Tag Archives: Substance Abuse & Addictions

What are we treating?

By Collin Nordby June 10, 2014

whatarewetreatingMental health treatment has greatly improved over the past century. It has moved away from exiling patients to mental “hospitals” and instead offers inpatient, outpatient, partial hospitalization, individual therapy, group therapy and several other options. There is, however, one specific mental health population that is underserved and underrepresented time and time again — the mental health population with co-occurring substance use and abuse (addictions). Substance use and abuse is on the rise all over the country. Why is it then that these individuals with a commonly co-occurring disorder are so infrequently treated by mental health professionals outside of the drug and alcohol community?

I have a personal powerful experience that illustrates this uncommonly treated mental health issue. Shortly after my family experienced the tragic death of two very close friends, all hell broke loose. Depression, anxiety and heightened levels of stress came out in everyone. For me, this resulted in exclusion from groups, hiding in the hallways at school and focusing only on specific tasks such as sports and grades. For my older brother, it resulted in experimentation with drugs and moving down a path of crime.

My parents forced me into counseling when I was 15, in my mind to keep me from turning down the road that seemed inevitable for my brother. My sister kept moving on and used this tragic event as motivation to push forward. My brother began to drink and drink some more and then find whatever drug he could to numb the pain he experienced as a result of his unrelenting grief.

My response and my older brother’s response to this tragedy were quite similar. We were both depressed. We both talked of ending our lives. In fact, there were threats and attempts. There were also times of panic in our home because someone couldn’t be found. Eventually, I was forced into counseling. Initially, this was against my will, but to this very day, I cannot thank my parents enough for doing that. It not only saved my life, but it also inspired me to help others and, hopefully, help save their lives too.

My older brother continued on the same path and would not listen to anyone. My parents tried to help him and talk him into counseling, but he refused. Eventually he ended up being arrested, spent five different periods of time in jail totaling roughly four years and has had eight different stints in drug rehabilitation centers. He has been hospitalized due to numerous suicide attempts and still talks of wanting to die (while currently in counseling and rehabilitation).

My experience with depression and anxiety during this time led to much-needed counseling and a deep growth experience that eventually led to my entrance into the counseling profession. My older brother’s experience of possible posttraumatic stress disorder (PTSD) and/or depression has led to drug addiction and a criminal record (in addition to a lack of treatment, he has never received any formal diagnosis aside from his addiction). To me, this suggests that PTSD and/or depression are not merely co-occurring mental health issues but rather pre-occurring mental health issues. While he has received treatment on several occasions, treatment has been pulled from him as well. Mental health treatment has always been an additional side treatment, never the primary focus. When a relapse occurred, often triggered by a specific event, time of year or painful memory, mental health treatment ceased to continue, thus moving him further into the depressive state of mind.

So, as you can see, this topic hits close to home for me. Growing up, I witnessed the destruction that addiction can have on a family. Experiencing several deaths and tragic events early in life has a prominent effect on what road an individual will take. For my brother, that road ended up being drugs, alcohol and crime. For me, it had the opposite effect. I saw what my brother’s actions did to him and to those around him. Don’t get me wrong. I was tempted to follow that same path and even tiptoed that line, but ultimately I made the decision to help those in need instead of joining them.

In my exploration of this topic, study after study validated the connection I see. A 1998 study by Pamela Brown, Robert Stout and Jolyne Gannon-Rowley found that 42 percent of women in an inpatient substance abuse treatment facility had co-occurring PTSD. The idea that PTSD clients frequently suffer from substance use disorders, while clients with substance use disorders often present with additional psychological disorders is represented in several studies, including from Pamela Brown, Patricia Recupero and Robert Stout in 1995; Sudie Back, Angela Waldrop and Kathleen Brady in 2009; and Ping Wu, Christina Hoven, Ngozi Okezie, Cordelia Fuller and Patricia Cohen in 2007.

Several studies discuss the implications this has on substance use/abuse as well. For example, Brown, Stout and Gannon-Rowley found that PTSD symptoms and substance use disorder (SUD) symptoms moved in a positively correlated manner; when PTSD symptoms worsened, SUD symptoms worsened as well. Wu and colleagues stated that “alcohol abuse/dependence was significantly associated with depression even after controlling for several potential confounding factors, such as other psychiatric disorders.” These issues seem to have been addressed rather readily in the late 1990s. So why are we not taking note of these findings and allowing them to influence current treatment?

