1999 EDO-CG-99-4
Substance Abuse and Counseling: A Perspective
Amos Sales
Overview
Substance abuse is a critical problem in the United States across
all segments of the population and impacts in some way all members of
our society. It is the most prevalent mind disorder, the number one
continuing health problem, and the number one prison problem in the
United States (Inaba, Cohen, and Holstein, 1997). The significant number
of the United States population having substance abuse problems is
indicated by approximately 6% abusing illegal drugs, 12% having
problems with drinking, 25% being addicted to nicotine and,
conservatively, 10% addicted to prescription medications.
All counselors no matter what their specialty or setting will
encounter clients with presenting or related problems of substance abuse.
However, counselor education programs and their accrediting bodies
do not require knowledge or skill development in this area. Thus, it is
critical that we implement strategies to insure that all counselors in
practice and in counselor preparation programs understand the process
of substance abuse, the etiology of addiction, and related counseling
and treatment approaches. An important step in this process is the
identification of research supported perspectives on counseling with
substance abusers.
Discussion
Substance Abuse
Substance abuse is defined as the categories classified in the
Diagnostic and Statistical Manual IV (DSM-IV) (American Psychiatric
Association, 1994) as Substance-Related Disorders and Substance-
Induced Disorders. These disorders include the active use and/or
dependency on any mood-altering substance. Substances include alcohol,
sedatives, amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opiod, caffeine, nicotine, and prescription drugs, as well as legal drugs.
Similar addiction processes to those of substance abuse include
experiences such as eating, gambling, sex, and work addiction. Addictive
behavior is characterized by preoccupation with the substance or the
experience, withdrawal symptoms after not engaging in the substance
or experience, increased tolerance for the substance or activity in order
to achieve the same effect, and continued use despite negative
consequences. While similarities of behavior exist across all types of
substance abuse, individuals cannot be categorized, defined, and treated
in relations only to their substance abuse problem. An individual with a
substance abuse problem is unique in his/her history, pattern of use and
abuse, and counseling and related treatment needs.
While many models of causation of substance abuse have been
proposed, no clear etiology has been identified. Models emphasize
morality or individual conscious choice, biological or disease
vulnerability, behavioral learning patterns, cultural–environmental
concerns, or biopsychosocial impact. The biopsychosocial model views
substance abuse as a complex interaction of all of the other models and
endorses multiple strategies for counseling from these models as
appropriate. Counselors need to review these models to develop a
conceptual position regarding causation upon which he/she can make
consistent therapeutic assumptions and decisions to guide counseling
practice.
Counseling
Conclusions regarding effective counseling strategies for
counseling individuals with substance abuse are limited in that this
counseling specialty area has been driven more by experience and clinical
intuition than by research. As a result, most traditional substance
abuse treatment programs (e.g., Alcoholics Anonymous, alcoholism
education, half-way houses and therapeutic communities utilizing
confrontation, group therapy, individual counseling, and use of
medication) have not demonstrated their efficacy. Some successful
treatment outcomes have been linked to short-term interventions,
aversion therapy, stress management, solution-focused brief therapy,
and social skills training, yet seldom are these methods utilized in
traditional substance abuse treatment programs in the United States.
Given this, conclusions regarding counseling and substance abuse
have to come from general counseling research data.
Counselors, regardless of their settings, impact as change
agents within the context of therapeutic relationships with individuals.
Successful relationships are facilitated by a skilled counselor who
helps the client become more invested in the process and who utilizes
therapeutic techniques appropriate to the client. A thorough review
of counseling outcome research (Sexton, Whiston, Bleuer, and Walz,
1997 pp. 58-62, pp. 87-93) concludes the following:
1) Counseling is a process beneficial to most clients of skilled
counselors. However, it is not always so. A significant number of
clients get worse.
2) Counseling models (e.g., cognitive, experiential,
behavioral, dynamic) are effective and when compared, seem
equivalent in their effect on counseling outcome.
3) Successful counseling has process factors which are
common across the various counseling models. These factors include
the counselor's establishing an open, trusting,collaborative
relationship, facilitating client cognitive learning through reframing,
feedback, and insight, and assisting the client in behavior changes
through behavioral regulation, reality testing, and successful
experiences.
4) Successful counseling outcome is dependent on counselor
therapeutic skills such as focusing conversations on life problems,
addressing presenting problems directly, and providing structure for
counselor-client intervention.
5) Successful counseling progresses through various process
stages, wherein different types of counselor-client interactions are
reflected by different counseling techniques.
Perspective
The above research conclusions support the following
perspective regarding counseling clients with substance abuse
problems. Counselors, to be effective, first must have the ability to
develop an open, collaborative relationship with clients wherein
clients perceive trust and commitment. Carl Rogers identifies, and
research supports, this ability as related to the counselor’s skill in
conveying, in interaction with clients, unconditional positive regard
and empathic understanding (Austin, 1999). Within this relationship,
the counselor must provide focus for the process by addressing the
client’s presenting problems directly and identifying client need for
change. Counselors of clients with substance abuse problems often
find this process difficult because of the chronic nature of interrelated
destructive attitudes and coexisting disorders these clients often bring
to counseling. Once problem identification and client need for change
are identified, the counselor must be able to articulate and implement
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