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Substance Abuse and Counseling: A Perspective
Author: Amos Sales
Substance abuse is a critical problem in the United States across all segments of the population and impacts in some way all members of our society. It is the most prevalent mind disorder, the number one continuing health problem, and the number one prison problem in the United States (Inaba, Cohen, and Holstein, 1997). The significant number of the United States population having substance abuse problems is indicated by approximately 6% abusing illegal drugs, 12% having problems with drinking, 25% being addicted to nicotine and, conservatively, 10% addicted to prescription medications.
All counselors no matter what their specialty or setting will encounter clients with presenting or related problems of substance abuse. However, counselor education programs and their accrediting bodies do not require knowledge or skill development in this area. Thus, it is critical that we implement strategies to insure that all counselors in practice and in counselor preparation programs understand the process of substance abuse, the etiology of addiction, and related counseling and treatment approaches. An important step in this process is the identification of research supported perspectives on counseling with substance abusers.
Substance abuse is defined as the categories classified in the Diagnostic and Statistical Manual IV (DSM-IV) (American Psychiatric Association, 1994) as Substance-Related Disorders and Substance-Induced Disorders. These disorders include the active use and/or dependency on any mood-altering substance. Substances include alcohol, sedatives, amphetamines, cannabis, cocaine, hallucinogens, inhalants, opiod, caffeine, nicotine, and prescription drugs, as well as legal drugs. Similar addiction processes to those of substance abuse include experiences such as eating, gambling, sex, and work addiction. Addictive behavior is characterized by preoccupation with the substance or the experience, withdrawal symptoms after not engaging in the substance or experience, increased tolerance for the substance or activity in order to achieve the same effect, and continued use despite negative consequences. While similarities of behavior exist across all types of substance abuse, individuals cannot be categorized, defined, and treated in relations only to their substance abuse problem. An individual with a substance abuse problem is unique in his/her history, pattern of use and abuse, and counseling and related treatment needs.
While many models of causation of substance abuse have been proposed, no clear etiology has been identified. Models emphasize morality or individual conscious choice, biological or disease vulnerability, behavioral learning patterns, cultural-environmental concerns, or biopsychosocial impact. The biopsychosocial model views substance abuse as a complex interaction of all of the other models and endorses multiple strategies for counseling from these models as appropriate. Counselors need to review these models to develop a conceptual position regarding causation upon which he/she can make consistent therapeutic assumptions and decisions to guide counseling practice.
Conclusions regarding effective counseling strategies for counseling individuals with substance abuse are limited in that this counseling specialty area has been driven more by experience and clinical intuition than by research. As a result, most traditional substance abuse treatment programs (e.g., Alcoholics Anonymous, alcoholism education, half-way houses and therapeutic communities utilizing confrontation, group therapy, individual counseling, and use of medication) have not demonstrated their efficacy. Some successful treatment outcomes have been linked to short-term interventions, aversion therapy, stress management, solution-focused brief therapy, and social skills training, yet seldom are these methods utilized in traditional substance abuse treatment programs in the United States. Given this, conclusions regarding counseling and substance abuse have to come from general counseling research data.
Counselors, regardless of their settings, impact as change agents within the context of therapeutic relationships with individuals. Successful relationships are facilitated by a skilled counselor who helps the client become more invested in the process and who utilizes therapeutic techniques appropriate to the client. A thorough review of counseling outcome research (Sexton, Whiston, Bleuer, and Walz, 1997 pp. 58-62, pp. 87-93) concludes the following:
1) Counseling is a process beneficial to most clients of skilled counselors. However, it is not always so. A significant number of clients get worse.
2) Counseling models (e.g., cognitive, experiential, behavioral, dynamic) are effective and when compared, seem equivalent in their effect on counseling outcome.
3) Successful counseling has process factors which are common across the various counseling models. These factors include the counselor's establishing an open, trusting,collaborative relationship, facilitating client cognitive learning through reframing, feedback, and insight, and assisting the client in behavior changes through behavioral regulation, reality testing, and successful experiences.
4) Successful counseling outcome is dependent on counselor therapeutic skills such as focusing conversations on life problems, addressing presenting problems directly, and providing structure for counselor-client intervention.
5) Successful counseling progresses through various process stages, wherein different types of counselor-client interactions are reflected by different counseling techniques.