This is where my interest turns from personal to public. Can we not see the obvious co-occurring mental health issues with addiction? Things such as PTSD, depression, anxiety, etc., are so commonly seen among this population by the general public, yet many counselors still refuse to treat an addict who is not currently clean or sober. Why? In 2008, Theresa Souza and Richard Spates pointed out that upward of 50 percent of individuals in inpatient treatment facilities for substance abuse also met criteria for PTSD. Is it not possible that the use continues because of that untreated mental condition? The issue of pre-occurring (or even co-occurring) mental health issues is one that does not seem to be new in the realm of substance use disorders, yet it is one that is commonly, in my opinion, overlooked. I have seen firsthand the impact that PTSD symptoms or depression or anxiety (you name the mental health condition, and it most likely fits) has on one’s substance use and abuse. So why are we not treating these as well?

Yes, there are arguments to be made that until an individual gets his/her substance use under control, we are limited in our abilities to assist them. But what about those who began using because of the pain they feel within? The ones who ultimately want to stop but cannot bear to be clean/sober long enough to face those emotions, memories and issues until the pain inside subsides. Are we not called ethically and morally to provide support and services to those that need them? Who is to say that some other mental health condition led to this substance use/abuse? What if this is not the major concern with this client? What are we doing to help them then? Sending a client to a rehabilitation facility to treat an addiction if we are not working toward the solution to the bigger problem is doing nothing to help the individual. The client will find a new way to cope with his or her issues. Maybe it won’t involve drugs, but let’s face it — it is likely going to be a socially unacceptable coping mechanism.

Granted, several agencies provide services for individuals with co-occurring addictions and mental health issues, but in many areas, these services are scarce and already overpopulated with clients. In the rural area I am from, very few treatment facilities provide treatment for co-occurring addictions and mental health issues even though we are in an area that surrounds one of the largest opiate usage areas in nation. With that in mind, how is an addict supposed to become sober if treatment for a co-occurring mental health issue is present?

I believe that mental health disorders are often the root cause for addiction. Oftentimes, in my opinion, mental health disorders are pushed aside when an addiction or substance use/abuse disorder comes to light. We often ignore what I consider to be the main cause for an addiction in these cases and attempt to approach the substance use/abuse disorder as the sole issue. I believe that by treating an addiction without assessing the full needs of the client and diminishing his or her mental health treatment, we are only covering the wound with a Band-Aid. Instead, we need to get to the root of the problem. Yes, addiction is an issue that needs to be dealt with appropriately. However, by diminishing the client’s other issues, we may be dealing with an issue (addiction) that will simply return once treatment has ceased. An Australian study by Wenbin Liang, Tanya Chikritzhs and Simon Lenton in 2011 points out that treatment of mental health disorders and substance use disorders has poor outcomes in cases in which one of the disorders is not diagnosed.

If we focused on the other co-occurring issue as well as the substance use issue, I believe we would see a dramatic rise in success rates for these individuals. I think that many times the addiction comes about due to self-medicating or as a coping mechanism. Taking away this way of dealing with the root issue without also confronting the root issue is akin to saying, “Your only problem is that you use (insert drug here).” If we can help an individual control his or her depression, worry, PTSD, etc., we can then approach the substance use issue from a broader lens — and possibly a more successful one.

I believe it is part of our duty as professionals to help serve and advocate for clients. Perhaps I am just a naïve graduate student looking for answers to a question that is beyond me, but maybe, just maybe, there are other professionals out there contemplating how to approach and help solve this problem on a daily basis like I do. It is to you I ask: What are we not doing? What is there that can be done to improve this issue? What are we missing?

We are called to be advocates for our clients, right? We need to advocate for appropriate services for those with mental health disorders co-occurring with addictions (substance use disorders). Addressing these pre- and co-occurring issues may improve treatment outcomes and lead to healthier and more effective treatment modalities.



Collin Nordby is a graduate student in the clinical mental health counseling program at Indiana University of Pennsylvania. He was recently chosen as one of six recipients of a 2014 NBCC Foundation rural scholarship, awarded to counseling students who commit to practicing in rural areas upon graduation. Contact him at rszs@iup.edu.

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