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Approaches to Drug Abuse Counseling
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A Counseling Approach

Fred Sipe
1. OVERVIEW, DESCRIPTION, AND RATIONALE
1.1 General Description of Approach
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This approach to counseling is based on the belief that a condition of susceptibility to chemical addiction exists prior to the first use, sometimes referred to as a "genetic predisposition." It is also based on the belief that chemical addiction is a disease repeatedly reinforced by self-judgment; therefore, it is a disease of self-judgment.

This model views addicts and alcoholics as individuals chronically addicted to chemicals in spite of their attempts to change. They are in a vicious cycle of use, self-judgment, and avoidance that is repeated time and again. The model focuses on three elements of the cycle:

  1. Chemical use.

  2. Self-judgment.

  3. Avoidance behaviors.

The approach to counseling is strongly based on the 12 steps of Alcoholics Anonymous (AA).

The three elements of the addictive cycle are impacted by a process created by using:

  1. A therapeutic environment.

  2. A thorough assessment.

  3. A group process.

  4. Education.

  5. Self/peer assessment.

All five items are incorporated into a therapeutic process, which begins with the first contact.

The creation of an environment that supports the therapeutic process is essential to this approach. Clients must be provided with an opportunity to explore their self-judgments without fear of the judgment of others. They must feel they are listened to with empathy and respect. In earlier models of this approach, the counselor was the only one who possessed so-called counselor characteristics. Although this element is still critical, it now applies to the whole multidisciplinary team, a staff of professionals who are naturally therapeutic.

The counselor conducts an initial assessment, identifies the presenting problem, and, if indicated, schedules the client for treatment.

A thorough psychosocial assessment is conducted, and identified blocks to treatment or problems are noted. The counselor begins the bonding with the client during the assessment process. All counseling skills come into play. The counselor then prepares a therapeutic or treatment plan (i.e., the change model) to help the client deal with those identified problems or blocks that will prevent response to the treatment process.

The client follows a simple change model that closely aligns with the 12 steps of AA.

Model AA Step
Identify the problem Step 1
Develop trust (renewed hope) Steps 2 and 3
Ventilate Steps 4 and 5
Gain new insight Steps 6 and 8
Change behavior Step 7 and Steps 9 through 12

Clients are guided through the first 5 steps of the 12-step model and receive educational materials on the remaining 7. The first five steps help clients focus on the goals of this approach.

Step 1. Acceptance is clearly necessary in identifying the problem.

Step 2. The perception is a return to a sense of hope.

Step 3. Turn over to a new behavior.

Steps 4 and 5. Facilitate ventilation or catharsis and give clients new insight and, as a result, new behaviors.

After completing the treatment process, clients are referred to continuing care groups that meet once a week. Additional meetings can be scheduled if indicated.

Psychotherapy or marital counseling can also be a part of the continuing care process, if appropriate.

Twelve months of continuing care and a minimum of three AA meetings a week are a part of the treatment program.

1.2 Goals and Objectives of Approach

Goals. Identify the primary problem as chronic addiction to mind- or mood-altering chemicals.

Gain a renewed sense of hope; come to believe wellness is possible.

Experience lifestyle changes that promote a renewed sense of self-esteem by practicing healthy emotional management and increasing personal responsibility.

Objective. Identify the problem.

No one can change what cannot be seen. The program leads clients through a sequence of tasks that are designed to help identify the problem.

  • Life story.

  • Ten consequences.

  • AA first step.

All of these tasks are shared with staff and peers.

Strategies/Techniques. The counselor asks the client to look at a mirror image that he or she has created through drug use (i.e., self-discovery). All of the tasks will be reviewed with or by the counselor and peers. The counselor may choose to have the client review them in a one-on-one session first. This session can provide emotional insulation from a more public sharing with a group of peers, but it is not intended to take the place of receiving peer feedback.

Objective. Develop trust.

A common philosophy that is shared by all staff members is the basis for helping the client develop trust. Clearly written policies and procedures that are understood by all the staff members facilitate trust and create an environment of consistency. Beginning to trust brings a renewed sense of hope.

Strategies/Techniques. The counselor can use all the counseling skills to facilitate this objective. The initial assessment, or in some programs the psychosocial assessment, is where this development of trust with the counselor begins. Attending, empathy, genuineness, and honesty are some of the counselor's tools. The psychosocial assessment is an excellent opportunity for the counselor to create a therapeutic relationship with the client. The counselor should make it a joint effort to explore the different areas of the client's life. It must be more than a process to collect data.

Objective. Experience a catharsis/ventilation.

