Refusing Offers to Use Substances

Social pressures are the second most common relapse precipitant after negative emotional states. Clients who are not prepared to resist pressures to use are more vulnerable to relapse. Direct social pressures include situations in which others offer the client substances. Pressure may vary from mild to extreme, in which another person tries hard to influence the client to use. The objectives of this chapter are to help the client identify direct and indirect social pressures (people, places, events, social and work situations) to use alcohol, tobacco, or other drugs; to identify feelings experienced during social pressure situations (e.g., anger, anxiety, excitement); to identify thoughts experienced during social pressure situations (e.g., wanting to fit in, wanting to be normal, thinking substance use can be limited or controlled); and to identify strategies to avoid high-risk people, places, situations, and events and to cope with social pressures that cannot be avoided.

Managing Emotions

An emotion that is prolonged or persists over time is referred to as a mood. Emotions or moods that are too intense, extreme, or chronic and that cause problems in life often need to be addressed as part of ongoing substance use recovery. An overall goal of recovery is to reduce negative emotions and increase positive emotions, although any emotion can have a positive or negative effect depending on the circumstance. Negative emotional states can also be exacerbated by physical withdrawal, in addition to life problems, stresses, and interpersonal difficulties. These emotions are also associated with the initial period of becoming drug-free. The objectives of this chapter are to identify the role of negative and positive emotions in recovery and relapse, to help clients identify high-risk emotional issues (specific emotions or deficits in coping skills) to address in recovery, and to help clients learn appropriate strategies to manage emotions.

Psychosocial Therapies for Substance Use Disorders

There are many counseling approaches, treatment programs, and psychosocial interventions for individuals with substance use disorders (SUDs). Although some have been shown in clinical trials to be more effective than others, to date there is no single, superior treatment approach appropriate for all clients. While brief treatments have been successful with alcohol problems, longer term treatments are often needed for drug problems. For clients with more severe SUDs, long-term involvement in professional treatment (including medication-assisted therapies), mutual support programs, or both may be needed. This chapter includes a summary of treatment principles and guidelines that can serve as a framework for helping clients with SUDs.

Understanding Substance Use Problems

This chapter provides an overview of substance use, substance use disorders (SUDs), and co-occurring disorders (CODs, or SUDs combined with psychiatric illness). The authors address current trends in substance use, challenges for practitioners, the importance of a therapeutic alliance with clients, causes and effects of SUDs, classification of SUDs based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and specific symptoms of a SUD. A substance problem exists when an individual experiences any difficulty or adverse effect caused by the use of alcohol, tobacco, or other drugs. These include illicit street drugs and prescription drugs with addiction potential used for pain, anxiety, sleep, and attention deficit disorder.

Medications for Substance Use Disorders

Substance use disorder (SUD) is a chronic medical condition with relapses and remissions, and it has a strong genetic component. Risk for relapse increases with continued use because changes to the brain neurocircuitry pathways created by extensive substance use do not completely revert to normal after detoxification or stopping substance use. Medication-assisted treatment (MAT) is used for addiction to alcohol, opioids, or nicotine and is usually offered in combination with behavioral therapy and/or mutual support program participation. Medications can play a major role in facilitating initial abstinence, reducing relapse risk, and increasing the likelihood of the client maintaining longer periods of abstinence. Behavioral interventions can influence clients to use MAT in their recovery and influence adherence and impact on retention.

Reducing the Risk of Relapse

Any client who attempts to modify alcohol, tobacco, or drug use behavior faces the possibility of lapse or relapse. A lapse refers to the initial episode of use following a period of abstinence. A lapse may be quickly stopped by the client or it may lead to a relapse or continued use of a substance. How a client interprets and responds to a lapse plays a significant role in whether or not it leads to a relapse. The risk of lapse or relapse is highest in the first 3 months of recovery, when most relapses occur. Low motivation and poor participation in therapy or mutual support programs can raise the risk of relapse, even for clients who recently completed a residential or ambulatory treatment program. Other precipitants of relapse include psychiatric illness or an inability to cope with the challenges of recovery. Helping clients remain in therapy and identify and manage early relapse warning signs and high-risk situations are ways to lower the client’s risk of relapse.

Treatment of Co-occurring Psychiatric Disorders

Effective treatment of clients with co-occurring disorders (CODs) requires the practitioner to be familiar with the continuum of care so that clients become engaged in services needed to address their disorders and related problems. Evidence suggests that clients receiving integrated treatment have higher rates of treatment adherence and improved clinical outcomes, particularly those with more persistent and chronic forms of psychiatric disorders. Therefore, it is best to provide integrated care that focuses on both types of disorders, regardless of whether the client is in an inpatient, residential, or ambulatory treatment setting. Given that clients with CODs have higher rates of problems with treatment adherence compared to those with a single type of disorder, this chapter reviews strategies to improve adherence. It also delineates recovery issues in the domains of physical/lifestyle, psychological, behavioral/cognitive, family/interpersonal/social, and personal growth/maintenance. The authors stress the potential helpfulness of mutual support programs and discuss clinical challenges such as suicide, violence, HIV/AIDS, and hepatitis C.

Assessment of Co-occurring Psychiatric Disorders

Co-occurring disorders (CODs) refers to the occurrence of both a substance use disorder (SUD) and a psychiatric disorder, such as mood disorder, anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, schizophrenia, eating disorder, antisocial personality disorder, and borderline personality disorder. This chapter reviews the prevalence, patterns, and effects of CODs. Next, the relationships between psychiatric disorders and SUDs, challenges for practitioners, and types and causes of psychiatric disorders are discussed. The chapter continues with the process of conducting a comprehensive and thorough assessment using the format of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The authors also discuss the importance of conveying assessment findings to the client and/or family and concerned significant others, as well as getting the client to accept help.

Managing Thoughts of Using Substances

Helping clients to become aware of and challenge thoughts of using substances reduces the risk of relapse and raises the client’s level of self-confidence. Clients who experience a high-risk relapse situation and have positive thoughts of using are more vulnerable to taking a drink, smoking, or using other drugs. This is especially true if the client has little confidence in his or her ability to manage thoughts of using. The objectives of this chapter are to help the client become aware of how thoughts of using substances can contribute to relapse, to help the client identify common thoughts and apparently irrelevant decisions that precede substance use, and to help the client learn strategies to manage and challenge thoughts of using alcohol, tobacco, or other drugs.

Screening, Assessment, and Diagnosis

Screening is a process used to identify individuals who may be at risk for a substance use problem by having them answer a few questions about their use of alcohol, tobacco, or other drugs. An extensive assessment of substance use disorders (SUDs) requires a multidimensional approach and differs from other mental health assessments in that detailed information is obtained on patterns of alcohol or other drug use, negative consequences of use, physiological and behavioral dependence, cognitive impairment, motivation for change, potential effects of substances on psychiatric disorders, attitudes and beliefs about continued use and abstinence, and the client’s strengths, resources, and social support networks. Diagnosis determines whether a client meets criteria for a SUD, which in turn may affect treatment planning and access to services. The best approach to diagnosis is through a comprehensive clinical interview and identifying criteria that match a client’s symptomatology.