CHAPTER 1: Introduction Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory First Edition Todd F. Lewis Developed by Katie A. Wachtel, University of North Carolina at Greensboro

Introduction The pervasiveness of substance abuse and addiction begs the questions: What is the best way to address substance abuse problem clinically? What does effective treatment look like? A survey of the substance abuse literature suggests there is much more information on the first question compared to the second. In this chapter and text, both questions are addressed, with much greater emphasis on the “how to”, with counseling theory as the foundation.

The Importance of Theory Counseling theories serve as the foundation of mental health training programs. Theories offer: an organizing philosophy of how problems develop grounding from which to develop techniques assumptions about people and a common desire to help Theories can provide a central, organized set of principles for substance abuse treatment.

Overview of Theories Motivational Interviewing (MI) Born out of the addictions field and has an impressive array of empirical support for its effectiveness Cognitive Behavioral Therapy (CBT) Well-known, evidence based model used in substance abuse treatment Relapse Prevention Based on CBT principles an important part of any substance abuse treatment and strong research base

Overview of Theories Continued Group Therapy A “best practice” in substance abuse treatment; both traditional psychotherapy and mutual help groups (e.g., AA) are important in substance abuse treatment Family Therapy Substance addiction rarely occurs in isolation. Substance addiction often impacts entire family systems warranting effective family-based interventions. Solution-focused therapy Brief model making it attractive in today’s managed care environment

Overview of Theories Continued Adlerian Therapy Comprehensive theory that has much to offer substance abuse treatment; a good contrast to the disease model of addiction (discussed in Chapter 2) Gestalt Therapy Can help addicted individuals live with greater awareness, integration, and authenticity Existential Therapy Substance abuse often manifests as a crisis in meaning and the “givens of existence.”

Roadmap to Theory Utilization Based on Brown’s Developmental Model of Alcoholism Four stages in Brown’s model: 1. Active Drinking or Use 2. Transition 3. Early Recovery 4. Ongoing Recovery

Roadmap to Theory Utilization Continued Early in the recovery process (active use, transition), or when clients are in restrictive environments (e.g., residential inpatient) clinicians should rely more on: MI, CBT, relapse prevention, group therapy, and family therapy Later in the recovery process (ongoing recovery), or when clients are in less restrictive environments (e.g., outpatient), Gestalt, existential, and Adlerian become more appropriate and relevant. Flexibility is key! Some approaches can be used across stages and settings as appropriate.

A Word About “Evidence Based” In recent years, “evidence based treatments” (EBTs) have been challenged by a number of authors and researchers. Overemphasized to the exclusion of other common factors (e.g., counselor-client relationship) Other equally valid approaches are ignored Manualized treatments are no more effective than any other Conclusion: EBTs can provide a roadmap, BUT client feedback is key! Once size does not fit all!

Running Case Study: Michael Michael’s five axis diagnosis (based on DSM-IV criteria): Axis I: Alcohol Dependence, With Physiological Dependence Cocaine Abuse Major Depressive Disorder, Recurrent, Moderate, Provisional Axis II: No diagnosis, prominent use of displacement and denial Axis III: Pre-diabetic Axis IV: Marital problems; Occupational problems Axis V: GAF 53 (current)

Multicultural Issues Must understand one’s cultural background to better conceptualize substance abuse problems Sensitivity, awareness, and knowledge of diversity issues Miller’s general suggestions for substance abuse clinicians: 1. Be aware of own culture 2. Be aware of socio-historical-political aspects of some groups and how they have been treated in the U.S. 3. Develop a dialogue friendly stance to aid in communication Different meanings of substance abuse, addiction, and recovery across cultural, religious, gender, and ethnic lines