Approaches to Drug Abuse Counseling U.S. Department of Health and Human Services, National Institutes of Health Delinda Mercer 1. OVERVIEW, DESCRIPTION, AND RATIONALE 1.1 General Description of Approach
Addiction counseling addresses the symptoms of drug addiction and related areas of impaired functioning and the content and structure of the client’s ongoing recovery program. This model of addiction counseling is a time-limited approach that focuses on behavioral change, 12-step ideology and tools for recovery, and self-help participation. 1.2 Goals and Objectives of Approach
The primary goal of addiction counseling is to help the client achieve and maintain abstinence from addictive chemicals and behaviors. The secondary goal is to help the client recover from the damage the addiction has done to the client’s life.
1.3 Theoretical Rationale/Mechanism of Action
Addiction counseling works by first helping the client recognize the existence of a problem and the associated irrational thinking. Next, the client is encouraged to achieve and maintain abstinence and then develop the necessary psychosocial skills and spiritual development to continue in recovery lifelong.
1.4 Agent of Change
Within this addiction counseling model, the agent of change is the client. The client must take responsibility for working a program of recovery. However, although recovery is ultimately the client’s task, he or she is encouraged to get a great deal of support from others such as the client’s counselors, treatment staff, sponsor, drug-free or recovering peers, and family members.
1.5 Conception of Drug Abuse/Addiction, Causative Factors
Drug abuse is thought to be a multidetermined, maladaptive way of coping with life problems that often becomes habitual and leads to a progressive deterioration in life circumstance. Habituation of drug abuse is addiction, seen as a disease in its own right, which damages the addict physically, mentally, and spiritually. Causation is not a prominent focus of treatment.
2. CONTRAST TO OTHER COUNSELING APPROACHES 2.1 Most Similar Counseling Approaches
Because this model of addiction counseling is time limited and focuses on behavioral change and 12-step ideology and participation, the most similar approaches would be short-term cognitive behavioral therapy to treat addiction or short-term counseling based on the 12-step approach to recovery.
2.2 Most Dissimilar Counseling Approaches
The most dissimilar approaches are the traditional approach as provided in a therapeutic community, not because of the content that might be similar but because of the format that would probably be more punitive and confrontational and less respectful of the client, and the open-ended, nondirective psychotherapy approach.
3. FORMAT 3.1 Modalities of Treatment This counseling model has been developed for use in individual and group contexts. 3.2 Ideal Treatment Setting This model was developed for use as part of an outpatient addiction treatment program. It could, however, be adapted readily for use in an inpatient program with the following modification: It is planned to span 6 months, and usually inpatient treatment is 4 to 10 days for detoxification and up to 28 days for rehabilitation. The model could be altered to offer sessions more frequently over a shorter period of time. 3.3 Duration of Treatment This model is progressive and time limited; the active treatment phase runs 6 months, and there are followup sessions of up to 1 year. For individual treatment, there are two sessions a week for 3 months followed by one session a week for 3 months. The followup phase involves one session every other week for 3 months followed by one session a month for 3 months.
The group component of treatment is twice a week for 2 months and then once a week for 4 months. An advanced recovery group for post-6-month clients would undoubtedly be helpful but was not developed as part of these treatment manuals.
Individual sessions should run from 45 to 50 minutes; groups run 1-1/2 hours, including about 15 minutes for collection of urine and breathalyzer data.
3.4 Compatibility With Other Treatments These manuals for addiction counseling, as developed for individual and group counseling, were designed to be components in a more comprehensive treatment program. Combined with detoxification, initial medical and psychosocial assessments, and ongoing participation in a self-help program, individual and group addiction counseling can make a complete treatment package. However, these treatments may also be used in conjunction with pharmacotherapy, other medical therapies (e.g., acupuncture), family or couples therapy, or professional psychotherapy. 3.5 Role of Self-Help Programs Participation in a self-help program is considered an extremely valuable aid to recovery. It helps recovering individuals develop a social support network outside of their treatment program, teaches the skills needed to recover, and helps clients take responsibility for their own recovery.
