Over 50% of Americans drink alcohol as part of their daily routine. 10% of these routine drinkers, statistically, will fall into addictive, habitual use. 25% of the population has had some experience with marijuana. Statistics show that approximately 2% of the American population is addicted to illegal drugs, despite the Harrison Narcotic Act of 1914, the first legislation to ban the use of illegal drugs. Emergency rooms have exponentially increased their caseloads of patients who are drug abusers that accidentally overdose, take poisonous drug substitutes, or try to commit suicide. ER caseloads of drug casualties have also increased, for example: Date-rape victims; drug mules whose swallowed condoms broke; drunk or impaired driving victims; and children who are accidentally poisoned by eating their parents’ stash, or through toxins absorbed from grow-ops. Alcohol and drugs are linked to thefts and domestic violence. Children who watch intoxicated parents come to accept addiction, and may suffer similar problems later in life.
Illegal and pharmaceutical drugs alike may be abused by your patients. Addicted parents may have children who are addicts at birth. Often, parents even share drugs with their children. Children who live in grow-ops or meth labs can be accidentally poisoned. It’s, also, not uncommon for a therapist to find drug problems in an entire family because of how cheap and easily accessible drugs are. Letting a detox center patient suffer through opiate withdrawal syndrome “cold turkey” or through Rapid Opiate Detoxification (ROD also known as the Waismann Method) can be detrimental. Ensure your patients get Naltrexone after rapid detox to give addicts a time cushion to make lifestyle changes. Naltrexone blocks the effects of the opioid, not giving them the feeling they are looking for. It’s common for a patient to resist ongoing treatment. In fact, 45% to 80% of patients relapse within six months, because of psychological dependence. Which, is why physical rehabilitation and detoxification alone is not enough. The physical rehabilitation is a very good and necessary part of treatment, but temporary behavioral modification is not the answer. 10 years. Often, recovering addicts go on to abuse a different drug, like alcohol.
Stages of progression
Not everyone who has used drugs or alcohol has a problem with addiction. You must determine if your patient has a pathological addiction or just engages in experimental use.
Grade your patient on the continuum of drug use, based on a five-stage progression.
Stage 1. Is the patient abstinent or involved in self-denial of use. Abstinence may allow for an occasional glass of wine. However, it is possible that the person who chooses this route was heavily addicted to alcohol in the past, and completely abstains now to keep from falling back into old, addictive ways. Twelve step programs like AA and NarcAnon advocate complete abstinence. Groups such as these are complementary reinforcement for your formal therapy because meetings are held daily in most metropolitan areas, and peer- to-peer encouragement and accountability can prevent a relapse. Your therapeutic role in cases of past addictions is to help them keep sight of their goal for abstinence. Even one drink can be detrimental to an alcoholic, because it can trigger a drinking binge.
Stage 2 of progression on the continuum of drug use involves experimental use. Teens and young adults partake of a chemical to find out what it feels like. It is an expected rite of passage for many segments of our culture. Problems with experimentation include drunk driving and date rape. GHB is dissolved in alcohol at raves because it enhances the libido and lowers inhibitions. Victims enter a dream state and act drunk. They relax, sometimes to the point of unconsciousness, have problems seeing clearly, are confused, and have no recall of events or the passage of time while drugged.
Stage 3 of the progression involves social use of drugs or alcohol. The test to determine if a person is a social user or addicted is whether or not the person can stop drug use. Social users do not get outside help without coercion from either a parent or an authority figure. Counseling involves an educational group to develop coping skills and relationship skills with peers.
Stage 4 of progression on the continuum of drug use involves abuse. Your patient’s problem can be physiological or psychological in nature, or both. The addiction is detrimental to personal safety, family relationships, academic life, and work functions. Spousal and child abuse often coincide with drug abuse. Drunk driving and theft to support a habit are societal problems resulting from addictive behavior. Friends and associates are probably uncomfortable around the abuser by the time the addiction is visibly evident. At this point, the employer can insist the abuser get help on a professional level through Employee Assistance or public programs as a condition of continued employment. Abusers benefit from psychological counseling on a weekly basis and an intervention program to stop the alcohol or drug abuse. Antabuse (disulfiram), methadone, LAAM, buprenorphine, ibogaine, and naltrexone are useful adjuncts to counseling to wean the abuser off the drug. Intensive out-patient programs may be sufficient for recovery.
