($u nq Todffiy An Amerion Counseling Association Publication I I . Fighting fear . Counseling d6FS-rt3t6E st{ SSnsslIlISH lnq t{U3snl 86} ;lISt3ft IH{l *luc3 }'lgrllrt'.l 'u Alliss rlsil}.eHr s}slj 50*ii 's'l,l rf33r{ !f{ {rii} - ;} u + lt} 1 l;J - iJ{;} $ u3HH0E eoo:5Et $ IEd, rs s &'t" t,s $.+r $.$ it t' tr't' rn f, ' $ E !: l' s ii\t e fiffilent in sight By Laurie Meyers ryx AMERICAN CoUNSELING ASSOCIATION 24 | ct.counseling.org I February 2015 . I *, , ,it the beliefthat addiction happens to "other" or other counselors' clients. people - Counselors know that addiction is a disease, of course. But itt a disease with a particularly bad reputation, and many counselors may associate it with resistant clients and low rates of successful ffeatment. For some counselors, it might even seem to avoid working with clients who are struggling with addiction. The problem is, easier thatt not possible. "I think I've heard more often than not [from counseling students], 'You know, I really dont want to work with alcoholics and addicts,"' says Ford Brooks, an addictions specialist and counselor educator at Shippensburg Universiry in Pennsylvania. "And I'm thinking, 'Well, unless you work on the moon, most of your caseload is going to have some impact through [the clientt substance use] or someone elset use."' Gerald Juhnke, an American Counseling Association member who has been involved with addictions counseling since 1995, confirms that thought. 'I didnt really want to go into addictions counseling," he says. "I mean, who would talk to a counselor whose name is Juhnke? I wanted to go into marriage and family therapy, but what I found is that so many of the couples and families I saw came in with issues related to addiction." According to the 2012 National Survey on Drug Use and Health conducted bY the Substance Abuse and Mental Health Services Administration (SAMHSA)' an estimated 20.7 million Americans have a substance use disorder. The survey data n is based on face-to-face interviews with a representative portion of the population. However, because of the strong stigma attached to acknowledging addiction, many I the presenting cause. Myriad bring clients to counbeling, such as marital and family discord, problems at work and especia.lly mental health addiction as issues that complaints such as depression and anxiery are frequently connected to substance abuse and addiction. who To genuinely help these clients may or may not recognize their substance 66un5s1615 of all stripes use problems - and specialties need to educate themselves about addicdon. This knowledge includes the various types ofaddiction, how to spot addiction, how to help treat it and when to refer clients for more intense or specialized help. Counselors should begin by examining their own beliefs about addiction, says Broola, who was a practicing addictions counselor for l4 years and is the co-author, with Bill McHenry of A Contemporary Approach to Substance Ue Disordrrs and Addiction Counseling, the second edition of which ACA published this month. "l want people to be aware of their own biases and preconceived notions about people who use drugs and alcohol," Broola explains. "For students, it may be, 'An alcoholic is my Uncle Joe' or'Drug addicts are worthless and dont work."' Brooks makes a point of discussing with all of his counseling students their perceptions of what addiction is and loola like. "Ifyou have the attitude of'I'm better than you or you think, 'Oh, you dope. You shot up drugs and got pregnant and are still using,' these biases are going to get in the way," he notes. To help banish such stereotypes, Brooks has students go to Alcoholics Anonymous and Al-Anon meetings. He says they are almost always surprised by what they see, February2015 | CounselingToday | 27 including that the individuals struggling with alcoholism and addiction seem so "normal." More than that, the students are often able to recognize refections of themselves or their families in members of the recovery groups. Julie Bates, an ACA member and former addictions counselor, would like to see all counselors-in-training given opportunities early on to interact with people who have substance abuse problems. She notes that education and exposure have been shown Even when counselors haven't been exposed to issues surrounding addiction in training or early in their careers, they can strive to understand the person suuggling with these issues, just as they would with any other client. "'We need to train our counselors to be curious 6upisu5 about the of addiction," says Bates, complexity a who is now counselor educator at the The International Associarion of Addictions and Offender Counselors, a division of the American Counseling Association, was chartered in 1972. Members of I.AAOC advocate for the development of effective counseling and rehabilitation programs for people with substance abuse problems and other addictions, as well as for adult and juvenile public offenders. For more information, visit iaaoc.org. In addition, ACA is publishing three new or updated books this year on treatment of addictions: t A Contemporary Approach to Substance Ue Disorders and Addiction Co uns e ling, second edition, by Ford Brooks and Bill McHenry (available in February) J t TTeatment Snategies for Substance Addictions by Robert L. Smith (available in March) Addiction in the Famif: \Yhat Euery Counsehr Needs to Know and t Proce.rs by Virginia A. Kelly (available in M"Y) For more information or to order these books, visir counseling. org/ boohstore or call 800.422.2648 ext.222. I ct.counseling.org I February 2015 Universiry of 'Wisconsin-Stout, where she teaches classes on addiction. "The why' questions, such as '\,Mhy do you use?' and '\Mhy dont you just stop?' are not inherently bad questions. In fact, ifasked in curiosiry and not judgment, [they] are actually exceptionally valuable. tWe should be very interested and invested in the answers to those questions." In fact, asking 'why," along with other questions, has become an essential part of addiction therapy. Counselors and other helping professionals have largely abandoned the confrontational addicdon therapy model previously used for decades and exchanged it for more collaborative and client-centered techniques. New perspectives on addiction These newer techniques and perspectives on addiction and substance in part by research that has upheld what counselors and other helping professionals have long contended: Addiction is a disease, not other mental health disorder, the brain not does not hold the fuII story physically, at least. Although addiction has a strong genetic component, psychological, environmental and social factors also play essential roles. Probing these elements is a critical part of addiction therapy and recovery. lVhen Brooks began working with clients struggling with addiction in to reduce stigma. Additional guidance that cause behavioral impairment, helps ease some of the stigma attached to addicdon and substance abuse disorders. Of course, in addiction, as with any abuse are driven a moral failing. In 20 1 l, after years of research, including an extensive focus on the chemistry and wiring of the brain, the American Sociery of Addiction Medicine officially defined addiction specifically, as a disease of the brain a "primary chronic disease of brain reward, motivation, memory and related circuitry." Brooks believes this definition, with its emphasis on physical changes the mid-1980s, the recovery field was dominated by helpers who had been formerly addicted themselves. These individuals didnt necessarily have training in mental health disorders or counseling but instead drew upon their personal experiences in recovery. This was a seemingly practical approach, based in both the 12-step process and directly confronting clients with their problems by saying things such as, "This is your sixth DUI. Time to make a changel" Brooks says. This approach came from a place of compassion, he notes, but tended to increase defensiveness in a client base that was already on guard and often in denial. By the late 1980s, treatment was no longer routinely dispensed by formerly addicted helpers in recovery. Instead, it became the realm of counselors and other tra-ined professionals. However, until the past decade or so, the confrontational model still dominated treatment, notes Juhnke, a former president of the International Association of Addictions and Offender Counselors, a division ofACA, and a counselor educator at the University ofTexas at San Antonio. Now, in addition to the l2-step process, which many professionals still consider an essential part ofrecovery Juhnke, Brooks and other counselors have increasingly been turning to more collaborative, person-centered methods such as motivational interviewing. Brooks and McHenry note in their book that motivational interviewing can be particularly helpful for evaluating the existence and extent of a clientt addiction. "MI [motivational interviewingJ ... has the counselor or group work side by side with the client," Brooks explains. "I'm helping you side by side, versus me sitting across from you relling you all that your disease has don.." lVhen the counselor and the client collaborate, it allows them not only to identify the problem but also ro more clearly understand the triggers, behaviors I I and negative consequences associated with the addictive behavior, Juhnke notes. "MI allows me to ask simple questions to help them figure our what might be causing their problems," he says. For instance, Juhnke might ask the client a question or make a statement such as, "Help me understand what you are doing when you have trouble gerring into work in the morning." \[ith this process, Juhnke is probing for and simultaneously opening the clientt eyes to the addictive behavior that caused a particular negarive outcome. This line of questioning might reveal that the client drank several beers before work, allowing Juhnke to call amention to the damage that the clientt overconsumpdcin of alcohol is doing. In Juhnket experience, clients don't usually come to counseling looking for help with addiction but rather for assistance with work problems, family troubles or some other issue. But if Juhnke explains thar if he were using the "old school" approach ro rreatmenr, substance abuse is a contributing or precipitating factor to the client's he would be in the clientt face, determined to show the person rhat he or she has an addiction. problems, careful probing through the technique of motivational interviewing can reveal a pattern, he says. "You might say, Are you using any substances?"' Juhnke explains. "And they might say, 'Yeah, I m drinking a limle bir.' And then you ask, 'How's that going?' .Well, itt going pretry good I have - begin to no problems.' But then, as you talk with them, you 6nd out that it is a problem thar they're losing money because they drink so much, and they jusr got terminared from rheir job because of their drinking on the job or before going into work." Even after this revelation, Juhnke