Substance abuse and dependence are complex problems that are often encountered in a counseling practice. Substance abuse and dependence have been defined as disorders that affect the mind, the body, and the spirit. This entry summarizes the background, definitions of the clinical problem, levels of care and counseling modalities, components of counseling and clinical approaches, and future of counseling for substance abuse.
Counseling for alcohol and drug problems can be distinguished from exploratory psychotherapy in its direct focus on attaining abstinence and problem solving around situations that can trigger a relapse or impede recovery. Historically, substance abuse counseling has been the preferred approach in community treatment programs in residential and outpatient settings. In addition, in most treatment settings, the emphasis on a disease model of alcoholism or addiction leads to a counseling approach rather than psychotherapy. Individuals with alcoholism or drug dependence tend to benefit from guidance, assistance with recovery-oriented decision making, and support for their capacity to cope with stressful events that can lead to relapse.
Key Terms and Concepts
Many terms are used to describe alcoholism and other substance related disorders. Some use substance misuse as a general term for the unhealthy or harmful use of substances. Substance misuse can include use of alcohol or other drugs with negative consequences to individuals’ social, psychological, and physical well-being.
Substance abuse, the most widely used term, has both general and specific meanings. In general usage, substance abuse is the catch-all term that is used in governmental department titles and federal grant programs to describe programs and services dealing with illicit drug use and alcohol misuse or abuse. More precisely, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) divides substance misuse into two main classifications: substance abuse and substance dependence. Substance abuse is a diagnosis having four criteria, at least one of which must be met within a 12-month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home; (2) recurrent use in situations in which it is physically hazardous such as driving an automobile; (3) recurrent substance-related legal problems; and (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of substances. In addition, individuals cannot have ever met the criteria for substance dependence for the particular class of substances.
Substance dependence is a more serious problem related to substance use. The term chemical dependency is often used to mean substance dependence and is used more often than substance dependence in Alcoholics Anonymous-oriented programs. Others use the term addiction or addictive disease to describe substance dependence, although addiction can include compulsive behaviors other than substance use, as in sexual addiction or gambling addiction.
Individuals diagnosed with substance dependence must meet at least three of the following DSM-IV-TR criteria within a 12-month period: (1) tolerance as defined by either increased use for the desired effect or diminished effect from the same amount; (2) withdrawal when the substance is abruptly stopped or the individual uses the substance to stave off withdrawal symptoms; (3) often taking the substance in larger amounts or for longer periods than intended; (4) desire to reduce use or failed effort to reduce use; (5) spending excessive time procuring the substance; (6) giving up social, occupational, or recreational activities because of substance use; and (7) continuing to use the substance in spite of negative emotional or physical consequences.
Recovery is a process undertaken by individuals who are working on their substance-related problems. Many counseling programs actively promote recovery activities such as participating in Alcoholics Anonymous (AA) or other self-help programs. Most of these recovery activities are called 12-Step programs because they are built around the 12 steps of AA, and many programs also use the 12-step framework for counseling.
Levels of Care and Counseling Modalities
Counseling has been the mainstay of substance abuse treatment across all modalities of care, including residential, intensive outpatient, and outpatient care. However, substance related problems are not treated in just one type of counseling setting. Instead, based on the assessment, individuals with substance-related problems may receive services in very intensive settings, such as residential treatment or intensive outpatient settings, or they may be seen in less intensive outpatient counseling offices. For individuals with substance dependence who cannot achieve detoxification on their own, the treatment episode may well begin with an inpatient stay in a hospital or in a nonmedical, residential detoxification program. Once detoxified, clients may be referred either to a residential programs or to other less intensive settings. The continuum of treatment is often described in terms of levels of care, and the American Society of Addiction Medicine has outlined levels with defined physical and psychosocial problems tied to different treatment intensities. Levels of care are also often defined as modalities of care because they describe different types of treatment setting. Counseling is typically a part of the treatment approach at every level of care.