Stage 5 of progression involves chemical dependency or addictions that must be relieved. The addict experiences withdrawal symptoms when the drug or alcohol is not available for consumption. The addict builds up a tolerance to the drug to the point that more and more is needed just to keep from experiencing physical withdrawal. The high is harder and harder to reach. The addict is now at increased risk for unintentional overdose, because street drugs have inconsistent strengths. The addict is now on the verge of failing in marriage, academics, and work. The addict experiences serious medical issues like ventricular tachycardia and atrial fibrillation and more powerful drugs like Clonidine (Catapres patches or tablets) are used to prevent death. Permanent damage from Korsakoff’s syndrome or Wernicke’s encephalopathy may result from a poor diet lacking in vitamins. Long-term, in-patient rehabilitation programs are crucial in most cases. Intensive out-patient programs may be sufficient for the minority.
Models and Theories
The disease model is accepted by organizations such as Alcoholics Anonymous (AA). The disease model contends that alcoholism is chronic (an unremitting, gradual disease that becomes more severe over time) and requires treatment. Alcoholism likely has a genetic root. Persons predisposed to the disease of alcoholism have genetic markers for lowered levels of platelet MAO activity, serotonin function, prolactin, adenylate cyclase, and ALDH2. Other theorists believe alcoholism is a learned behavior, rather than genetic. Research in this area is inconclusive. In 1956, E. M. Jellinek endorsed the American Medical Association’s adoption of alcoholism as a disease.
He described alcoholism as an infirmity with four stages of progression:
Jellinek believed that alcoholics suffer from chemical dependencies that became relentless cravings for alcohol.
The psychoanalytic model states the use of alcohol or drugs is the way a person has chosen to cope with anxiety or unconscious conflicts within his or her mind. The psychoanalytic model is directly related to the work of Sigmund Freud, who used the term id to describe instinctual urgings. He believed id instincts are seen in the libido and in aggressive acts. The superego tries to control the instinctive urges of the id. This is where internal conflict develops and is displayed in the ego, which exhibits states of anxiety. Defense mechanisms take the form of denial, projection, or redirecting the unacceptable impulses. Conflicted people use drugs and alcohol to disguise emotions that they are unwilling to confront. In this case, addiction is a form of self-medication.
Ego psychology and Object-Relations theory
Ego psychology encourages the addict to cope with the pain that caused the dysfunction. The Object-Relations theory holds that the alcoholic or drug addict is really trying to deal with negative feelings about botched relationships.
The addict may experience: Depression; anxiety; anger and aggression; insularity; negativity, atypicality; and post-traumatic stress disorder (PTSD).
Often, the addict was the victim of child sexual abuse (CSA), or neglect, or physical abuse as a child. Memories of these abuses were suppressed as a survival mechanism, and festered untreated in the person’s mind. The addict may also have residual physical damage, like improper development from malnutrition that leads to poor academic and intellectual functioning, and secondary conditions like dyspareunia from scar tissue. The addict tries to assuage the pain with a chemical that lessens it for a while. Alcohol, legally prescribed drugs, toxic herbs, or street drugs are self-medication to decrease the pain by making it difficult to think clearly.
Conditioning Classical conditioning theory was developed by Russian Ivan Pavlov in the 1890’s. Pavlov’s experiments were based on the reflexive reactions of dogs who had been conditioned to salivate (the conditioned response) at the sound of a bell (the conditioned stimulus) that meant they would be fed soon. Addicts have a conditioned response associated with circumstances where drugs or alcohol were used. The conditioned response can be psychological (craving the drug or alcohol), or physical (e.g., involuntary defecation in anticipation of a dose of heroin). The circumstance or environment is the conditioned stimulus. Operant conditioning was developed by American B.F. Skinner in the 1930’s using rats and pigeons. It describes responses of the conditioned individual to negative or positive reinforcers. Negative reinforcers are the addict’s withdrawal signs and symptoms. The positive reinforcer is relieving the withdrawal symptoms by taking the drug or alcohol. This theory holds that, addictive behaviors can be switched off by removing the reinforcers.