doesnt confront the clienr. Instead he might say, "Hey, I m a lirtle confused. You youte not having problems with your alcohol consumption, yer you rell me you got terminated from yourjob [and] that you're abusive toward your spouse or partner when you drink. Help me understand that." say "But with MI, if they dont admit he says. "I just keep asking questions, and my goal is to help them gain insight by their answers. And hopefully they'll begin to realize, 'Hey, I it, no problem," do have a problem here."' Once a client recognizes thar he or she has a problem, Juhnke will continue to use motivational interviewing in conjunction with family or couples therapy, ifpossible, and have the client attend l2-step meetings. ACA member !7. Bryce Hagedorn, an addictions counselor in Orlando, Florida, and an associate professor and coordinator of the Department of Child, Family and Communiry Sciences at the Universiry of Central Florida, frames his addicdon counseling around the Srages of Change Model. "Research has shown thar no marter what kind of change rhey are seeking," Hagedorn says, "clients go through six billing Therapy Practice Management - Designed Nowthat's lntriguing! by Therapists for Therapists Cloud-based. HIPM and HITECH compliont Automotic bockup . Long-term doto storage Unlimited cloims, scheduling & documentation Honds-off updating. Reliable. Secure servers Workfrom any computerwith lnternet occess. 30 Day No RiskTrial No Credit Carc . No Set-up Fees Therabill Simple. lntegrated. Online Billing Come see us at ACA 2015 - Booth 408 bgg.8zz.34s4 www.therabill.com February2015 | CounselingToday | 29 contemplation, planning, action, maintenance and termination." stages: PrecontemPlation, NEW EDITION! Hagedorn tailors his approach according to what stage the client is in. Contemporary APProach to Substance Use Disorders and Addiction Counseling A Second Edition Ford Brooks ond Bill McHenrY This edition o/A Contemporary Approach to Substance Use Disorders and Addiction " Counseling is superior. h is clearly witten, easy n . beginning and uperienced couruelon. 11 mpands thi authirs oiginal worh and is one of tbe most caedtiue, addictions-specifc boo hs for counse bn auaikble." -Gerald A.Juhnke EdD Profesor/Amedcan (ounseling Association Fellow Ihe Univers$ ofTexas at Sn Antonio ti an introducdon to fie field of addiction counseling, this teift covers the fundamental knowledge, understanding, and skills necessary to counsel people who are struggling widr addiction' Drs' Broola and McHenry prwide a straighforward, compassionlte, an{ . holistic approach to uotrrr.t t and recovery from-the major theoretical underpinnings, to assessment and diagnosis, to relapse prwendon and \Triuen I : as soiritualiw. ftth a focus on currenr clinical applications and how-tos, fiis book'ls ideal both for mastert-level addictions courses and mental health clinicians. Topia addressed include cultural and gcnder issues, including workwith LGBT clients; drug classifications and refeffal; assessment, diagnosis, and interview techniques; the continuum from nonuse to ,dd"i.tio.r; work in college/univirsiry, school, and community/mental health asency setings; d*welopmental approaches in treatment; the ,ol. of ,f,. family; giief and loss in addiidon; ,.'YP counseling; relapse and support grouPs; addictions training' the imponance of counselor self-care' and ...rino,lo.,,'*a.*tiot activities are presented in each s.rgg..ted F-plor"tio.r-questions "rrd and recovery; tpitil"rliry chapter. 201s | 336 pgs I Order #78108 | ISBN 978-1-s5620-339-8 List Price:568.95 IACA Member Price: 549'95 Shippingand.Handling$8.75($1'00foreailadd'itioralbooh) Order Online: counsel in g.org/bookstore By Phone: 800-422-2648 x222 (M-F 8am - 6Pm) resistance by connecting directly with their emotions. Once a client reaches the of planning, action, maintenance and termination, Hagedorn advises stages and tbe tlPical areas couered proui* "ndrrsand"highly rebuant informationfor both useful and. He notes that motivational interviewing is particularly helpful in tackling the denial that is entrenched in the precontemplation and contemplation stages. He also likes to use "heartcentered" therapies such as Gestalt or art therapy in the contemplation stage. He thinks this provides a way for clients to bypass the mental blocks of denial and using a behavioral method such as. cognitive behavior therapy, dialectical behavior therapy or acceptance and commitment therapy. Juhnke says motivational interviewing is also panicularly effective in helping clients identifr circumstances that might trigger an episode of substance abuse or, for those in recovery a relaPse. "The hard part with addiction is that everyone always thinks that they have their addiction beat," he says. "I just had a client recently who thought he had his addiction beat. He had been sober for seven years and, suddenly, at the department Christmas parry he has a drink. And then he thinks, 'W'ell, I ve already had one drink and it didnt hurt me. I bet I could have two.'And then by the end of the night, he's got a fifth of vodka down and het saying inappropriate things to his boss and subordinates." Afterward, the client was embarrassed and ashamed, but Juhnke helPed him work through the issue by examining what had happened' He asked the client why he suddenly took a drink after so \Vhat specifically was long in recovery. that decision? made he happening when 'Vzh", how could And *... the triggers? he learn from that? "Because in recovery it's all about learning from your relapses," Juhnke emphasizes. "Anyone in recovery is going ,o h"r. relapses, but it's learning from each dme you relaPse, learning what happened. How did that haPPen? AMERICAN COUNSELING ASSOCIATION ki.rd of things can I do to insulate myself from that same situation or having those feelings again?" 