorder symptoms. For example, medical professionals are often necessary to assess and monitor the physical health of clients, and working with nutritionists can also be incredibly valuable forclients.

In terms of counseling techniques, therapies such as cognitive behavioral therapy have strong empirical support in the literature. Moreover, authors have also discussed the import of experiential strategies. For example, given that clients who struggle with eating disorders frequently have challenges verbalizing their emotions, art-based techniques can be instrumental in theprocess of accessing and expressing emotional experiences.

Prevention efforts are also crucial. Researchers have documented a range of risk factors for eating disorder development, including dissatisfaction with one’s body and thin-ideal internalization, which refers to an individual’s belief that the thin body shape, often lauded by the media, signifies beauty and is an ideal toward which to strive. Counselors can target these risk factors in prevention programs. For example, some prevention programs introduce the construct of thin-ideal internalization and help clients evaluate this thin ideal and become critical consumers of media messages.

— Lynne Shallcross