Social learning theory
In 1977, Albert Bandura developed his social learning theory to describe the relationship of a person to his or her environment. Bandura theorized that people learn from watching other people. He believed people self-regulate and manage their behaviors based on their established principles and inner values. Inner values are not influenced unduly by external rewards or retributions. An inner value that does not oppose drinking to excess contributes to a person’s alcoholic behavior. An inner value (standard) that opposes drinking to excess means the person has a restrictive view of drinking and will self-regulate by stopping before he or she is intoxicated. The person who experiences a distinct difference between values and behaviors finds it necessary to change one or the other. The person finds his values win out over the undesired behavior. This leads to a change of behavior that befits the person’s set of values.
Developmental preventive model
The mental health counselor helps the client to handle life stresses by applying developed skills. The MHC also helps the client to evaluate his or her own character strengths. The MHC operates on a developmental preventive model. This positive approach model concentrates on the client’s normalcy and the client’s ability to obtain wellness. The MHC attempts to prevent relapses of the mental illness or disorder, and to keep new illness from developing. The MHC model recognizes that each person will go through certain crises in life. The way a person deals with the crises constitutes normal development. The developmental preventive model allows for a more natural way to view and accept needed mental health services.
Chemical dependency assessment and the clinical interview
A chemical abuse or dependency assessment is a tool to help determine the severity of a substance use disorder, and is not a tox screen or brain scan alone. A tox screen is performed on blood, stomach contents, or urine to determine the amount of toxin in a person’s body at the time of testing. There are several ways for people to alter their urine specimen.Clients can defraud a urine drug screen by adding bleach, chromium VI, nitrites, or water to a urine specimen from a small vial hidden in the underwear or sock. Your client can dilute drug levels by drinking 120 ounces of liquid before the test, or using colonics, diuretics, golden seal, and psyllium. Do not accuse your client of attempting internal dilution, as there may be a bona fide problem with their antidiuretic hormone the doctor of record needs to investigate. Substitution is done through a prosthetic belted under the client’s clothes that delivers a clean, drug-free urine specimen into the collection container by a straw or through simulated, color-matched genitals connected to a reservoir. Simulated urine can also be substituted.
There are 12 standard questions to ask as you conduct your clinical interview. Record your client’s history and personal data. Question members of your client’s social group. Construct a picture of your client from the data collected. Differentiate casual drug use from addiction. Be intentional about creating rapport with your client.
Here are the questions you should ask a client in a clinical interview:
Question 1: Find out your client’s motivation for getting a mental health referral.
Question 2: Obtain historical background about the beginning and severity of your client’s drug and alcohol use. Discuss changes or deterioration in your client’s behavior from the since alcohol and drug use.
Question 3: Determine the longest length of time that your client has stayed sober. Delve into the why this period of sobriety ended.
Question 4: Ask about the intoxication level that your client reaches when drinking or drugging. Are there blackouts? Violent incidents? Is it harder to get a high now than when the client first started using drugs?
Question 5: Find out the arrest record of your client. Pay particular attention to impaired driving (DUI) and domestic violence charges resulting from chemical abuse.
Question 6: Find out about military service where drug or alcohol use was part of the client’s service time.
Question 7: Discuss addictive cycles of abuse found in your client’s family. Note psychological disorders in family members and dysfunctional family relationships.
Question 8: Find out the psychiatric history of your client.
Question 9: Ask your client about his or her educational and work experience, including any drug or alcohol activities at school or in the workplace.
Question 10: Get the medical and substance use history of your client. Note chronic pain treated with OxyContin or other pain relievers, which subsequently led to addiction.
Question 11: Ask about prior drug and alcohol abuse treatment programs in which your client participated. Is your client a recidivist (or pathological criminal offender)? If so, you must use a different treatment technique.
Question 12: Discuss drug and/or alcohol levels revealed by your client’s latest tox screen.
The answers you glean in the clinical interview should correspond with other data collected from various sources. If there is a discrepancy, determine the truth of the situation.