Inpatient and Detoxification
During detoxification in either a hospital or a non-medical program, counseling generally has the primary goal of helping clients make the transition into an intensive, focused treatment, and recovery program. Medical detoxification programs use medications to provide a stepwise reduction in the use of intoxicating substances. For example, if the client has been using central nervous system depressants such as alcohol or tranquilizers, the detoxification will include the use of a similar medication in incrementally decreased amounts until the person is drug free. Likewise, clients on opiates may receive methadone in incrementally decreased amounts until withdrawal symptoms are expected to be very mild and unlikely to lead to a return to illicit opiates to blunt withdrawal effects. Nonmedical detoxification programs do not use any psychoactive substance to ease the individual toward a drug-free status. A calm environment and mild foods and drink are offered to create a reduced stimulus setting for withdrawal. During detoxification, clients generally lack the cognitive clarity needed to address the range of problems that will arise in changing their substance use patterns. At this phase, the goal is simply to stay on track with abstinence from any nonprescribed intoxicating substance and to prepare for and enter a comprehensive treatment program. Counselors may work with clients undergoing detoxification as recovery coaches who encourage clients to follow through with treatment, and as discharge planners who make arrangements for more sustained treatment.
After clients have successfully detoxified, they are often referred to residential treatment, which is a non-medical environment that typically offers intensive group and individual counseling services within a controlled, drug-free environment. Counseling in residential programs is often structured around 12-Step concepts. The counseling goals are threefold: (1) to support and strengthen client commitment to recovery; (2) to educate clients about the effects of substance use on the body, the mind, and brain, and on social, educational, vocational areas of life; and (3) to prepare clients for long-term aftercare counseling in outpatient settings. Residential treatment is usually thought of as the first major step in beginning treatment and recovery. Residential stays used to be very lengthy (6 to 18 months) and to rely on the therapeutic community which used other clients who were further along in recovery to provide supportive counseling. Current programs are typically 3 to 4 weeks in length and use professionally trained counselors as well as some counselors who have personal recovery experience with or without professional training.
Intensive Outpatient Programs
Sometimes used as an alternative to residential treatment, intensive outpatient programs (IOPs) offer a structured outpatient setting that is in between the confines of residential and the open-ended quality of weekly outpatient counseling visits. IOPs include 3 to 5 days of group and individual counseling and participation in 12-Step self-help groups for 3 to 5 hours each day. Clients receive an intensive regimen of counseling that either builds on residential counseling experiences or is the first substantial treatment after detoxification. The individual counseling sessions address the relation of clients’ substance-related problems to specific situational problems such as relationship problems (e.g., divorce or difficulty with children and parenting), employment problems, or personal experiences (e.g., emotional, physical, or sexual abuse). Group counseling addresses ways to maintain recovery-oriented behavior (i.e., remaining abstinent and watching for signs or triggers for relapse). In other words, the group counseling tends to address the common characteristics of addiction, substance abuse, or dependence, while individual counseling shows how specific personal issues relate to the addiction or substance use problem. Both forms of counseling are essential components of a comprehensive IOP program.
Outpatient counseling is the least intensive form of treatment for substance use problems. Outpatient usually includes mostly individual counseling, but it can also include group counseling. The focus of individual counseling is the same as in IOPs (i.e., how personal life issues relate to substance use problems). Outpatient groups focus mostly on the common characteristics of substance use problems. Outpatient counselors usually encourage clients to use 12-Step self-help programs (e.g., Alcoholics Anonymous or Narcotics Anonymous) in addition to counseling as a way of supporting their recovery processes. Outpatient counseling may also include the use of couples or family counseling.
Couples or Family Counseling
While not a separate level of care, family or couples counseling is distinctly different from other outpatient counseling approaches. The focus of couples or family counseling is centered on the whole family relationship and how it can contribute to substance use or recovery. The family members are seen as playing roles that can support or hinder recovery. Counseling approaches are aimed at engaging all members of the family in recovery because, to some extent, the entire family is affected by the problem and needs to make changes to promote the substance using member’s recovery. Family counseling may be used when any member of the family is the substance user—the husband, wife, grandparent, adolescent child, partner, or another person who lives in the home and is “like family.”
