11 – Stages of Readiness for Change, Engagement and Building Rapport
Addiction Counselor Exam Review

 
 
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Review for the Alcohol and Drug Counselor Exam

• Past 30 Day statistics, According to the 2012 National Survey on Drug Use and Health,
• 6.5% of the population over 12 reported heavy drinking
• 9.2% reported illicit drug use
• The majority of people who use recreationally will not need treatment
• Addiction is characterized by compulsive craving for the substance and using that substance despite negative consequences
• Cravings and compulsive behavior are caused in large part as a consequence of substance use or addictive behaviors on the brain causing
• Emotional
• Cognitive
• Physical
• Behavioral changes
Definition of Addiction
• Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.
• Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations reflected in pathological pursuit of a reward and/or relief by a substance.
• Without treatment and/or engagement, addiction is progressive and can result in disability or premature death. (ASAM 2011, NIDA 2007)
Characteristics of Chronic Disease
• Disrupts normal functioning
• Have serious, harmful consequences
• Are preventable and treatable
• Can last a lifetime
• May be fatal if untreated
Addiction—A description, not a Diagnosis
• Addiction is a description, not a diagnostic term.
• Addiction erodes a person’s self-control and ability to make sound decisions
• The DSM V has 2 diagnostic categories
• Substance abuse
• Substance dependence (The medical definition of addiction)
• Dependence is always characterized by dependence and withdrawal
Factors Influencing Addiction
• No single factor is causative
• General Categories
• Biological/genetic makeup
• Gender
• Ethnicity
• Developmental stage/early use
• Social environment
• Proximal (neighborhood, school/work, friends, family)
• Cultural/Media/Availability
• Method of administration
Factors Influencing Addiction
• Genetic Factors
• 40-60 % of a person’s vulnerability is genetic.
• Expression of these genes is influenced by:
• Effects of the environment
• Reactions/effects of addictive behaviors
• Genetic predisposition to mental health issues (self-medication)
• Social Environment & Peer and School
• Access
• Social learning of acceptability and use patterns
• Exposure to peers/family who engage in criminal behavior
• Academic/work failure
• Poor social skills / unstable relationships

Factors Influencing Addiction
• Developmental/Early Use
• The earlier the initiation, the greater the likelihood it progresses to addiction
• Addictive behaviors have a stronger impact on the developing brain (esp. the prefrontal cortex)
• Indicative of a set of vulnerabilities/triggers
• Genetics
• Mental Illness
• Unstable family relationships
• Exposure to abuse

Factors Influencing Addiction
• Method of Administration
• Smoking and injection increase addictive potential due to
• Rapid transit to the brain (seconds)
• Rapid fade of effects (crash)

Theories of Causation
• Moral Model
• Addiction is the result of defects of character
• Rejects any biological basis
• Focuses on individual choices and values retraining
• Disease Model
• Addiction is an illness resulting from an impairment of neurochemical or behavioral processes
• Presented by Jellinek leading the APA and AMA adopting the disease model
• Addiction is a primary disease and not caused by anything else
Theories of Causation
• Genetic Model
• Individuals have a genetic predisposition
• Difficult to separate social causes from family and genetic causes
• Cultural Model
• Cultural attitudes and availability impact which addictions people develop
• Blended Model
• Addiction develops in each individual as a result of a unique set of factors
Continuum of Addiction
• Social – risky/problematic –abuse –dependence
• Many individuals never progress beyond risky consumption
• Recovery from addiction is a multidimensional process which differs between people and changes over time.
• Risky/problematic users have some amount of control and can learn methods to cope.
• Dependent users seem to have no control over their use.
• One and done
• Progression over time

Reinforcers Within the Cycle of Addiction
• Reinforcers
• Add to the benefits of use
• Become less important as the drug causes neurochemical imbalances
• Psychological
• Enhance the rewards of other experiences (Sex, social)
• Boosts self-confidence
• Alleviates stress and dysphoria
• Reduces pain
• Coping skills fail to develop or atrophy as addictive behaviors substitute
• Confidence in dealing with life on life’s terms diminishes
• Avoided problems worsen and increase anxiety
Reinforcers Within the Cycle of Addiction
• Social Aspects
• Social lubricant
• Social bonding
• Biological Aspects
• Impact the reward/pleasure centers in the mesolimbic system
• Brain begins producing less dopamine or letting less dopamine through the system
• Person becomes dependent on surges of dopamine to feel pleasure
• Sobriety produces feelings of dysphoria until the brain can rebalance itself
• Self-medication of mental health disorders