MAST and DAST assessment tools
The Michigan Alcohol Screening Test (MAST), developed in 1971. The client must answer yes or no to 22 questions. Clients who score 0—2 have no alcohol problem. Clients who score 3—5 are early to middle problem drinkers. Clients who score 6 or more are problem drinkers. This test is accurate to the .05 level of confidence, according to the National Council on Alcoholism and Drug Dependence. Some research indicates that the 6-point cut-off for labeling an alcoholic should be raised to 10 points. The Drug Abuse Screening Test (DAST) is the non-alcoholic counterpart to the MAST. If either the MAST or DAST is positive for addiction, then use the Addiction Severity Index (ASI) to determine in what areas the drug use has been the most invasive. The areas assessed include: Medical; legal; family; social relations; employment; psychological; and psychiatric conditions. The ASI test is longer, covering 180 items.
Substance Abuse Subtle Screening Inventory l
The Substance Abuse Subtle Screening Inventory (SASSI) was developed in 1988 to help disclose covert abusers.
Typically, abusers hide their drug problems with lies, subterfuge, and defensive responses because they are:
Unwilling to accept responsibility
Unwilling to rake up bad feelings and pain
Afraid of the consequences (incarceration or rehabilitation programs)
Conflicted (have mixed feelings) about quitting use of the chemical
The counselor uses the SASSI to determine the truth, and produce profiles useful for treatment planning, and understand the client. The adult version has an overall accuracy of 93%. The Adolescent SASSI-A2 has an overall accuracy of 94%. They both contain face-valid and subtle items, which do not tackle drug abuse in a directly apparent way.
Substance abuse treatments
Substance abusers do best when they abstain from drug and alcohol use entirely during their treatment programs. Relapses in the client’s use interfere with treatment. Try not to conduct a session with an intoxicated client. If your client is intoxicated always encourage your client to reschedule his or her session. Make travel arrangements to ensure your client does not operate a vehicle on the way home while in an intoxicated state. Encourage your client to stay out of old hangouts where alcohol or drugs were used, and to discard drug paraphernalia and t-shirts associated with drugs or alcohol because they can evoke a conditioned response. Most addicts are also pathological liars so, make it a priority to establish a culture that celebrates openness and honesty. Often times addicts feel shameful, and without any apparent way out, addictions can be a temporary though effective means to avoid feeling that shame. Gently confront that shame.
Alcoholics Anonymous is a 12-step plan with many locations throughout the U.S. that encourages sobriety. Meetings are held in church halls, libraries, and clubs. AA should be offered along with appropriate counseling by a therapist, because the meetings are not considered psychological therapy. AA meetings can work as reinforcement of the coping skills you teach and a peer group that is supportive. The group provides a same-sex sponsor to help your client see a good role model who has enjoyed a long period of sobriety. The alcoholic develops a more positive outlook of self and a sense of unity with the group, so feelings of isolation are removed. The client gains a sense of hope about his or her future, and comes to recognize that the substance use is out of control. Often led by people of faith, such as Christians, alcoholics are told that they are not out of reach of being helped, and that everyone one has fallen short, because of their wrongdoing. However, Jesus, God’s son, did what they could not, and obeyed God and took their punishment for them, thus enabling them to overcome shame and addiction in this life. Some religious institutes may also take part in trying to help with AA by providing self-help books, steps to modify certain behaviors, or encourage them to seek a another deity.
The alcoholic carries an AA relapse prevention card. Your client is given this card to help him or her find alternative activities that do not include drugs or alcohol. The card contains instructions to communicate his or her feelings to a trusted AA member, and phone numbers for the sponsor and the client’s spouse, or parents. The card may also instruct your client in relaxation techniques or imagery to get through the cravings. Your client may find it beneficial to write down his or her feelings in a journal and bring it to your counseling sessions. Teach your client assertiveness techniques to stand up to his or her AA peers if they make inappropriate suggestions.
As a counselor you should always be encouraging the client towards growth. Remind them of the goal, and why they desire to be free from addiction.
I hope this video was helpful. To check out more of our video’s click here.
See you next time!