The MerrillCounselingSeries 5TH EDITION SUBSTANCE ABUSE COUNSELING theory andpractice; PATRICIA STEVENS ROBERT L. SMITH CONTENTS Chapter 1 INTRODUCTIONTO SUBSTANCE ABUSE COUNSELING 1 The Historyof Substance:NoWonder We Use 4 Alcohol 4 Cocaine 6 Heroin 7 Marijuana 7 Opioids 8 Amphetamines 10 Hallucinogens 10 Tobacco 11 Caffeine 12 SocietalCostsof ATOD Use,Abuse,andDependency 13 Substance-Related Diseases 14 Hepatitis 14 HIV/AIDS 16 TheImportanceofTerminologyinSubstanceAbuseCounseling 17 The Professioninthe21stCentury 19 An Overviewof this Book 20 Conclusion 20 Chapter 2 ETHICALAND LEGAL ISSUES INSUBSTANCE ABUSE COUNSELING 27 EducationandTrainingof SubstanceAbuse Counselors 28 Ethics 30 Confidentiality 32 CodeofFederalRegulations42, Part2 34 HealthInsurancePortabilityandAccountability Act of 1996 (HIPAA) 35 Confidentiality inGroupCounselingor 12-StepGroups 36 Confidentialityof Minors 37 Multiculturalism,Diversity,andEthics 41 EthicalConflictsSpecifictoSubstanceAbuse Counselors 42 Dual Relationships 42 ClientsandCriminalActivity 43 Conflicting Laws 44 EthicalCodeConflicts 44 Contents xiii EthicalDecisionMaking 44 Conclusion 50 Chapter 3 THE MAJOR SUBSTANCES OF ABUSE AND THE BODY 51 The Brain 52 NeuroscienceResearch 52 TheStructureofthe Brain 53 PsychoactiveSubstancesandthe Brain 58 ControlledSubstances Schedules 59 Depressants 59 Alcohol 60 Benzodiazepines:PrescriptionandOver-the-Counter Medications 64 Barbiturates 66 GHB (Identifiedasa Club Drug) 67 Opiates(PrescriptionDrugsOftenAbused) 69 Stimulants 71 Cocaine 71 Amphetamines 74 MinorStimulant:Nicotine 76 MinorStimulant:Caffeine 78 Cannabis 79 Hallucinogens 82 LysergicAcid Diethylamide(LSD) 83 Phencyclidine(PCP) 84 Ketamine(Targetedasa Club Drug) 85 A FurtherLookat ClubDrugs 86 MDMA(Ecstasy) 86 Volatile Substancesor Inhalants 88 Anabolic-Androgenic Steroids 89 Conclusion 92 Chapter 4 ETIOLOGY OF SUBSTANCE ABUSE: WHY PEOPLE USE 98 UnderstandingTheory 98 OverviewofATODTheories 99 MoralTheory 99 Aspectsof UseAddressed bythe MoralTheory 99 DiseaseTheory 101 Aspects of UseAddressed bythe DiseaseTheory 101 _ xiv Contents GeneticTheories 105 Aspects of UseAddressed byGeneticTheories 107 BehavioralTheories 110 Aspectsof UseAddressed bythe BehavioralTheory 111 SocioculturalTheories 114 Aspects of UseAddressed bySocioculturalTheories 115 An IntegratedApproach 119 Conclusion 121 Chapter 5 ASSESSMENT AND DIAGNOSIS 122 IssuesinAssessment 122 The DiagnosticInterview 124 DSM-IV-TRDIAGNOSIS 126 Criteriafor SubstanceDependence 126 Criteriafor SubstanceAbuse 127 BehavioralCharacteristics 127 Phase 1:The Prodomal Phase 128 Phase2:TheCrucial Phase 130 Phase3:TheChronic Phase 131 Assessingthe BehavioralSymptoms 132 SocialCharacteristics 132 FamilyCharacteristics 132 Assessingthe SocialandFamily-RelatedSymptoms 135 ScreeningandAssessment Instruments 136 The MichiganAlcoholism ScreeningTest (MAST) 137 The Short MichiganAlcoholism ScreeningTest (SMAST) 138 The DrugAbuse ScreeningTest (DAST-20) 138 The CAGE Questionnaire 138 TheSubstanceAbuse SubtleScreening Inventory(SASSI-3 andSASSI-A2) 139 TheAlcohol UseInventory(AUI) 140 TheAddiction Severity Index(ASI) 140 TheAdolescent Diagnostic Interview(ADI) 141 The MillonClinical MultiaxialInventory(MCMI-II)and Minnesota MultiphasicPersonalityInventory(MMPI-2) 141 TheASAM Criteriafor PatientPlacement 142 Diagnosis 143 DifferentialDiagnosis 143 Dual Diagnosis 144 _ Contents xv Chapter 6 TREATMENT SETTING AND TREATMENT PLANNING 155 What IsaTreatment Setting? 