What is Recovery
• Improvement of health and wellness in order to live a self-directed life and strive to reach one’s full potential.
• Recovery involves the interaction between
• Race/ethnicity
• Gender
• Sexual orientation
• Family history
• Developmental stage
• Environment
• Culture
• Individual strengths, values and needs
What is Recovery
• Recovery
• Begins with accepting there is a problem and that
• Help is needed to overcome it
• Responsibility for recovery from the problem and associated issues lies with the person
• Is individualized and lifelong
• Abstinence is often the goal
• Harm reduction can be considered as an alternate goal
• Relapse occurs when a person
• Is unaware of the process of recovery
• Unable to accomplish the tasks required at each stage of recovery
• Lacks adequate access to treatment/support

Recovery Capital
• Resources necessary to achieve sustained recovery
• Personal
• Family/social
• Community
Recovery Capital
• Personal Recovery Capital
• Physical Health
• Financial stability
• Health insurance and prescription coverage
• Safe shelter conducive to recovery
• Clothing
• Food
• Transportation
Recovery Capital
• Personal Recovery Capital
• Values
• Knowledge/education/skills
• Problem solving abilities
• Interpersonal effectiveness and communication skills
• Self-awareness, esteem, efficacy
• Hope and optimism
• Sense of meaning and purpose
• Perception of the past, present and future
Recovery Capital
• Family of Choice/Social Recovery Capital
• Supportive relationships
• Community Recovery Capital
• Emphasis on efforts to address and reduce stigma
• Availability of diverse local role models
• Continuum of recovery-focused substance abuse, mental health and medical treatment
• Available resources (food, shelter, clothing, transportation, childcare, training, employment)
• Multiple recovery support organizations

• American Society of Addiction Medicine (ASAM) 2017 https://www.asam.org/resources/definition-of-addiction
• University of Oklahoma Department of Medicine (2017) http://www.drugdetection.net/PDF%20documents/Dubowski%20-%20stages%20of%20alcohol%20effects.pdf
• Center for Substance Abuse Treatment (2009) https://www.samhsa.gov/sites/default/files/partnersforrecovery/docs/ATR_Approaches_to_ROSC.pdf
• DEA Drugs of Abuse (2017) https://www.dea.gov/pr/multimedia-library/publications/drug_of_abuse.pdf#page=42
• White, W. & Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27.
• Davidson, L & Roe, D (2007) Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. Journal of Mental Health, August 2007; 16(4): 459 – 470

Engagement, Screening and Assessment
• Demonstrate verbal and nonverbal skills to establish rapport and promote engagement
• Discuss with clients the rationale, purpose and procedures associated with screening and assessment
• Assess clients immediate needs including detoxification
• Administer evidence based screening and assessment instruments to determine client strengths and needs
• Obtain relevant history to establish eligibility and appropriateness of services
• Screen for physical needs, medical conditions, co-occurring mental health issues
• Interpret results of screening and assessment and integrate information to formulate a diagnostic impression and determine appropriate course of action
• Develop a written integrated summary to support diagnostic impressions
Engagement
• Establish rapport and an effective working alliance in which the client feels heard and understood
• Respectful
• Nonjudgmental
• Attentive
• Motivate and engage the client in identified service needs
• Engagement puts the clinician in the best position to negotiate with the client about what to do and how to do it.
• Engaged clients are more likely to
• Participate willingly
• Be treatment compliant
• Successfully complete treatment
Engagement
• Create a welcoming environment
• Pleasant physical environment sensitive to
• Age
• Gender
• Disability
• Sexual orientation
• Religion
• Socioeconomic status

Factors Impacting Engagement
• Stigma
• About the diagnoses
• About help seeking
• Expectations
• About the effectiveness of treatment
• About one’s role/power in the treatment process
• About the treatment process itself
• Likeableness
• Client’s social skills
• Client’s attentiveness
• Client’s attractiveness
Factors Impacting Engagement
• First Impression
• Professional presentation
• Promptness
• Courtesy
• Smooth handling of paperwork
• Environment
• Calm, clean, comfortable
• Not too formal or informal
• Avoids interruptions
• Provides appropriate privacy