In addition to encouraging clients to attend self-help groups at least three times a week and to locate a sponsor, the addiction counseling program educates clients about the 12-step program and incorporates many of its concepts into the content of the counseling. Breaking through denial; staying away from negative people, places, and things; taking a personal inventory; working on character defects; and spirituality in recovery are among the concepts addressed within the content of the counseling sessions.
As to 12-step versus other programs, participation in any legitimate self-help program the client gravitates toward, such as Rational Recovery and Women for Sobriety, is supported. However, because the 12-step approach to recovery is well known, more widely available, and has been an integral part of many addicts’ recovery programs, it is this approach in addiction counseling that is drawn on.
4. COUNSELOR CHARACTERISTICS AND TRAINING 4.1 Educational Requirements For purposes of the research protocol for which this treatment was designed, the educational requirement for group or individual addiction counselor was no higher than a master’s degree. The range of education is associate’s to master’s degree in a human services field. 4.2 Training, Credentials, and Experience Required Counselors must have a minimum of 3 years’ experience in addiction counseling and must be knowledgeable of and use the 12-step model. Group counselors must also have experience in leading groups. The professional credentials for addiction counselors (in Pennsylvania, associate addiction counselor [A.A.C.] and certified addiction counselor [C.A.C.]) are encouraged but not required. Counselors often become credentialed after having worked with institutions for a period of time. 4.3 Counselor’s Recovery Status Many counselors in this field are either in recovery themselves or have had a family member who was addicted. An indepth knowledge of addiction and the tools for recovery and ability to empathize with the client are essential for an addiction counselor. One way to develop this knowledge and ability is for the counselor to be in recovery. It is important that the counselor be relatively healthy and able to demonstrate a minimum of 5 years in recovery. The best situation is a mixture of recovering and nonaddicted counselors, because this fosters maximum learning from one another. 4.4 Ideal Personal Characteristics of Counselor
Addiction counselors should exhibit good professional judgment, be able to establish rapport with most clients, be good listeners, be accepting of the client for who he or she is (and not have a negative attitude toward working with addicts), and use confrontation in a helpful versus an inappropriate or overly punitive manner. A good addiction counselor must also be personally organized so as to be prompt for all sessions and able to maintain adequate documentation.
4.5 Counselor’s Behaviors Prescribed
The counselor will perform the following behavioral tasks:
- Help the client admit that he or she suffers from the disease of addiction.
- Teach the client about addiction and about the tools of recovery.
- Encourage and motivate the client.
- Monitor abstinence by doing frequent urine drug screens and breathalyzers and by encouraging self-report of any relapse.
- Analyze any relapse and strongly discourage further use.
- Introduce or review the 12-step philosophy and encourage regular attendance in a self-help program.
- Provide support and encourage development of a support network.
4.6 Counselor’s Behaviors Proscribed
The counselor should not be harshly judgmental of the client’s addictive behaviors. If the client did not suffer from addiction he or she would not need drug counseling, so it is useless to blame the client for exhibiting these symptoms. Also, because clients often feel a great deal of shame and guilt associated with their addictive behaviors, to help resolve those feelings it is important that they be encouraged to speak honestly about drug use and other addictive behaviors and to be accepting of each client’s story.
It is also important that the counselor be respectful of clients. The counselor should not be late for appointments and should never treat or talk to clients in a disrespectful manner.
The counselor should avoid too much self-disclosure. While occasional appropriate self-disclosure can help the client to open up or motivate the client by providing a role model, too much self-disclosure removes the focus from the client’s recovery. A good rule regarding self-disclosure, if the counselor is so inclined, is that the counselor first have a clear purpose or goal for the intervention and then think about why he or she is choosing self-disclosure at this time.
Finally, the counselor should be aware of when his or her own issues are stimulated by a client’s problems and therefore refrain from responding to the client out of his or her own dynamics. For example, if a counselor in recovery feels it extremely important to break ties with addicted peers, but a particular client with an addicted spouse or partner cannot break free of the relationship, it is imperative that the counselor respond flexibly and creatively to the client’s perception of the situation and not rigidly adhere to the notion that breaking ties with all addicts is the only way to recovery.