30 | ct.counseling.org I February 2015 Juhnke finds it is helpful to teach all bur particularly those of his clients battling addiction the acronym H.A.L.T.: hungy, angry, lonesome, tired. ), l I\ He says these feelings often represent precipitating evenrs for subsrance abuse, and ifclients can learn to recognize those feelings as they're happening, they can address the situarion without reaching for a substance. lntervening on campus Addiction uearmenr isnt rhe only thing that has changed in rhe field; the diagnosis of substance abuse has changed as well. The 6fth edition of the Diagnoxic and Statistical Manual of Mental Disorders (DSM-fl has combined the DSM-M categories of subsrance abuse and substance dependence into a single disorder measured on a continuum from mild to severe. As a fact sheet published by the American Psychiarric Association notes, "In DSM-IV, the distinction berween abuse and dependence was ! based on the concept of abuse as a mild or early phase and dependence as the' more severe manifestation. In practice, the abuse criteria were sometimes quite severe. The revised substance use disorder, a single diagnosis, will bemer match the symptoms that patients experience." This new diagnosis range fits nicely with what ACA member Rick Gressard is trying to do at rhe College of'lTilliam & Mary with the New Leaf Clinic. Gressard and his colleague Sara Scort created the student substance abuse clinic to provide counseling services to students and a place for counselors-in-training to get hands-on experience with addicdon treatmenr. Gressard, Scort and the college view the clinic as playrng a crucial role in the prevention of future, more serious substance abuse problems. New lraf Clinic operares in conjunction with the Office of Srudent Affairs and is part of the disciplinary system at the college. The clinic is open to any student who wants to come in voluntarily for counseling, bur dl students ar the college who incur an alcohol or subsrance use infraction, such as being drunk in public, destroying properry or possessing marijuana or another illicit substance, are required to visit the clinic. Depending on the infraction, the student faces three different levels of intervendon, all of which are nonconfrontational, nonjudgmental and focused on harm reduction, Gressard says. The first level consisrs of required attendance at a single psychoeducational session. "We take rhe approach that people are seeking a high from alcohol, and they think more is better," Gressard says. "But we try ro help them see that high levels really bring problems, and you actually dont feel better but worse." The session covers topics such as binge drinking and the increased likelihood that studenrs will experience negarive consequences such as being arrested, passing out, gerting injured, getting into fights, having a sexual experience they regret, being sexually assaulted or otherwise harmed, or ending up in rhe hospital because of an overdose the more frequendy they engage in the behavior. "It's become a clichC college students falling offbalconies - but we see a lor of - Gressard says. those kinds of accidents," "These are the kinds of problems we are hoping to help them avoid." The second level of intervenrion consists of rwo sessions. In rhe first, f February2015 | CounselingToday | 31 underlying the pain," Hagedorn says. However, he believes that counselors should nor rry to address both cooccurring disorders simultaneously. "You dont start digging into why the client [with addiction] struggles in the first six months," he asserts. "Dont dig until you know how the client will cope with this understanding. A lot of clients wanr to understand why, and some counselors take them there way too early. I have seen the bad results of understanding why too soon." Hagedorn explains his line of thinking lt :1/*;' with It [' tt students fill out a survey on their patterns ofdrinking and substance use, receive additional psychoeducation and are asked to track their use over the course of the next week. During rhe second a hypotheticd situation. "Say someone comes in and says, 'I just dont understand why I keep drinking. I want incidence of comorbidiry is actually much higher. Broola thinks rhe comorbidiry rate continues to rise with the field's increasing awareness of co-occurring disorders. In session, students receive an assessment otler words, addiction and other mental health issues have always been intemvined; of their drinking or subsrance use habits professionals based on the survey they completed bemer in session one. The survey was designed specifically for William & Mrry and uses data provided by the schoolt students so that respondents can compare their lr L In Gressardt experience, where there is substance abuse, there are often other mental health problems. He nores rhar the epidemiology has shown that rhose counselor-in-training then discuss the studentt feelings about the assessment and any concerns or problems and vice versa. Hagedorn mighr peg rhe rate of comorbidity even higher. He says he rarely sees a client who presents solely with a substance abuse problem such as alcoholism or solely with a mental health disorder such as depression. questions. The third