Skills for Building the Helping Relationship
• Rapport—Sense of connection
• Both parties contribute to the relationship
• Active listening
• Demonstration of credibility and dependability
• Being respectful and responsive
• Support
• Encourage the client and build self-esteem
• Encourage appropriate expression of feelings
• Validate and recognize, but don’t encourage negative feelings or behaviors
Skills for Building the Helping Relationship
• Empathy—Shared feelings of hope
• Acceptance– Unconditional positive regard
Communication Techniques
• Active Listening
• Reflecting
• Clarifying
• Focusing/directing to a particular topic
• Summarizing
• Questioning
• Open-ended
• One and a time
• Avoid “why” and confrontational questions
• Observing nonverbals
Communication Techniques
• Nonverbals (information and congruency)
• Rate of speech
• Volume of speech
• Posture
• Gestures
• Eye contact
• Facial expressions

Communication Techniques
• Observing nonverbals
• Dress and presentation may communicate
• State of mind
• Cultural values
• Body image
• Self-concept
• Look for bodily signs of
• Drug use
• Physical abuse
• Poor nutrition

Goals of the Initial Interview
• Establish trust and develop rapport
• Be empathetic
• Convey warmth and respect
• Explore client strengths and skills
• Facilitate client’s understanding of rationale, purpose and procedures of the screening and assessment process
• Explore the client’s problems and expectations regarding treatment and recovery
• Determine whether a further assessment is needed
Screening
• The process by which the counselor, client and SOs review the current situation, symptoms and collateral information to determine the probability of a problem
• Used by all types of human service personnel to determine eligibility and appropriateness of services and needed referrals
• Screening helps determine the immediacy of need
• Must be a transparent process
• Requires informed consent
• Identification of early warning signs helps provide early intervention services and/or resources
Screening
• Screening is the first opportunity to engage the client in the therapeutic relationship and treatment process
• Sometimes, based on observation or other circumstances people may be referred directly for assessment.
• The client’s internal motivation is the primary reason for engaging in treatment.
• Internal motivation may be fleeting, so rapid engagement is vital.
Screening
• Successful screening should be
• Brief
• Conducted in a variety of settings by a range of professionals on persons deemed to be at risk
• A collaboration among a multidisciplinary team
• Sensitive to racial, cultural, socioeconomic and gender related concerns
• Developed from information gathered from multiple sources when possible

Screening
• Assess signs and symptoms of intoxication and withdrawal
• 3 key elements
• Verify that behavior deviates from the norm
• Rule out all non-drug related causes
• Use diagnostic procedures to determine the types of drugs being used
• Assess clients
• Mental health/trauma history
• Safety/environmental needs
• Physical health needs
• Other wrap-around needs
• Danger to self or others
Screening Methods
• Interview (client, SOs)
• Screening instruments
• Lab tests
Signs of SUDs or Mental Health Issues
• Circumstances of contact
• Client’s demeanor and behavior
• Signs of acute intoxication or withdrawal
• Physical signs of drug use or self-injury
• Information spontaneously offered by the client or SOs
Screening Instruments for SUD
• Can be developed by the agency or use standardized instruments
• CAGE (Cut Down, Annoyed, Guilty, Eye Opener)
• GAIN-SI
• Michigan Alcohol Screening Test
• SASSI
• Must clearly detail what action should be taken based on received scores
Screening for Mental Health
• Screen for
• Acute symptoms such as hallucinations, delusions or depression
• Suicidal thoughts and behaviors
• Other mood and thought disturbances
• Time, place, purpose, person
• Short and long term memory
• Prior involvement in mental health treatment
• Use of prescription medication
• Recent traumas
• Family history of mental illness
Screening Instruments for Mental Health
• Modified mini screen
• Mental Status Exam
• Mini Mental Status Exam
• Brief Symptom Inventory
• Brief Psychiatric Rating Scale
• Symptom Checklist 90-R

12 Assessment Steps
• Engage
• Get authorizations and gather information from collateral sources
• Screen for co-occurring disoders
• Determine the severity of mental and SUDs
• Determine appropriate level of care
• Determine diagnoses
• Determine disability and functional impairment
• Identify strengths and supports
• Identify cultural and linguistic needs and supports
• Identify additional problem areas (medical, housing, education…)
• Determine readiness for change
• Plan treatment
Assessment
• Screening determines the possible presence.
• Assessment
• Is an ongoing process
• Determines the nature and severity
• Develops specific treatment recommendations
• Surveys client strengths and resources for addressing “life problems.” (wrap-around)
• Substance Abuse Assessment Foci
• Historical and situational factors contributing to or triggering use
• Patterns of use
• Common signs and symptoms
• Consequences of use
Assessment
• Examines the context(s) in which the disorder(s) manifest
• Explores reciprocal interactions of…
• Family/marital life
• Social support/interpersonal functioning
• Physical health needs
• Spirituality
• Employment
• Financial issues
• Legal issues
• Other issues which may impact treatment (transportation, childcare)