The client must be given the opportunity to begin looking at and bringing out the secrets that are the bases for his or her self-judgments. It is the primary purpose of the fourth and fifth steps of AA. Self-disclosure is cathartic and can lead to self-discovery.

Strategies/Techniques. The counselor should guide the client to deeper levels of self-disclosure through the use of treatment plan objectives and helping skills and must stay focused on those areas related to the addiction or the identified blocks that prevent the client from responding to the program. Remember that catharsis/ventilation does not necessarily mean crying. For example, ask the client to share with the group five words that describe how his or her parent feels about having a child in treatment. Then have the group help the client explore this issue.

Objective. Gain new insight.

It is important that this be the client's self-discovery and that he or she begins to see the consequences of his or her behaviors, the defects of character, and the people who have been harmed. This insight, facilitated by Steps 4 and 5 (catharsis), leads the client to Steps 6 and 8 (insight).

Strategies/Techniques. Treatment plan objectives, group tasks, and facilitated exploration of the issues identified by the client can lead to new insight. Have the client share one of the items from his or her list of 10 consequences with the group and ask for feedback. Have the client read the story from the Big Book of AA that is closest to him or her and share with the group. Ask each client to share a secret not previously shared and tell the group what he or she has learned.

Objective. Change behavior.

The program must contain activities designed to facilitate learning of new behaviors. Being assigned to a small group helps clients learn to use groups as support. The buddy system used in some programs helps clients begin to learn the behavior of using a support system outside of themselves.

Strategies/Techniques. The counselor should monitor the client's behavior throughout the treatment process, frequently giving feedback. This is the beginning of learning to use a sponsor, which is deemed critical by most AA members. Treatment plan tasks can require the client to try using a new behavior to cope with certain problems.

1.3 Theoretical Rationale/Mechanism of Action

By facilitating the client in experiencing a change in the way he or she believes, feels, and behaves, this approach is implemented with the following premises:

  1. What the client believes is the basis for his or her self-judgment. Self-esteem is not taken away by others. It is taken away by self-judgment based on the client's belief system.

  2. A key to this approach is the premise that negative feelings that are not dealt with do not go away. These avoided feelings become the basis for the loss of self-esteem.

  3. Successful new behavior is the basis for a renewed positive sense of self.

Change Model
  1. Identify the problem as chemical use.

  2. Gain a sense of trust.

  3. Ventilate feelings.

  4. Gain new insight into life and behaviors.

  5. Change behaviors.

1.4 Agent of Change

The primary agent of change is the combination of spirituality, the individual, and the treatment process (the therapist, the group, the 12 steps, and the treatment program).

1.4.1 Spirituality.

In general, spirituality is defined as a healthy relationship with the things and people who are valued. By helping the client improve his or her relationships, spirituality becomes a primary agent of change.

1.4.2 The Individual.

Drug addiction, which is classified as a disease, requires three components to meet the definition:

  1. An agent or drug.

  2. A host or individual.

  3. An environment.

If any one of the three components is removed, the chronic progression of the disease is interrupted. By focusing on the individual, he or she becomes a primary agent of change.

1.4.3 Treatment Process.

The treatment process is a primary agent of change in this counseling approach; the therapeutic community, which encourages honesty, openness, and bonding, becomes a primary agent of change.

1.5 Conception of Drug Abuse/Addiction, Causative Factors

This model is based on the belief that drug addiction is a disease. Most probably the client is genetically predisposed. Certainly the client is biochemically altered. The client is also psychologically affected by the emotional mismanagement and distortion of the defense systems. By inhibiting or supplanting the social coping skills of the client, drug addiction has a disastrous effect on all social areas. Drug addiction is a biopsychosocial disease characterized by physical deterioration, a prevailing sense of hopelessness, and severe emotional isolation. The client also experiences a gross violation of his or her value system.

2. CONTRAST TO OTHER COUNSELING APPROACHES
2.1 Most Similar Counseling Approaches

Counselors who have been fortunate enough to be trained in a program that is based on an interdisciplinary philosophy will have the benefit of both counseling psychology and the 12-step model. Hazelden would probably be the closest. All counselors trained at both the Navy Alcohol Treatment Specialist School and the Johnson Institute during the 1970s would share this approach to counseling.

2.2 Most Dissimilar Counseling Approaches

These include:

  • Approaches that are not based on total abstinence.

  • Approaches that do not deal with feelings.

  • Approaches that do not use the 12 steps of AA.

3. FORMAT
3.1 Modalities of Treatment

This approach primarily uses the small group process. Individual sessions are used when warranted.