The premise of family approaches is that all members have roughly equal power and control (albeit sometimes tacit or indirect control) within the family. For that reason, couples and family counseling approaches are not indicated when the family has a violent or abusive member. When there is an abusive parent or partner, there is no power equilibrium and victims of abuse are not in a position to initiate change without threat to their safety. Hence, family or couples counseling for alcohol or drug problems is used only after violence has been ruled out by a thorough and competent assessment. Partner violence is typically seen either as situational or as a version of terrorism where there is a pattern of intimidation, coercion, and control. Cases involving milder forms of situational violence can sometimes be treated in couples counseling. However, cases of more persistent violence are not candidates for couples counseling.
Opiate Replacement Programs
There are some substance dependent clients who cannot achieve or maintain abstinence and whose repeated treatment attempts have failed. Two govern-mentally sanctioned alternative medical treatments exist for those clients whose dependence pattern involves opiates such as heroin, morphine, codeine, or the many prescription opiate pain killers: methadone and buprenorphine. The latter is often used in combination with an opiate antagonist to block the effects of any additional opiates that clients might use in addition to buprenorphine. Both of these medications are opiate substitutes that stave off withdrawal symptoms and block the effects of additional opiates. Counseling is a federal requirement for all licensed opiate replacement programs, and the counseling usually focuses on improving clients’ abilities to seek and maintain gainful employment, complete their education (that may have been neglected due to a drug user lifestyle), and abandon a life of crime.
Components of Counseling in Substance Abuse Settings
Counseling begins with screening to identify clients having a substance use problem. The Alcohol Use Disorders Identification Test (AUDIT), the Drug Abuse Screening Test (DAST), the Michigan Alcoholism Screening Test (MAST), and the CAGE (the acronym comes from first letters in key words in the questions) have all been used in counseling settings to screen for potential substance use problems. For clients who are identified as possibly having substance use problems, an assessment is the next step.
An assessment determines the scope and severity of substance-related problems. The assessment also guides the development of a counseling plan with clients. Assessment includes obtaining information about the specific substances being used, frequency of use, quantity of use, social context of use, route of administration (smoked, oral, or injected), age of first use and age of beginning regular use, and clients’ level of motivation or readiness for change. Counselors can use any of a number of standardized and validated instruments to guide the assessment process, but most assessments use semistructured interviews that draw questions from standardized instruments. Counselors may feel too constrained by lengthy questionnaires that make it difficult to remain client centered.
Generally, counseling assessment of substance use is more effective when substance use questions are delayed until there is a level of trust or rapport established between the counselor and client. Self-reports of substance use can be unreliable in the absence of trust and a beginning working alliance. The assessment must be thorough, however, because the more indirect approaches give clients too much room for denying problematic use. A direct, matter-of-fact, but kindly approach is most effective. Unless directly asked about specific substance use behaviors, clients may avoid bringing them up, thus misleading the focus of a counseling plan.
Assessing Motivation for Change
Counselors also need to assess clients’ motivation for change. Since the introduction of the transtheoretical stages of change model, substance abuse treatment has been attentive to clients’ level of interest in personal change rather than simply trying to make all clients accept the standard treatment package. This model identified five stages in the change process: (1) precontemplation: the individual has not yet begun to think about having a problem associated with substance use; (2) contemplation: the individual has begun to think about the problem and may have a distant intention to look into help; (3) preparation: the individual has begun a specific behavioral plan for change; (4) action: the point at which changes are now under way; and (5) maintenance: the person sus-tains the gains made during the action phase. The transtheoretical model is widely used in the substance abuse treatment field, regardless of the theoretical orientation underlying the treatment approach. For example, 12-Step-oriented programs make use of it as do cognitive-behaviorally oriented programs. It has the simplicity of offering a way to think about clients’ preparedness for counseling and the degree to which they are open to being challenged about their problem behaviors. The 32-item University of Rhode Island Change Assessment (URICA) is widely used to assess the client’s stage of change.