Assessment
• Explores reciprocal interactions cont…
• Gender, cultural, linguistic issues
• Readiness for change
• Relapse risk
• Recovery support
• Special life circumstances (single parent)
• Medical conditions
• Client centered—respecting
• The client’s perceptions of his problems
• Goals he wishes to accomplish
• Strengths he has
Assessment Instruments
• Forms
• Standardized interviews
• Limits interviewer to a script
• Requires limited training
• Collects the same information on all clients
• Structured interviews
• Probing questions can be asked
• Requires additional training/knowledge
• Self-administered tests/questionnaires
• Require some motivation and reading ability on the client’s part
• Standardized instruments have:
• Reliability
• Validity information
Assessments
• Sources of information (with written consent)
• Personal reports
• Family
• Other professionals/prior treatment experiences
• May be the most objective resource
• Employment history
• Criminal records
• Drug tests
• Collateral information gathered should be confirmed to the extent possible
• Accurate assessment requires the coherent integration of multiple sources of information to avoid under- or over-estimation of the problem.

Drug Testing in SUD Treatment
• Drug testing is
• Part of the initial assessment
• Used to identify drugs to make most appropriate treatment recommendations
• Screen to prevent adverse effects of prescribed medications
• Component of the treatment plan
• Way to monitor use of substance and compliance with medications
• Method to assess efficacy of treatment
• Method to document abstinence for legal matters, disability, custody etc.
• Drug testing cannot replace an assessment to diagnose a substance use disorder.
Drug Testing in SUD Treatment
• Drug Testing
• Can accurately reveal drugs in the system
• Time frame for detection is limited
• Dependable for identifying frequent users
• Less accurate for infrequent or binge users
Types of Drug Tests
• Breathalizer (hours)
• Urine (up to a month)
• On-site
• Gas chromatograph
• Can produce false positives
• Saliva (past day)
• Sweat and hair
• drug use patterns over periods of time
• Cannot discriminate between recent and past drug use
• Not able to identify use within past 3-8 days
• Blood
Risk Assessment
• One of the most important functions at both screening and assessment
• Presence of any risk warning signs
• Requires immediate referral (detox, CST, ER)
• Screening and assessment are inappropriate
• Assess for:
• Intoxication
• Substance toxicity
• Withdrawal
• Aggression/danger to others
• Potential for self-harm or suicide
• Co-existing mental health issues
Risk Assessment
• Signs of Drug Toxicity or Intoxication
• Nausea
• Vomiting
• Diarrhea
• Agitation
• Lethargy or stupor
• Increased or decreased heart rate
• Lack of coordination
• Slurring words

Risk Assessment
• Signs of Violence
• Previous violence
• Young age at first incident
• Relationship instability
• Employment problems
• Substance use problems
• Major mental illness
• Personality traits that deviate from social norms (exploitation, manipulation…)
• Early maladjustment or trauma
• Paranoia
• Failure to respond to treatment in the past
Risk Assessment
• Suicidality
• Alcoholism (a factor in 30% of suicides)
• Psychiatric disorder
• 90% of people who die by suicide have a mental health disorder
• 60% of people who die by suicide have depression
• For alcoholics who are depressed the rate is 75%
• 3 Domains for Assessment
• Current presentation of suicidality
• History
• Risk management
Risk Assessment
• Signs of Suicidality
• Suicidal or self-harming thoughts, plans, behaviors or intent
• Specific methods identified
• Evidence of hopelessness, impulsiveness, panic attacks or anxiety
• Lack of future plans
• Signs of “tying up loose ends.”
• Alcohol or other substance use
• Thoughts, plans or intentions of violence toward others
• Psychiatric illnesses
Risk Assessment
• Signs of Suicidality
• Previous attempts or aborted attempts at suicide or self-harm
• Family history of suicide attempts, suicide, mental illness, addiction
• Acute psychosocial crises including financial or changes in socioeconomic status
• Chronic psychosocial stressors including actual or perceived interpersonal losses
• Family discord, domestic violence, current or pase sexual or physical abuse
• Absence of external supports
Mental Health Disorders Common in Co-D
• Borderline Personality Disorder
• Pervasive pattern of instability in personal relationships, self image and affect in addition to impulsivity.
• Antisocial Personality Disorder
• Pervasive disregard for and violation of the rights of others
• Inability to form meaningful relationships
• Lack of empathy