3.1.1 Individual Sessions.

The individual session is used in the assessment phase at the beginning of treatment and for individual planning sessions during the course of treatment. Some individual counseling may be offered to give the client an emotional insulation. A client's first attempts at being more open will be frightening. By sharing with a counselor beforehand, the client may be able to disclose within his or her group more readily.

  • Goals. These include individual planning, clarification, reassessment, or help in exploring a client's highly traumatic issues.

  • Process. The individual session can be scheduled at the request of the counselor or the client. The goal is stated, and the process begins. The process is dictated by the goal, but all have a beginning, a middle, and an end.

3.1.2 Group Sessions.

All activities are designed to have the client learn to use small groups as a support system. Each group remains as autonomous as possible to encourage the client to be more open and share at a deeper level. This also prevents triangulation and defocusing. It is easier to hide in a large group.

  • Goals. Help the client learn to use small groups for support, for feedback, and for communication skills, as task oriented or process oriented.

3.1.3 Other Group Sessions.

Other special groups can be utilized for topics like grief or sexual abuse and other types of physical and emotional abuse. These are sometimes called special treatment population groups or focused groups.

  • Goal. To help the client use peers who have a similar experience for support.
  • Process. Having clients who share a significant experience facilitates the bonding and thus the self-disclosure or catharsis.

3.2 Ideal Treatment Setting

The ideal setting would be to match the treatment to the individual. This approach works best in inpatient and outpatient programs; however, the approach can be utilized as a base in any setting.

Some of the activities would be altered, but the process would be the same.

  1. Identify the problem.

  2. Develop a sense of trust and hope.

  3. Ventilate.

  4. Gain new insight.

  5. Change behavior.

3.3 Duration of Treatment

The ideal format for this approach is a small group. The duration would be 1-1/2 hours (± 15 minutes). The group should number between 8 and 10 people (the number could affect the duration). Each client's level of functioning would also have an impact on the duration.

The use of open-ended groups in alcohol and other drug counseling is almost universally utilized and is probably the best format. Clients should attend the primary group for at least 6 weeks. This could include 2 to 3 weeks of inpatient treatment and 3 to 4 weeks of outpatient treatment. The number of sessions would generally vary with the settings. Key, however, is to include 12 months of continuing care.

There have been some studies suggesting that it takes 21 days (3 weeks) to let go of old attitudes and 21 days to develop new ones. This premise would strongly indicate the need for a program with a 6-week duration.

Inpatient groups should have one primary counseling group every day. Outpatient groups should meet once a day, four times a week.

3.4 Compatibility With Other Treatments

This approach would be compatible with family programs, diversion programs, probation and correctional programs, adolescent programs, and driving under the influence programs, within a broad range of treatment settings.

This counseling approach would not be compatible with programs that used psychoactive drugs or programs that did not focus on abstinence as a primary goal.

3.5 Role of Self-Help Programs

This approach is a balanced integration of 12-step programs and a solid counseling approach. NA, AA, and other self-help groups are key elements in this approach. Since NA and AA have abstinence as a primary goal, both are a part of the counseling approach. Using attendance at meetings as part of the treatment plan sets the groundwork for using meetings as a continued support after treatment.

4. COUNSELOR CHARACTERISTICS AND TRAINING
4.1 Educational Requirements

The educational requirements for the counseling approach would ideally include:

  • Bachelor's or master's degree in either the behavioral sciences or the counseling psychology fields.

  • Certification by a State or national certifying organization.

  • Specific training in working with special treatment populations.

4.2 Training, Credentials, and Experience Required

Counselors should have a certificate in chemical addiction education and should be certified as addiction counselors by a State or national organization. Counselors should also have a minimum of 3 years of experience.

All counselors using this counseling approach need:

  • Comprehension of the addictive process and how it is to be treated.

  • A comprehensive curriculum of the addictive process and how it is to be taught.

  • A viable, realistic opportunity to demonstrate knowledge, comprehension, and expertise to practice the counseling skills in a classroom setting with clients in a supervised practicum.

  • A method of analysis and an opportunity to apply it.

  • A method of analyzing client data and the opportunity to apply it.

The opportunity to demonstrate an ability to synthesize knowledge, comprehension, application, and analysis into a viable approach to counseling.

4.3 Counselor's Recovery Status

The counselor need not be recovering, but counselors who are not in recovery must have a demonstrated understanding of the disease. Counselors who are recovering might be quicker but not necessarily better.

4.4 Ideal Personal Characteristics of Counselor

To utilize this counseling approach, an individual needs some innate helping skills. He or she must have the ability to touch people emotionally.