156 TypesofTreatment Settings 157 Medical DetoxificationandStabilization 157 Dual-DiagnosisHospitalInpatient 158 Free-StandingRehabilitationand ResidentialPrograms 159 PartialHospitalization 164 Temporary Recoveryor HalfwayHomes 164 IntensiveOutpatient 164 The Importanceof MatchingTreatment to Client Needs 167 What IsTreatment Planning? 168 Howto DevelopaTreatment Plan 170 The Elementsof a SevereSubstance UseDisorder Treatment Plan 171 SampleSubstance UseTreatment Plan: RelationshipFactors 171 External ReviewersofTreatment Planning:HealthCare Accreditation Organizationsand ManagedCare 175 Conclusion 178 Treatment of DrugandAlcohol Problems inthe Military 185 Chapter 7 INDIVIDUALTREATMENT 188 BeginningIndividualTreatment 189 Intervention 189 IndividualTherapy 191 Therapeutic Alliance 191 DirectEffectStrategies 191 MotivationalInterviewing 191 Cognitive-BehavioralTherapy 192 MindfulnessTechnique 193 Pharmacotherapy 193 BroadSpectrumStrategies 195 HarmReduction 195 HarmReductionfrom theTherapist's Perspective 196 CopingSkillsTraining/Life SkillsTraining 197 Vocational Readiness 197 Support Groups 198 Conclusion 201 xvi Contents Chapter 8 GROUPTREATMENT INTHE CONTINUUM OF CARE 203 Evolutionof GroupTreatment 204 Group Dynamics,Process,andStructure 207 CurativeFactorsinGroupTreatment 207 Group Dynamics 209 Stagesof GroupDevelopment 212 StructuralConsiderations 216 GroupTreatment intheContinuumof Care 217 Prevention 218 Detoxificationand InpatientTreatment 218 ResidentialTreatment 219 PartialHospitalizationand DayTreatment 219 Aftercare andSober Living 220 OutpatientGroupsandCommunityCare 220 Pragmaticsof GroupTreatment 221 Therapeutic Community 221 Self-HelpGroups 222 PsychoeducationalGroups 222 Cognitiveand BehavioralInterventions 223 Group Psychotherapy 228 RelationalTherapy and FamilyGroups 229 GroupTreatment Efficacy 232 Conclusion 238 Chapter 9 FAMILYTREATMENT 240 DefiningFamily 242 GeneralSystemsConcepts 243 Homeostasis 244 Feedback Loops 244 Hierarchy,Roles,Rules,Subsystems,and Boundaries 245 Wholeness 246 Change 247 Values 247 SystemsandAddictive Families 247 The MaritalDyadandSubstanceAbuse 248 The FamilyandSubstanceAbuse 250 ChildrenintheAddicted Family 252 Treatment withAddictive Families 253 Contents xvii The ProcessofTreatment 255 ProgramsUtilizingFamilyTherapy 255 HowSuccessful IsFamilyTherapy? 256 Conclusion 260 Chapter 10 RETAININGSOBRIETY: RELAPSE PREVENTION STRATEGIES 261 Determinantsof Relapse 263 Environmental 263 Behavioral 264 Cognitive 265 Affective 265 InterpersonalDeterminants 266 Summary 267 Modelsof RelapsePlanningand Management 267 The DiseaseModel 267 DevelopmentalModels 268 A Cognitive-Behavioral/Social LearningModel 271 Self-HelpRecoveryOrganizations:Adjunctsto Professional Intervention 274 AlcoholicsAnonymous Model 275 Spiritualityasa Resource 277 AA-Associated 12-StepPrograms 278 ModerationManagement(MM) 278 RationalRecovery 280 Secular Organizationsfor Sobriety/Saveour Selves (SOS) 281 Womenfor Sobriety (WFS) 281 Self-Helpfor DuallyDiagnosedPersons 283 A Weil-Rounded Lifewith Joy 283 Conclusion 286 Chapter 11 WORKING WITH SELECTED POPULATIONS: TREATMENT ISSUESAND CHARACTERISTICS 