Mental Health Disorders Common in Co-D
• Major Depressive Disorder
• Lack of pleasure in most things most days for at least 2 weeks
• Changes in sleep, appetite, energy, concentration
• Excessive feelings of worthlessness and/or guilt
• Suicidal ideation
• Bipolar Disorder
• Fluctuations between elation (mania) and depression

Mental Health Disorders Common in Co-D
• Anxiety Disorders
• Panic attack
• Distinct period of intense fear usually peaking within 15 minutes
• Significant fear-related physiological symptoms
• Panic disorder
• Panic attacks + persistent fear of recurrence of attacks
• Obsessive Compulsive Disorder
• Anxiety disorder involving obsessive thoughts which cause anxiety and compulsive behaviors to address those thoughts

Mental Health Disorders Common in Co-D
• Post Traumatic Stress Disorder
• Exposure to an stressor which involved the threat of death or significant injury to self or another in which there was significant helplessness and horror.
• Can occur when learning about a trauma which occurred to someone else, especially a significant other
• Eating Disorders
• Person is intensely afraid of gaining weight and exhibits a disturbance in the perception of the shape of size of his or her body.
• Types
• Anorexia
• Bulimia
• Binge Eating Disorder

Mental Health Disorders Common in Co-D
• Schizophrenia and Psychotic Disorders
• Psychosis is the term for a severely incapacitated mental and emotional state involving thinking, perception and emotional control
• Hallucinations –False perceptions
• Delusions –False beliefs and a deterioration in thinking, judgement or self-control
• Schizophrenia is the most common psychotic disorder
• NOT multiple personality
• Symptoms (often begin to develop before the first psychotic episode)
• Hallucinations or delusions
• Disorganized speech
• Disorganized or catatonic behavior
• Deficits in functioning

Diagnosis and the DSM
• The Diagnostic and Statistical Manual is created to
• facilitate communication between and within professions regarding mental health and substance use disorders
• Improve interrater reliability regarding diagnosis
• Improve sharing of information about client presentation and needs
ICD-10
• International Classification of Disease is used for diagnosis (like the DSM)

Diagnosis of Substance Use Disorders
• The DSM V recognizes 10 separate classes of drugs
• Alcohol
• Inhalants
• Opioids
• Sedatives
• Hypnotics/Barbiturates
• Anxiolytics
• Stimulants
• Caffeine
• Tobacco
• Cannabis
• Hallucinogens
• Other/Unknown substances
SUD Diagnosis
• Although how each types of drug acts in the brain differs, they all activate the brain’s reward system
• Two groups of substance disorders
• Substance use
• Substance induced
SUD Diagnosis
• Diagnosis
• Using in larger amounts or for longer than intended
• Wanting to cut down or stop but failing
• Spending increased time getting, using or recovering from use
• Cravings and urges
• Neglecting work, school, family, social obligations because of use
• Continue to use even when it causes problems in relationships
• Giving up important social, occupational, recreational activities because of use
• Using in risky situations
• Continuing to use despite knowing that it is making a physical or psychological problem worse
• Tolerance
• Withdrawal

Diagnosis of Substance Use Disorders
• SUD severity is dependent on how many symptoms are present
• 2-3 symptoms = Mild
• 4-5 = Moderate
• More than 5 severe
• Qualifiers
• In early remission
• In sustained remission
• On maintenance therapy
• In a controlled environment

Substance-Induced Disorder Diagnosis
• Result from effects of the use of a substance
• Intoxication
• Withdrawal
• Anxiety or depressive disorders
• Bipolar and related disorders
• Psychotic disorders (hallucinations, delusions)
• Sleep disorders
• Sexual dysfunctions
• Neurocognitive disorders
• The teeter-totter principle helps predict symptoms in the withdrawal period (Polysubstance complicates things)
Substance Induced vs. Mental Illness Dx
• Substance induced means that the current presenting symptoms are likely the result of use of a substance not an underlying (pre-existing) mental disorder
• Concurrent mental disorders can (and often do) occur
ASAM Treatment Criteria
• 6 Dimensions
• Acute Intoxication/Withdrawal Potential
• Biomedical Conditions and Complications
• Emotional/Behavioral or Cognitive conditions
• Readiness for Change
• Relapse Potential
• Recovery/Living Environment
ASAM Treatment Criteria
• Levels of Treatment (Placement)
• Level .05 Early Intervention
• Level 1: Outpatient Treatment
• Level 2: Intensive Outpatient Treatment/PHP
• Level 3: Residential Treatment
• Level 4: Medically Managed Intensive Inpatient Treatment