Assessing Problems Related to Substance Use
A wide range of psychosocial problems co-occur with substance use problems. The most likely co-occurring conditions are (1) mood disorders, (2) anxiety disorders, (3) posttraumatic stress disorders, (4) antisocial and borderline personality disorders, (5) partner and/or parental abuse, and (6) eating disorders. Other problems related to substance use may include housing, child removal/custody, legal problems, crime victimization, and social problems. Counselors initially screen for these conditions and then assess the ones that are positive for screening. Counseling approaches for assessing co-occurring disorders may follow DSM-IV-TR criteria or may involve assessment instruments. The difficulty with using instruments is that they can add considerable structure and length to a counseling assessment session since so many disorders can co-occur. For example, depressed substance abuse clients may also have posttraumatic stress disorder or another anxiety disorder and they may also have a personality disorder. In current practice, competent substance abuse assessment also addresses all the likely co-occurring conditions. Once the assessment is complete, counselors must decide which problems the intervention(s) should target. Current practice following the assessment of the most immediate threat to well-being also involves counseling on all conditions simultaneously, an approach called integrated treatment, rather than treating one condition (what used to be called the underlying condition) followed by treating the other.
Counseling Practices and Approaches
There are many approaches to counseling individuals with substance use problems, which range from open-ended, client-centered to very structured, curriculum-based approaches. Increasingly, public policies call for the use of evidence-based practices. However, the application of these practices is limited by numerous problems in “translating” research into real-life situations. First, there is only very limited evidence from clinical trials to support the benefits of one approach versus any others. Second, research studies are usually careful in selecting subjects with only one disorder to test their interventions while in real-life practice, most clients have at least one other co-occurring condition. Third, there are many different cultures among clients in real-life practice, and research studies typically have limited cultural representation among their subjects. Thus, while there is considerable interest in using evidence-based practices, there are numerous limitations to the implementation of these practices.
Most substance abuse treatment centers (particularly residential programs) use a form of counseling that is derived from the AA, NA, or another 12-Step self-help recovery philosophy. Recovery Dynamics is a more formalized treatment program that takes the 12-Step ideas and turns them into phased treatment objectives. Every client in a recovery dynamics program is exposed to all the phases. Recovery Dynamics and other 12-Step approaches have had general treatment outcome support but have not been tested in clinical trials against other approaches.
Cognitive-behavioral approaches have been favored in treating substance abuse problems across many different modalities of treatment. Part of the reason is that cognitive approaches place an emphasis on the discovery of unrealistic or irrational beliefs and the replacement of those with rational decision making. Many irrational beliefs drive the compulsive use of substances and counseling can address those beliefs while laying the groundwork for more rational responses. Cognitive-behavioral approaches enjoy a high degree of empirical support for their efficacy in treating substance abuse and a wide range of co-occurring disorders.
Motivational Interviewing and Motivational Enhanced Treatment
Motivational interviewing owes much to the client-centered Rogerian approaches of the 1960s and 1970s. It is a client-centered approach rather than a “program” of content that each client must experience. It places an emphasis on gradually inducing clients into treatment by recognizing their stage of change and by not rushing into an immediate recovery plan. Motivational approaches highlight the importance of empathy, feedback to clients about their problems as perceived by the counselor, and enlistment of client decisions for change plans instead of “administered” interventions. The techniques of motivational interviewing were extended into the intervention phase in what came to be known as motivationally enhanced treatment. Motivational approaches have been used with all types of substance abuse clients, including adolescents, women suffering from violence victimization, and criminal justice clients. Motivational approaches have received research support in a variety of settings and with different populations.
Social Skills Building
Another counseling approach emphasizes teaching clients the social skills that are necessary for recovery and living without dependence on alcohol or drugs. Social skills building approaches are designed to discover and address gaps in clients’ skill set. Hence, social skills approaches tend to be more compatible with strengths-based case management, an often-used adjunct to counseling for substance use problems. While case management is not necessarily a counseling activity, it is often used along with counseling to help clients carry through on counseling goals and attain community resources to support recovery. Social skills training has received research support as an effective approach for treating alcoholism and alcohol abuse.