To utilize this approach successfully, the counselor should have the following characteristics:

  • Empathetic understanding.

  • Respect and acceptance for others.

  • Sincerity.

  • Good timing.

4.5 Counselor's Behaviors Prescribed

The counselor needs to be able to facilitate clients' exploration of their disease. He or she must be:

  • Tactful, yet confrontive.

  • Evaluative.

  • Emotionally present, yet objective.

4.5.1 Comment/Confrontation. Confrontation is the most confused and misused of the counseling skills. When it comes to misused skills, it is probably second only to doing therapy without the necessary skills to do it correctly. Confrontation must be done with respect for the client. It is a tool, not an end item. The avoidance behaviors must be confronted; the elephant in the living room must be brought to someone's attention. If the counselor's empathy is accurate, he or she will know how to gauge the confrontation. Confrontive therapy can be long and expensive and generally does not work with addicts and alcoholics.

4.6 Counselor's Behaviors Proscribed
4.6.1 Judgmental Behavior.

If the counselor does not believe addiction is a disease, or he or she has personal beliefs that go against the program's philosophy, the counselor needs to work elsewhere.

4.6.2 Coaddiction.

If the counselor has enabling behaviors that shortcut the process or enable the client's avoidance system, the counselor should either find another helping field or get help.

4.6.3 Dishonesty.

If the counselor cannot be honest with his or her peers and with the clients, the counselor should either find another helping field or get help.

4.6.4 Fear.

If the counselor is frightened by addicted clients, he or she cannot help them.

4.6.5 Feedback.

If the counselor cannot work as a part of a team and accept and consider feedback, he or she will prevent clients from receiving the best possible therapy.

4.7 Recommended Supervision

Supervision works best when it is provided by a trained staff member who is outside of the management team. Too many programs use the clinical supervisor as the program supervisor. The combination of direct supervision and case review gives the counseling staff the most credible supervision and feedback.

4.7.1 Direct Supervision.

Frequent and rotational direct participation in counseling groups and sessions gives the supervisor the opportunity to evaluate the counselor's skills and his or her application of them.

4.7.2 Case Review.

Counselors should follow a schedule of case presentation. They can present one on one to the supervisor or in a group of their peers.

5. CLIENT-COUNSELOR RELATIONSHIP
5.1 What Is the Counselor's Role?

The counselor's role is to facilitate, that is, to be a teacher, coach, peer, and even adviser.

5.2 Who Talks More?

Because the bulk of time is spent in group process and the client's peers are utilized, most of the talking is done by the client. This would depend somewhat on the style and personality of the counselor.

5.3 How Directive Is the Counselor?

The amount of direction by the counselor depends primarily on where the client is in the treatment process and who the client is emotionally.

5.4 Therapeutic Alliance

The client must trust the counselor. The counseling characteristics and their application are key to having a good relationship with the client. If the counselor frequently checks in with the client and involves the client in the planning of the treatment, the quality of the relationship will be maintained. When the relationship is poor, the counselor should ask the client to help get the relationship back on track.

6. TARGET POPULATIONS
6.1 Clients Best Suited for This Counseling Approach

The general population and its subgroups are suited for this approach. All forms of chemical addiction are suited for this approach, including alcohol and tobacco.

6.2 Clients Poorly Suited for This Counseling Approach

Individuals who have significant organic brain damage or a significant psychiatric or psychological block to insight based on a comprehension of behaviors and their resultant feelings are not well suited.

7. ASSESSMENT

This model uses a comprehensive psychosocial assessment tool that reviews:

  1. Initial assessment/problem evaluation. The presenting problem is often the basis for the initial assessment. This first contact reviews a client's current status and is the basis for an initial diagnosis.

  2. Physical/medical history. A physical examination of the client's medical condition is conducted, and a physician takes a medical history.

  3. Nursing assessment. The client's mental status and emotional and psychological history are tested, including any evaluated blocks to treatment.

  4. Spiritual assessment. The client's relationship with his or her spiritual connection and his or her religious experiences are reviewed, including any possible block to treatment.

  5. Psychosocial assessment. The client's mental status and emotional and psychological history are assessed, including any evaluated blocks to treatment.

  6. Social/chemical background. This includes chemical history, activities, financial, vocational, military, legal history, sexual history, marital history, losses, emotional behavior, and family of origin.

  7. Clinical formulation. The clinical formulation is the bringing together of a description of the identified behaviors and problems and formulating them into a behavioral and problematic description of the client.

8. SESSION FORMAT AND CONTENT
8.1 Format for a Typical Session

The format would be a group session. All the assigned members of the group would be seated in a circle. The session would begin with a reading of group rules and possibly a reading from a daily meditation book.