Integrated (Interpretive) Summary- Simple
• Weaves together the information gathered using a theoretical approach to infer or identify themes and treatment priorities
Integrated (Interpretive) Summary–Detailed
• Identifying information
• Presenting problems
• Sources of data
• Problem history
• Substance use history
• Family history
• Personal and Educational history
• Employment and vocational skills
• Spiritual and religious involvement
• Health conditions
• Psychiatric history
• Social, community and recovery supports
• Legal concerns
• Strengths
• Previous treatment history
• Diagnostic impression
• Treatment and other service recommendations

Recovery Oriented Systems of Care
• Affirms the real potential for permanent resolution of behavioral health problems
• Offers solutions to behavioral health problems on a community and cultural level
• Shift away from risk management and relapse prevention toward encouraging clients to self-define goals and take responsibility for achieving them
• A shift from emergency room/acute care model to one of sustained recovery management which include wrap-around recovery support services
Recovery Oriented Systems of Care
• Emphasis on
• Post-treatment monitoring
• Stage-appropriate recovery education
• Peer recovery coaching
• Assertive linkages to recovery communities
• Early re-intervention
• Maintaining functional ability in all life activities
• Recovery in illness instead of recovery from illness
Recovery Oriented Systems of Care
• Goals
• Foster health and resilience activities
• Increase permanent housing and sense home/belonging
• Ensure gainful employment and access to education to provide a sense of purpose
• Enhance communities by increasing availability of necessary supports from and for peers/family/community
• Reduce barriers to social inclusion
• Counselor functions
• Identify gaps in services
• Identifying emerging trends and needs
• Monitor system effectiveness
Recovery Oriented Systems of Care
• Guiding principles of Recovery emerges from hope and is…
• Person-centered – self-efficacy, self-direction
• Non-linear, and occurs via many pathways (methods)
• Holistic – mind, body, spirit, community
• Supported by peers and allies (counselors/case workers)
• Supported through relationships and social networks (family, peers, faith groups, community)
• Culturally based and influenced
• Supported by addressing trauma
• Based on respect of individual, family and community strengths and responsibilities

Recovery Oriented Systems of Care
• 3 core components
• Collaborative decision making /individual empowerment
• Continuity of services and supports
• No wrong door
• Services available as long as needed
• Service quality and responsiveness
• Evidence based
• Developmentally and culturally appropriate
• Gender specific
• Trauma informed
• Family focused
• Stage appropriate

Recovery Management
• Treatment does not need to be voluntary, but success depends on personal engagement
• Full recovery often comes from episodic, nonlinear treatment
• Previous treatment and relapse is not indicative of poor prognosis
• Relapse is viewed as evidence of the severity of the condition rather than a cause for discharge
• Recovery management is a time-sustained, recovery focused collaboration between consumers and service providers with the goal of stabilizing and managing the ebb and flow of co-occurring disorders until full recovery is achieved or self-management is possible.
Recovery Management
• Spans 3 phases
• Prerecovery identification and engagement
• Recovery initiation and stabilization
• Recovery maintenance
Referral
• Dual-diagnosis or co-occurring disorders indicates the presence of both mental health and addiction issues.
• People with co-occurring issues often experience more severe emotional, social and physical problems than someone with only one issue
• Medical, Mental health and Addictive disorders all influence each other
• Use and withdrawal can both cause mood, social and physical conditions
• Continuum: Disorders vary in terms of…
• Severity
• Chronicity
• Disability/degree of impairment in functioning

Diagnosis of Substance Use Disorders
• The DSM V recognizes 10 separate classes of drugs
• Alcohol
• Inhalants
• Opioids
• Sedatives
• Hypnotics/Barbiturates
• Anxiolytics
• Stimulants
• Caffeine
• Tobacco
• Cannabis
• Hallucinogens
• Other/Unknown substances
Drugs of Abuse
• Alcohol
• Classified as a sedative-hypnotic, CNS depressant
• Ethanol/Ethyl alcohol 8 stages of effect as BAC increases
• Subclinical
• Euphoria
• Excitement
• Excitement/confusion
• Confusion stupor
• Coma
• Death
Drugs of Abuse
• Alcohol
• Men drink more
• Women more likely to
• Develop drinking problems
• Experience alcohol related organ damage at lower levels
• Women’s BAC reaches higher levels with same amounts of alcohol as men
• Alcohol mixes with water and men tend to have more body water