The above research conclusions support the following perspective regarding counseling clients with substance abuse problems. Counselors, to be effective, first must have the ability to develop an open, collaborative relationship with clients wherein clients perceive trust and commitment. Carl Rogers identifies, and research supports, this ability as related to the counselor's skill in conveying, in interaction with clients, unconditional positive regard and empathic understanding (Austin, 1999). Within this relationship, the counselor must provide focus for the process by addressing the client's presenting problems directly and identifying client need for change. Counselors of clients with substance abuse problems often find this process difficult because of the chronic nature of interrelated destructive attitudes and coexisting disorders these clients often bring to counseling. Once problem identification and client need for change are identified, the counselor must be able to articulate and implement counseling intervention strategies perceived by both the counselor and the client as appropriate to the client's need to change.
These process considerations in counseling clients with substance abuse problems hold to be true for specialists in this area and for counselors working in school, rehabilitation, mental health, and social work settings. The counselor emphasis is on the person not the substance abuse problem. Additional knowledge and skill on the part of the counselor relates to being able to assess the extent and impact of a client's substance abuse problem and the client's need to change. Familiarity with and ability to utilize standardized assessment instruments specific to substance abuse will help the counselor in this assessment process. Familial and social environment assessment also is required to identify the extent of and to utilize the client's support systems. The counselor's ability to identify the needs of the client and the quality of counseling and related treatment intervention strategies obviously linked to his/her assessment and diagnostic skills.
Counselors should be thoroughly familiar with the facilities and services in his/her community to insure proper referral for clients with substance abuse problems. Referral options are determined by client need and collaboratively agreed upon as appropriate by the counselor and client. These include short-term, inpatient care lasting three to seven days for withdrawal from substance abuse, or intensive, outpatient programs lasting eight to twelve weeks wherein clients maintain vocational and family responsibilities while participating in treatment. Another option, the half-way house, provides moderately structured and supportive residential treatment lasting for three to six months, wherein successful living within the environment becomes part of the treatment plan. Other options include therapeutic communities, structured, highly intensive, residential treatment program such as Synanon, where clients may remain up to two years, and out-patient alcoholism treatment programs of two kinds, drug-free clinics with services lasting four to six months, and methadone or opiate clinics that a client may attend by medical referral for two to five years. Within these settings, group treatment is the predominant mode of therapy with individual counseling viewed as an adjunct.
Substance abuse is a major social problem and concern for counselors. It is the most prevalent mind disorder encompassing some 40 percent of the diagnoses in the DSM-IV (American Psychiatric Association [APA], 1994), the number one continuing health problem, and the number one prison problem in the United States (Inaba, Cohen, & Holstein, 1997). Yet, school, rehabilitation, and mental health counselor education programs do not require expertise in this area as a prerequisite to receiving a degree. Given this, a need exists to implement strategies to insure that all counselors have expertise in this area.
This digest focused on identification of counseling outcome research implications for counseling individuals with substance abuse problems. The following conclusions regarding counseling individuals with substance abuse problems have been highlighted.
1) All counselors, no matter what work setting or clientele, will counsel individuals with presenting or related problems of substance abuse.
2) Counselors counsel and empower individuals with substance abuse problems versus treat the substance abuse problem.
3) Counselors must be able to establish the same open, collaborative, therapeutic relationship in counseling individuals with substance abuse problems as they do with other client populations. This ability is viewed as a prerequisite to successful outcome in any counseling setting.
4) Counselors must focus the counseling relationship on addressing the client's presenting problems directly and identifying client need for change.
5) Counselors must be able to articulate and implement counseling intervention strategies perceived as appropriate by both the counselor and the client.
6) Counselors must know community resources and procedures for referral to be able to insure access to effective and appropriate support services for clients.
American Psychiatric Association (1994). Diagnostic and statistical manual (4th ed.), Washington, D.C.: Author.
Austin, L. (1999). The counseling primer. Philadelphia, PA: Accelerated Development.
Inaba, D.S., Cohen, W.E., and Holstein, M.E. (1997) Uppers, downers, and all-arounders: physical and mental effects of drugs of abuse. Ashland: CNS Publications.
Sexton, T. L., Whiston, S. C., Bleuer, J. C., and Walz, G. (1997). Integrating outcome research into practice. Alexandria, VA: American Counseling Association.
Amos Sales, Ed.D., CRC is a Professor of Special Education, Rehabilitation, and School Psychology and Coordinator, Rehabilitation Specialties, the College of Education, University of Arizona, Tucson, Arizona.
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