level of intervention involves a minimum of six individual sessions. Students at this level also take an inirial assessment during the first session. The remaining sessions are dedicated to individual counseling using motivational interviewing. According to Gressard, the intervention program has been surprisingly successful in reducing harm to students and helping those who are grappling with more serious forms of substance abuse. One of the most substantial complicating in addicdon ueatment is rle prevdence of comorbid or co-occurring disorders. According to the SAMHSA survey estimates, out of the more than 20 million Americans with a substance abuse problem and the narly 44 million Americans who have some form of mentd illness, 8.4 million people have both. Many professionals who treat addiction believe the factors i gening with substance lntertwining issues I are just drinking and substance use habits against the habits of peers. The srudent and the assessmenr, the ll in the field at recognizing it. 32 | ct.counseling.org I February2015 as abuse disorders are rwice likely to have other mental health "I subscribe to a self-medicating hypothesis, which is something of chicken-and-egg situation," says Hagedorn, president of tle fusociarion for Spiritual, Ethical and Religious Values in Counseling, a division ofACA. "Are they using substances to medicate mental health concerns? Or is the psychologicd pain or wounding that is contributing to the mental health disorder also a contributing to the substance disorder?" In the past, substance abuse counseling and mental health counseling were often separated, which meant that clients frequently missed receiving all the treatment they needed. "I think we are doing a real disservice to clients by only treating just what makes the most noise. 'We tend to listen to what clients say hurrs the most and not look for what is to know why,"' he says. As the counselor digs, he or she discovers rhat the client had a neglectful farher and feelings of inadequary. The clienr suddenly realizrs this is why he or she drinla, Hagedorn says, but what then? "How does rhe client deal with this without drinking again?" he asks. "You keep clients locked in pain without having [another method] to deal with the pain." Hagedorn believes the addiction should be treated first so that when the client experiences the pain of understanding the underlying cause, he or she will have learned not to auromatically turn to the addictive subsrance ro cope. Juhnke mkes a different perspective. He thinla that once disorders co-occur, theyre all but inextricable. "Itt kind of like Jell-O," he says. "You have the granules, and then water is added, and then they're dl just fused rogether." In addition, Juhnke asserts rhar clienrs with comorbidiry are often experiencing such severe problems that theret little time to separate disorders and rrear them independently. Brooks agrees that co-occurring disorders must be treated simultaneously. He points out that people with cooccurring disorders sometimes start their substance abuse as a way ro self-medicate, so ifcounselors treat the addiction but not the menml health problem, the rycle will start all over again. Comorbidiry greatly increases the chances that a client in recovery will relapse, he asserts. To guard against that, a counselor must consider both disorders at the same time. If the client is on medication, a counselor should be working with a psychiatrist who specializes in both substance abuse and mental health disorders, Brooks notes. Similarly, any treatment Program (whether inpatient or outpatient) should specialize in both substance abuse and mental illness, he says. Juhnke thinks itt best to double or even triple down on treatments and interventions when it comes to comorbidity. "Itt kind of like a big spider web. The more sticky substance we can put down, the better offthe client will be," he says. "Twelve-step programs once a month, that's not going to be very helpful. But if we have them doing family counseling, if we have them attending l2step meetings several times a week and if we've got them doing homework related to their panic disorder, pufiing that all together can be really helpful." A different kind of addiction To complicate the picture even further, addiccions dont always involve substances such as drugs or alcohol. Certain behaviors can become addictive, and equally as problematic, as well. Known as process addictions, these behaviors are most commonly connected to sex, gambling, shopping, exercise, eating, Internet use and, some even speculate, work. Process addictions can cause just as much damage as substances, but the behaviors involve common activities, making them more difificult to recognize. But both substance and process addictions follow similar Patterns. "'$7hen people are in pain, they find something to ease it," says Summer Reiner, an ACA member who researches addiction and serves as an associate professor and school counseling program coordinator at the State Universiry of New York at Brockport. That "something" might be alcohol or a substance, but it could also be a behavior such as sex, gambling or shopping, she a new secdon on behavioral addiction, but the only diagnosis included is for gambling. However, Internet gaming is listed in a separate section of the manual that includes diagnoses that need more research. Many addicdon researchers and professionals believe that other processes or DSM-5hx behaviors such as sex, er
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