4.7 Recommended Supervision Ongoing supervision is a necessary part of counselor training and support. Lack of adequate supervision can contribute to counselor stress and burnout, both of which are seen frequently.
The ultimate goal of supervision is to enhance the quality of client care. Focus to achieve this goal is twofold. First, it is centrally important that the supervisor provide support and encouragement to the counselor along with the opportunity to expand his or her skills. Second, it is important that the supervisor have the opportunity to review the clinical status of clients and offer suggestions or corrections.
The format of supervision is for each individual to have a supervisor and meet with that supervisor for 1 hour once a week to review counseling sessions. Individual counseling sessions are audiotaped, and the supervisor is responsible for listening to a percentage and rating them for adherence to the counseling manual. This feedback is then given to the counselor.
5. CLIENT-COUNSELOR RELATIONSHIP 5.1 What Is the Counselor’s Role?
The role of the counselor is to provide support and education and to hold the client accountable through nonjudgmental confrontation. Ideally, the recovering person sees the counselor as an ally in the struggle to achieve sobriety.
5.2 Who Talks More? The client should talk more than the counselor. The counselor should structure the session and provide information and direction, but also do a lot of listening. 5.3 How Directive Is the Counselor? The counselor must find a balance between being directive and allowing the client to be self-directed. The counselor must be directive in many ways. The counselor imposes a session structure that includes giving feedback on the most recent urine drug screens and the client’s progress in recovery as well as processing any episodes of use or near use. The counselor identifies the relevant topic for discussion, based on what the client seems to need, and introduces that topic. Also, the counselor may directly pressure the client to change certain behaviors, for example, to start attending three meetings a week. However, the client is also encouraged to be self-directed in this counseling approach. For example, within the framework of a particular topic, such as coping with social pressure to use, the client will ventilate or explore the direction he or she needs to take, and the counselor will respond to the client’s direction. Also, when the client is unable to change an addictive behavior, such as being in a dangerous situation, the appropriate counselor response is to accept where the client is and assist in exploring what the client can do to handle the situation differently the next time.
Ultimately, recovery is seen as the client’s responsibility, and the counselor wants to encourage self-directed movements toward the recovery. However, the counselor will discourage movements toward addiction in a number of ways, many of which are directive.
5.4 Therapeutic Alliance It is important for the counselor to give the client a sense of collaboration and partnership in the counseling relationship. This is accomplished in three ways. First, the counselor should possess a thorough knowledge of addiction and the lifestyles of addicts. Second, no matter how expert the counselor is in the field, he or she must acknowledge that it is the client who is the expert in discussing his or her own life. The counselor must listen well, empathize, and avoid passing judgment. Third, the counselor should convey to the client that he or she has an ally in the struggle to break the cycle of addiction. Their relationship is a collaborative one.
Generally, the interventions that are most helpful in fostering a strong therapeutic alliance (TA) are those that involve the counselor’s active listening and that emphasize collaboration. For example, after the client reports a relapse, the counselor might say empathically, “Let’s examine what happened and develop a plan together to help you avoid using the next time.” Language like this highlights the joint effort in the relationship.
If the TA initially seems weak, the counselor might find it helpful just to ask the client what is not working in the relationship. Often the client knows what might improve the therapeutic relationship but does not feel comfortable enough to mention it unless the counselor does so. It is important that the counselor be willing to accept feedback from the client and make changes if necessary. In responding to a request to change, the counselor should not feel pressured to change or compromise his or her philosophy of addiction but only the manner of relating to the client.
6. TARGET POPULATIONS 6.1 Clients Best Suited for This Counseling Approach This treatment has been developed for adult male and female ambulatory cocaine addicts. It has also been used with individuals addicted to alcohol and with those addicted to cocaine and other drugs, including alcohol, marijuana, and opiates, who have found it to be appropriate. 6.2 Clients Poorly Suited for?This?Counseling Approach Dually diagnosed individuals with significant psychopathology probably require more attention to the psychopathology than this approach provides. Previous research has shown that addicts with more psychopathology derive greater benefit from psychotherapy combined with addiction counseling than from addiction counseling alone.
Other research has indicated that most antisocial individuals do not fare particularly well with any type of psychosocial treatment.