A session could have a purpose or be open to the group need. Some clients may have scheduled tasks. The counselor may ask a group member to report on a previously discussed issue. Some group sessions will have an educational component, while others may be more task oriented.

All sessions would be closed in a specific manner. A closure activity, normally agreed on by the group, would add a specific emotional and symbolic closure of process.

8.2 Several Typical Session Topics or Themes

As a facilitator, the counselor may suggest a topic or point the group toward certain tasks. The session may be predesignated, assigning a certain day to a first-step group.

8.2.1 First Step.

The client is asked to write a first step related to his or her drug use following the guidelines of AA, usually with a form that asks for answers to specific questions. The client is asked to read this to the group and receive feedback. More than one first step may be read in a session.

8.2.2 Life Story With Feedback.

The client writes a life story using a guidesheet that leads him or her through important/significant life events. In some programs the reading may be done in a leaderless group. The peers are then asked to fill out a feedback sheet. The following day, in regular group, under the supervision of the counselor, the client's peers offer supportive feedback.

8.2.3 Secrets Group.

(This is a very brief description of the process.) The secrets group usually asks the client to share a secret not previously shared. One format asks the group members to write a secret on a slip of paper and put it in a bowl. The bowl is then passed around the group, each member taking out a secret and reading it aloud to the group and then making a comment. All group members who want to comment are then given a chance to share how they feel about this particular secret. It gives the writer of the secret a chance to receive feedback and still keep the secret.

8.2.4 Typical Group.

The session begins with a group member reading the rules. A round-robin may be used, going around the group in order. Issues can be identified and in some cases worked on. Before closing, the counselor sees where each member is in the group. Usually some ritual is used, like a group hug, a chant, or a prayer.

8.3 Session Structure

Sessions are generally not highly structured, which does not preclude the use of structure if indicated.

The counselor may choose to use an experiential exercise to address an issue of common concern or to get the group moving. The ideal group would be self-starting and possibly task oriented.

8.4 Strategies for Dealing With Common Clinical Problems Most logistical and clinical problems are dealt with as group issues. However, some problems may be dealt with one on one or with the clinical team, if available. Whatever happens in group or is brought to the group becomes a workable issue.

8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation
8.5.1 Peer Feedback.

The counselor can use the group to confront, support, or give feedback on particular issues. An issue may come up in group; after the client processes it, the counselor may ask how the group feels about it, the process, how their peer handled it, and so forth.

8.5.2 Staffing.

The counselor can ask the client to receive feedback from the clinical team involved in his or her case. Staffing may also be a part of the client evaluation system. The goal is to resolve the issue in a therapeutic manner. Some programs require the staff to conduct a staffing as a part of assigning poor progress. Staffing is usually feedback from the clinical team.

8.5.3 Conjoint Sessions With Family Members.

These sessions are usually used to ensure that all members of the family are aware of the continuing care plan. They also clarify any issues that may be problems in posttreatment.

8.5.4 Group Tasks or Experiential Exercises.

Group tasks are usually from a specific objective listed in the treatment plan. Experiential exercises are normally for an issue that is applicable to the whole group.

8.6 Strategies for Dealing With Crises

The primary strategy for dealing with crises is good training and a good clinical relationship with the client, guided by sound policies. The counselor and the facility in which he or she works should have clear policies regarding the management of a crisis. Good training in this area is needed, coupled with the knowledge of available resources.

8.7 Counselor's Response to Slips and Relapses

The counselor should use a nonjudgmental attitude in a confronting manner to focus the client on the disease. With the advent of the relapse prevention model, a special track may be utilized. Repeated slips also could be grounds for terminating the counseling or treatment process. In most inpatient facilities, when a client uses alcohol or other drugs while in treatment, he or she is asked to leave on the grounds of low motivation. In other facilities, the client may be asked to sign a nonuse contract, and the relapse is used as a clinical issue.

A slip or relapse can be another catalyst to help the client identify the problem.

9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT

This counseling approach presumes a concurrent family education and treatment program. The success rate increases significantly when family members are involved. A questionnaire should be sent to those significant others (SOs) considered to have the closest association with the client. The answers on the questionnaire assists the counselor in confronting the denial system and also helps stop the triangulation often used by clients to continue their avoidance system.

SOs who are themselves in recovery from coaddiction will provide a supportive, nonenabling support group for the client after treatment. The family who is in recovery together has a better chance.

AUTHOR

Fred Sipe, B.A., A.T.S.
9297 Siempre Viva Road, Suite 15-307
San Diego, CA 92173

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