Drugs of Abuse
• Alcohol related medical conditions
• Loss of control of eye muscles
• Hypoglycemia
• Gastritis / Pancreatitis
• Reduced immunity
• Cardiac arrhythmia
• Anemia
• Constant flushing
• Peripheral neuritis
• Fatty liver
• Cirrhosis
• Blood pressure increases
• Wernicke/Korsakoff’s syndrome / Alcohol related dementia
Drugs of Abuse
• Cannabis
• As of 2016, still considered a schedule 1 by the DEA
• Schedule 1 substances have no medicinal use and high risk of abuse
• Legal in 29 states for medical use and in 8 of those states for recreational use
• 9-17% of occasional users become addicted
• 25-50% of daily users become addicted
• Methods of administration
• Smoked (pipes, bongs, blunts) – rapid action
• Consumed (tea, brownies) –slower action
• Acts on cannabinoid receptors which influence memory, pleasure, concentration, sensory perception
Drugs of Abuse
• Synthetic Marijuana (Spice/K2)
• Synthetic cannabinoids refer to a growing number of man-made mind-altering chemicals sprayed on dried, shredded plant material or vaporized to get high.
• Synthetic cannabinoids are sometimes misleadingly called “synthetic marijuana” (or “fake weed”) because they act on the same brain cell receptors as THC
• The effects of synthetic cannabinoids can be unpredictable and severe or even life-threatening.
Drugs of Abuse
• Synthetic Marijuana (Spice/K2)
• Synthetic cannabinoid users report some effects similar to those produced by marijuana:
• elevated mood
• relaxation
• altered perception
• symptoms of psychosis
• Synthetic cannabinoids can also cause serious mental and physical health problems including:
• rapid heart rate
• vomiting
• violent behavior
• suicidal thoughts
Drugs of Abuse
• Cannabis
• Effects
• Respiratory illness
• Heightened heart attack risk
• Neurobehavioral effects on fetus
• Increased depression, anxiety and suicidal thoughts, esp. in adolescents
• Loss of motivation
• Exacerbation of schizophrenia
• Impaired judgement
• Impaired motor coordination
• Reduced life satisfaction
• Lower academic/career success

Drugs of Abuse
• Prescription Drugs
• Opiates
• Ranks #2 behind marijuana as most abused drug
• 60% of people who abuse it got it free from friends/relatives
• Treat
• Pain
• Depression
• Depressants (Benzos / Barbiturates)
• Anxiety
• Sleep disorders
• Stimulants
• Narcolepsy
• ADHD
• Obesity
Drugs of Abuse
• Prescription and OTC (i.e. DXM, pseudoephederine) drugs can be abused by:
• Taking medication prescribed for someone else
• Taking drugs in a higher amount or via a different method than intended
• Taking drugs for a different purpose than intended
• Combining drugs
• Same class
• Different class
Withdrawal from Drugs of Abuse
• Sustained use of addictive substances of behaviors causes reversible adaptations within the body
• Reduce the effects of the drug (tolerance, dependence)
• Withdrawal
• Euphoria producing drugs act on the nucleus accumbens (pleasure center)
• Alcohol and benzodiazepine withdrawal can be life threatening
Post Acute Withdrawal Syndrome
Intake
• Intake
• Is the process of enrolling a client in a specific course of treatment
• A series of activities designed to organize information about the client and their significant others
• Ensures eligibility
• Completes basic data collection
• Identifies barriers and assets
• Establishes a treatment approach
• Primarily administrative in nature
• Needs to be standardized in nature
• It is an extension of the screening and assessment process
• Can be used to engage the client in treatment and enhance motivation for change
Orientation
• Can be conducted in individual, family or group settings
• Completed after the intake
• Describes specific aspects of treatment
• Schedule
• Goals
• Rules and responsibilities
• Hours of service
• Medication
• Drug testing
• Treatment costs
• Client rights
Client Rights
• Florida Statute 381.026
• Individual dignity
• Confidentiality
• Right to nondiscriminatory services
• Standard (Age, race, gender, sexual orientation, disability)
• Prior service departures
• Number of relapses
• Level of psychotropics
• Ability to pay (public agencies)
Client Rights
• Quality services
• Communication
• With informed consent communication may be limited
• Personal effects
• unless for to do so would infringe upon the right of another patient or is medically or programmatically contraindicated for documented medical, safety, or programmatic reasons
• May be temporarily held by the agency but must be returned at the end of treatment
• Minors to be educated
• Counsel (involuntary proceedings)
• Habeus corpus (full evidence of what is being alleged)
Client Rights
• (Florida Specific)
• A patient has the right to a prompt and reasonable response to a question or request.
• A patient receiving care in a health care facility or in a provider’s office has the right to bring any person of his or her choosing to the patient-accessible areas of the health care facility or provider’s office to accompany the patient while the patient is receiving inpatient or outpatient treatment or is consulting with his or her health care provider, unless doing so would risk the safety or health of the patient, other patients, or staff of the facility
• A patient has the right to refuse any treatment
• A patient has the right to express grievances to a health care provider, a health care facility, or the appropriate state licensing agency regarding alleged violations of patients’ rights.
Client Rights
• (Florida Specific)
• A patient has the right to know the name, function, and qualifications of each health care provider who is providing medical services to the patient. A patient may request such information from his or her responsible provider or the health care facility in which he or she is receiving medical services.
• A patient in a health care facility has the right to know what patient support services are available in the facility.
• A patient has the right to be given by his or her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient
• A health care provider or health care facility shall respect a patient’s legal right to own or possess a firearm and should refrain from unnecessarily harassing a patient about firearm ownership during an examination.