7. ASSESSMENT The only assessment procedures that are necessarily a part of the addiction counseling treatment are the frequent, regular urinalysis and breathalyzer tests and self-reports of any drug use. The other assessment instrument routinely used in association with treatment is the Addiction Severity Index (ASI), an interview schedule that measures seven addiction-related domains: drug use, alcohol use, medical problems, psychiatric problems, legal problems, family/social problems, and employment/support problems. Because this interview examines problems and drug use over the previous month, it should be given at baseline, when the client enters treatment, and then either monthly or after 3 or 6 months to measure change. It requires approximately 45 minutes for the initial administration and about 30 minutes for a followup administration. 8. SESSION FORMAT AND CONTENT 8.1 Format for a Typical Session
In each individual session the counselor should:
- Find out how the client has been since the last session and ask specifically if the client has used any drugs. If the client has used drugs, analyze the relapse and develop strategies to prevent future relapses.
- Ask if there are any urgent problems and, if there are, deal with them.
- Provide feedback as to whether recent urine tests have detected drug use.
- Discuss the recovery topic most relevant to the client’s stage of recovery and current treatment needs.
Group sessions have the following format:
- Members submit a urine sample and take a breathalyzer test.
- Members introduce themselves, admit to their addiction, and state their date of last use of any type of drug or alcohol.
- Members are encouraged to talk briefly about how they are doing and about any cravings or temptations experienced since the previous group meeting.
- If any members have used since the last session, the group will help them process the event and develop a plan to prevent further relapse.
- If there is a topic, the group leader will introduce it and encourage members to discuss how it relates to their recovery. (In the more advanced problemsolving group, members are encouraged to describe a current problem or concern and get feedback from one another.)
- In the final 10 minutes, members are asked to state their plans for the next few days in an effort to help them structure their time. Members are also encouraged to mention the self-help meetings that they are attending and perhaps invite others to attend with them.
- Members then join hands and recite the Serenity Prayer aloud.
8.2 Several Typical Session Topics or Themes Treatment is conceptualized as occurring in stages. The first stage includes denial and motivation.
The next stage, early abstinence, includes issues of:
- Addiction and associated symptoms.
- People, places, and things.
- Structure of personal time.
- High-risk situations.
- Social pressures to use.
- Compulsive sexual behavior.
- Post acute withdrawal symptoms.
- Use of other drugs (other than the primary addiction).
- Self-help participation.
The next stage, maintaining abstinence, includes:
- The relapse process and tools for preventing it.
- Relationships in recovery.
- Development of a drug-free lifestyle.
- Shame and guilt.
- Personal inventory.
- Character defects.
- Identification and fulfillment of needs.
- Anger management.
- Relaxation and leisure time.
- Employment and finances.
- Transference of addictive behaviors.
8.3 Session Structure
Both group and individual sessions have a clear structure. However, within the framework of that structure, the content of the discussion is largely up to the client. An effort is made to address effectively the client’s individual needs at any point in treatment while also recognizing the commonality of many issues in addiction and recovery.
8.4 Strategies for Dealing With Common Clinical Problems
Clients are repeatedly urged to arrive for all sessions promptly, to call if they are going to be late, and to call at least 24 hours in advance if they must cancel a session. If they fail to fulfill these obligations, the counselor will confront them about it in the session.
If a client arrives late for a session, the consequence is a shorter session because the counselor will end the session on time. Repeated missed sessions without appropriate cancellations and rescheduling will eventually result in dismissal from the program, but because this occurs only after 2 months, clients are given many chances before termination from treatment for nonattendance.
Clients are requested to arrive clean for all visits. If a client arrives obviously intoxicated, the counselor will remind the individual of the responsibility to come clean and will reschedule the session. If a client arrives for a group or individual session mildly under the influence but not intoxicated (e.g., blows a low positive on a breathalyzer test), it is at the counselor’s discretion whether to continue with or reschedule the session.
8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation Denial and motivation are central themes in the beginning of addiction treatment. For this reason, they are addressed in the first several sessions of counseling and then repeatedly addressed, as needed, throughout the course of treatment. The major strategy is to chip away at the client’s denial by pointing out the addictive behaviors and consequences of addiction and gently confronting the client about the denial.