Special Populations for Counseling
Adolescents require treatment approaches that differ from those used with adults. The standard AA, NA, 12-Step ideas have little acceptance in adolescent counseling settings. There are adaptations of self-help models; however, they have yet to gain empirical support. Adolescent counseling is most likely to involve family counseling and even the active engagement of at least one parent in the intervention. Adolescent substance abuse is seen as directly tied to family systems issues and thus successful treatment is seen as requiring the engagement of the entire family.
Women have lower rates of both substance abuse and dependence than men, but related co-occurring problems such as childhood or adult victimization and depression, PTSD, and anxiety are very common among women who develop serious substance-related problems. Some programs have found that up to 80% of their female clients report childhood or adult experiences of physical or sexual abuse and well over half will experience depression, anxiety, or posttraumatic stress disorder. Others may have personality disorders. Women in substance abuse counseling typically have other kinds of concerns such as pregnancy and health problems that are related to victimization. Their substance use and all these co-occurring problems require attention in counseling.
Criminal Justice Clients
There is increasing need for substance abuse treatment both in prison and in probation and parole settings. For example, it has been estimated that 80% of men in prison were substance involved when they committed their crimes. In addition, drug courts (special court programs that provide close judicial supervision, case management, and treatment for drug-involved defendants) have increased in the United States and counseling is an integral part of the drug court approach. Counseling is provided as a direct service of the drug court in some jurisdictions and by contracting with counselors outside the court system in other jurisdictions. Cognitive-behavioral and 12-Step-oriented counseling approaches are frequently used with criminal justice involved substance abusers. Some programs also use a variation of cognitive-behavioral therapy that addresses criminal thinking more than irrational thinking. It examines criminal intent and automatic thoughts about stealing, harming others, or otherwise breaking the law. Counseling criminal justice-involved clients also means careful attention must be given to confidentiality issues, and that counselors may be required to release information about counseling compliance to the court or probation or parole officers.
Co-occurring Mental Disorders
A large percentage of substance abusers in counseling have co-occurring mental disorders. After assessing for immediate treatment needs, an integrated treatment counseling approach is used with clients who have co-occurring disorders because it addresses substance use and mental health simultaneously. The integrated approach avoids concerns about which disorder underlies the other or which is the more pressing. Nevertheless, an integrated treatment for co-occurring condition increases the counselor’s burden dramatically. Counselors must be competent in dealing with a wide array of problems in order to address clients’ needs. When the specialty needs exceed the competence of a counselor or program, the next best approach is a collaborative treatment in which clients receive services from multiple healthcare providers.
Cultural Competency in Counseling for Substance Use Problems
Counseling for substance use problems is conducted among people from many different races and ethnicities. Counseling approaches need to be sensitive to these differences to address substance use problems effectively without creating resistance or perceived stigma. The “fit” between client and counselor may be heavily affected by cultural factors. This is all the more complicated in substance abuse counseling because of the added factor of stigma associated with substance use. The counseling profession, like other human services, has struggled with how to develop and train meaningful competencies without promulgating stereotypes that conflict with individual cases. National organizations have been developed to help formulate competencies and training programs. Competency generally involves counselors’ recognition of their own culture as well as an appreciation of their clients’ cultures as they may be shaped by race and ethnic factors. With substance use problems, counselors’ own recovery experiences may add yet another consideration. Some clients want a counselor who has also been in recovery, while others do not regard this as important. Sensitivity to these factors as well as to race, gender, and ethnicity may be important in matching counselors and clients.
Future Directions and Trends
Funding for substance abuse counseling perhaps peaked during the 1980s when private insurance included generous benefit packages for inpatient care. Now, funding is largely restricted to individual out-of-pocket or public funding. However, the need for counseling for substance abuse problems is unlikely to abate. Brief interventions, some of which involved only one or two sessions, are being studied more closely than in the past. However, the complexity of problems presented by clients is also increasing and this complexity suggests more intensive interventions. The end result is that with the growing complexity of co-occurring conditions, counselors need to continually add to their basic skills to remain competent.
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- Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press.