Treatment Plan
• Is a contract between the client, counselor and treatment team, each being responsible for its development and implementation
• The clinician should recognize that
• Treatment occurs in different settings over time
• Much of the recovery process occurs outside of or immediately following treatment
• Treatment is often divided into phases
• Engagement
• Stabilization
• Primary treatment
• Continuing care

Treatment Planning
• Plots out a roadmap for the treatment process
• Treatment plans are completed once
• A diagnosis is made
• Level of care is determined
• Client is admitted to the program
• Level of care is determined based on
• Diagnosis
• Client’s strengths and assets

Treatment Planning
• Treatment plans address all biopsychosocial needs
• Establish what changes are expected through achievable goals
• Clarifies what interventions and counseling methods will be used to help the patient achieve those goals
• Sets the measures that will be used to gauge success
• Incorporates the clients strengths, needs, abilities and preferences
• Referrals are made to other agencies as needed
• When referrals are made, collaboration is essential to keep clients from falling through the cracks
Treatment Planning and Confidentiality
• Information, even within the agency, is restricted to need-to-know.
• Treatment plans may have to be co-signed by a clinician who is already certified or licensed.
Treatment Planning: Function
• Action-oriented process that lays out a logical, goal-directed strategy for making positive changes
• Establishes collaboration between client and counselor so they can prioritize mutually agreeable goals.
Treatment Planning: Structure
• Achievable goals are selected by assessing and prioritizing clients needs, taking into account
• Level of impairment
• Motivation
• Real-world influences on needs
• Treatment plans consider client
• Needs
• Readiness
• Preferences and prior treatment history (what did and didn’t work)
• Personal goals
• Obstacles
Treatment Planning: Structure
• Defines
• SMART Goals
• Objectives
• Anticipated type, duration and frequency of services
• Who is responsible for what
• Time table
• Incorporates client input and participation in development
• Have client prioritize presenting issues
• Get input on goals and objectives
• Both counselor and client sign the plan
• The clinician may also facilitate and manage referrals (i.e. housing, legal, medical)
Treatment Planning: Issues
• At minimum, the plan is a flexible document that uses a stage-match process to address:
• Identified Substance Use Disorders (SUDs)
• Recovery support environment
• Potential mental health conditions
• Potential medical issues
• Employment
• Education
• Spirituality
• Social needs
• Legal needs
Elements of an Initial Treatment Plan
• Done at admission (or within 24 hours)
• Based on information from assessment and screening
• Serves as the initial roadmap
• Includes
• Presenting problems
• Preliminary goals
• Type, frequency and duration of service
• Signature and date of client and counselor w/credentials
Elements of an Individualized Treatment Plan
• Problem and problem description “Why are you here”
• Strengths
• Concrete, measurable goals
• Objectives
• Strategies w/ frequency and duration
• Diagnosis
• Signature of the client and counselor
• Signature of clinical supervisor if required
Treatment Planning: Ongoing and Review
• Ongoing assessment and collaboration is used to regularly review the treatment plan and make necessary modifications
• Review should be completed at minimum at major or key points in the clients treatment course
• Admission or readmission
• Transfer
• Discharge
• Major change in condition
• After 12 months