Resistance is a concept that is not directly addressed in this addiction counseling model. Much resistance falls within the concept of denial and is addressed in that way. Also the 12-step suggestion of turning one’s will over to a higher power is a way of dealing with resistance that would be used in this model of counseling.
Regarding motivation, clients often express ambivalence at some point in treatment, and several strategies are used to address this directly. Clients may be encouraged to review the pros and cons of getting sober, or they may be pressed to explore fully the consequences of their addiction. Clients may also be asked to identify specifically the benefits of sobriety in their life. Basically, these issues are reviewed continuously throughout the early period in treatment.
8.6 Strategies for Dealing With Crises
If the client presents with an urgent, addiction-related problem such as marital dissolution or financial problems as a result of the addiction, the counselor should try to address these problems, with emphasis on how they are related to the addictive behavior. The counselor should then help the client develop strategies for dealing with the problems in a manner consistent with recovery, including identifying how to obtain appropriate assistance from social services.
If the client presents with a true crisis (spending all of his or her money on a cocaine binge and becoming suicidal), the counselor should organize a team effort among the appropriate treatment staff to provide any medical or psychiatric services that the client requires in order to remain safe.
8.7 Counselor’s Response to Slips and Relapses If a relapse occurs, the counselor and client should use the session immediately following the relapse to identify and process the events, thoughts, and feelings that precipitated the relapse.
Relapse to drug use is a common occurrence that can be devastating to the client. The counselor must communicate to the client that relapse to drug use does not mean that the entire treatment program has been a failure. The counselor should educate the client about relapse and about how important it is to take corrective action rather than be overcome by feelings of depression or failure. Most episodes of drug use can be managed without seriously interrupting the treatment program and can be used in a positive and educative way to strengthen the recovery process. In dealing with a relapse, the counselor should use the general principle that relapse is caused by failure to follow one’s recovery program. Thus, the counselor should identify where the client deviated from his or her recovery plan and help the individual do all that is reasonable to prevent such a deviation from recurring.
Relapse can be viewed as having differing levels of severity that determine the appropriate therapeutic response. The counselor must understand the appropriate interventions to be used in each case.
The least severe type of relapse is a slip. A slip is a common occurrence involving a very brief episode of drug use that is associated with no signs or symptoms of the addiction syndrome, as defined in DSM-III-R criteria. Such an episode can serve to strengthen the client’s recovery if it is used to identify areas of weakness and point out solutions and alternative behaviors that can help prevent future drug use from occurring.
The next most severe type of relapse is when the client resumes drug use for several days, and the use is associated with some of the signs and symptoms of addiction. In such a case, the counselor might want to intensify treatment temporarily. This intensified contact will usually reinstitute abstinence. The client should be encouraged to think about what was done and learn from the experience how to avoid relapse in the future. The client should also be encouraged to recommit to his or her recovery program.
The most serious form of relapse is a sustained period of drug use during which the client fully relapses to addiction. Often a client who relapses to this extent will also drop out of treatment, at least temporarily. In this case, if the client returns to treatment, he or she should most likely be detoxified again, either in an inpatient or outpatient setting. The decision to detoxify a client as an inpatient or an outpatient should be made conjointly by the treatment staff involved. The decision should be based on the severity of the relapse, availability of social support, and presence of unstable medical or psychiatric conditions.
9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT
This model of addiction counseling does not focus much attention on the role of family members in treatment, not because it is not important in treatment but because this model is not intended to provide all-inclusive treatment. This model offers the individual and the group the addiction counseling components of a treatment program that can include numerous other components.
In general, the inclusion of partners, family members, and even close friends in addiction treatment by holding family sessions can facilitate recovery. Encouraging family involvement can help the addict create a better, more knowledgeable support network; it may decrease the family’s enabling or codependent behaviors that tend to impede the addict’s recovery; and it will allow the counselor to intervene in any upsetting family situations that might otherwise potentiate a relapse.
Delinda Mercer, Ph.D.Center for Psychotherapy ResearchUniversity of Pennsylvania3600 Market Street, Room 766Philadelphia, PA 19104