287 ChildrenandAdolescents 287 Risk Factors 290 Preventionand Intervention 291 Women 294 Risk Factors 294 Preventionand Intervention 295 xviii Contents TheGay/Lesbian/Bisexual/TransgenderCommunity 297 Gay/Lesbian/Bisexual/Transgender IdentityDevelopment 298 Risk Factors 298 Preventionand Intervention 299 Peoplewith Disabilities 300 Risk Factors 301 Preventionand Intervention 302 Older Adults 304 Risk Factors 304 Preventionand Intervention 305 Homelessness 306 Risk Factors 307 Treatment 308 Conclusion 310 Chapter 12 WORKING WITH DIVERSECULTURES: EXPLORING SOCIOCULTURAL INFLUENCESAND REALITIES INATOD TREATMENT AND PREVENTION 311 American IndiansandAlaskan Natives 312 CulturalValues 314 Risk Factors 315 BarrierstoTreatment 316 Preventionand Intervention 317 AsianAmericans 318 CulturalValues 320 Risk Factors 321 Preventionand Intervention 322 AfricanAmericans 324 Risk Factors 325 CulturalValues 326 BarrierstoTreatment 327 Preventionand Intervention 327 Hispanics 328 CulturalValues 330 BarrierstoTreatment 331 Preventionand Intervention 333 Conclusion 334 Contents xix Chapter 13 PREVENTION 336 Typesof Prevention 339 Prevention:A Brief History 340 ComprehensivePrevention 343 CommunityPrevention 344 Riskand ProtectiveFactors 346 LifeSkillsTraining(LST):Effectivenessof a Comprehensive PreventionApproach 349 Stepstoan EffectivePreventionProgram 350 Implicationsfor Counseling 353 Conclusion 356 References 358 Index 392 CHAPTER 1 Introduction to Substance Abuse Counseling PatriciaStevens,Ph.D. MyCounselingLab Visit the MyCounselingLab' site for Substance Abuse Counseling, Fifth Edition to enhance your understandingof chapter concepts. You'll have the opportunity to practice your skills through video- and case-based Assignments and Activities as wellas BuildingCounselingSkillsunits,andto preparefor your certificationexam with Practicefor Certificationquizzes. Alcohol,tobacco,caffeine,prescriptiondrugs,illegaldrugs—allarecommonplacewords today. Alcohol, tobacco, and other drugs (ATOD) are used for celebrations, for mourning, for religious rituals, for pain relief,and recreationally. We read about them inthe newspaper daily, we hear about them on the radioand television, andwe can findjust about anything, fromwhat they areto howto makethem,about anysubstance useandabuseonthe Internet.We seechildrenabusingat younger ages and elders abusing. Drugsare misused to forget, to feel better or not feel at all, to be friendly, to disinhibit, and because of peer pressure.Tobacco and alcohol, legaldrugs, areusedandabusedwithsocialsanctionandareeasilyavailable.Ifwe don't usethem, we probably have a user/abuser in the family or a close friend who has abused, or knowsomeonewho usesalcoholorotherdrugsinappropriately. Consequences of use andabuse of legalizedsubstances continueto be minimized in a variety of settings. Untilthe mid-1990s, the tobacco industry denied addiction while people were dying from lung cancer and others continued to smoke. After multiple suits against the companies, they tried to settle, payingout $10 billion per year inperpetuity andplacinginthe public domain over 35 millionpages of internal documentsontheeffectsof smoking. In 2009, an estimated 69.7 million Americans aged 12 or older were current (past month) users of a tobacco product. This represents 27.7% of the population