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Chapter 4, “Professional Issues in Addictions Counseling”
Comorbidity ✔✔existence of multiple diagnosable disorders or diseases that occur simultaneously or sequentially and influence the outcomes of the present illnesses. The prevalence of comorbidity can be complicated to determine due to the overlap of diagnostic criteria and symptoms. Of the 20.2 million adults age 18 and older who were diagnosed with a substance use disorder (SUD), 39.1% were also diagnosed with a mental illness within the past year. Overall, SAMHSA (2015) reported that 3.3% of the adult population and 1.4% of adolescents experienced comorbid SUD and mental illness. Dual or multiple diagnoses may pose challenges for accurate diagnosis; therefore, it is necessary for counselors to utilize assessment tools that encompass a broad spectrum of screening processes
Can addictions counselors diagnose mental health disorders? ✔✔The National Association for Alcoholism and Drug Abuse Counselors (NAADAC; 2016) Code of Ethics indicates that addictions counselors are not ethically allowed to diagnose mental disorders without the proper mental health licensing; therefore, addictions counselors need to be cognizant of their limitations within their scope of practice and must provide referrals when necessary
Collaboration when working with comorbid disorders ✔✔it is a counselor's responsibility to ensure competent treatment; therefore, if an addiction counselor is not trained in working with the diagnosis beyond the substance use disorder, collaborative action may be necessary. It is difficult to determine the directionality of comorbid mental illness and substance use disorders. While each may be causative or a result, it is also likely that risk factors may influence the development of both (NIDA, 2018). Recognizing the need for more training and competency for comorbid conditions, the NAADAC will be offering a credential in "co-occurring competency"
Developmental stage and addiction ✔✔Clinicians should always be aware of the developmental stages of their clients and the individual experiences of substance use. For example, children and adolescent substance use and addiction must be conceptualized differently from adult substance use and addiction, but historical intervention strategies for school-based prevention programs have not produced desired outcomes (Pan & Bai, 2009). Early use of substances is damaging to the child or adolescent, but it is also linked to adult substance use disorders later in life
Homelessness and addiction ✔✔Though rates are varied, people who are homeless have higher rates of substance addiction (including tobacco, alcohol, and other drugs) and drug-related overdoses than the general population (Baggett et al., 2015). Due to lack of resources, the homeless population experiences many barriers to securing addiction services and treatment
Armed forced and addiction ✔✔Members of the United States armed forces experience a more varied relationship to substances than do the general population. Likely due to the zero-tolerance policy on illicit drugs by the Department of Defense (DOD), military personnel have rates of use
Significantly below the general population—2.3% versus 12% in one DOD study (NIDA, 2013). However, NIDA (2013) reported that military personnel use prescription drugs at a higher rate than the general population and has increased drastically, with 11% reported misuse in 2008, an increase from the reported 4% in 2005 and 2% in 2002. Alcohol use is much higher in military personnel, with nearly half (47%) reporting binge-drinking behavior and 20% reporting binge drinking every week for the past month (NIDA, 2013). Unlike other populations, military personnel report concern of stigma related to seeking mental health treatment (especially regarding employment-related discrimination), which decreases their likelihood to seek treatment
Sexual minorities and addiction ✔✔Consistently in studies, sexual minority adults and youth show higher rates of substance addiction as compared to members of the sexual majority (Newcomb, Birkett, Corliss, & Mustanski, 2014; Vrangalova & Savin-Williams, 2014). Reasons for increased use in sexual minority youth may be related to stigma, discrimination, bullying, and generally less disinhibition (Newcomb et al., 2014). Adults experience the same issues and are also subject to the gay community's culture, which is more accepting (and occasionally pressuring) of substance use
Polysubstance use or addiction ✔✔broadly describes the use of multiple substances simultaneously or within a specific time frame. polysubstance use and addiction is related to clients who seek an intoxicated state rather than a specific drug, which results in the use of a variety of substances. Within the United States, there continues to be a high incidence rate of substance and polysubstance use and addiction, especially among adolescents and young adults.
Adolescent and childhood use ✔✔As adolescent and childhood use and polysubstance use are both related to an increased rate of SUD diagnosis in adulthood, and children and adolescents are more likely to engage in polysubstance use, it is extremely important that professionals understand the value of early intervention and addressing polysubstance use at every developmental stage
Evidence-based or empirically-based practices ✔✔interventions for which empirical validation exists to suggest that these treatment protocols improve client outcomes
Value of the therapeutic relationship ✔✔Regardless of the specific theory or setting of treatment, practitioners must recognize the value of the therapeutic relationship and prioritize client- centered approaches that focus on shared decision making
Prochaska and DiClemente's (1984) transtheoretical model of change (TTM) ✔✔garnered increased empirical attention among addictions professionals over the course of the past 20 years. Historically, this model has been one of the leading approaches for explanation and intervention across a variety of health-related behaviors, such as smoking cessation, alcohol abuse, dieting, gambling, and substance addiction. This model has also been used to assess an addictions counselor's "readiness for change," in terms of adapting new treatment protocols,
language, cultural background, and treatments that include the client's perceived culture rather than the counselor's perception of culture and stereotypes
Factors that contribute to the prevalence of substance use disorders ✔✔There are several factors that contribute to the prevalence of substance use disorders, including low socioeconomic status, lack of education, economical challenges, and cultural attitudes toward substances. Researchers have found that individuals who are unemployed reported higher rates of substance addiction compared to those who had full-time employment (United States Department of Health and Human Services [DHHS], 2013). Other findings include the differences among races in reported drug use, including Native Americans (12.7%), African Americans (11.3%), Caucasians (9.2%), Hispanics (8.3%), Native Hawaiians (7.8%), and Asians (3.7%)
Education requirements for substance addiction counselors ✔✔Education requirements for substance addiction counselors have developed over time and vary with state requirements. In early licensing and certification of substance abuse counselors, training programs and coursework-specific credentialing was prioritized over degree programs (Iarussi, Perjessy, & Reed, 2013). Over time, counselors serving clients with SUDs have experienced an increase in expectations regarding their knowledge and skills related to practice, but training programs have not met the increasing need for education and preparation (Duryea & Calleja, 2013). Currently, while there are still no national curriculum standards or credentialing and while training requirements still vary from state to state, they sometimes differ greatly even within states (Counselor License Resources, 2018).
Standardizing addictions training ✔✔Accrediting bodies and programs are making attempts to standardize some processes for addictions training for counselors. or example, in 2009, CACREP finalized a set of guidelines and standards for addictions counseling in relationship to knowledge, skills, and practices, as they formalized addictions counseling as a specialization in professional counseling (Iarussi et al., 2013). Furthermore, in 2010, the National Addiction Studies Accreditation Commission was formed at the urging of the Center for Substance Abuse Treatment and the Substance Abuse and Mental Health Services Administration to standardize training of addictions specialists by providing an additional level of accreditation for programs (NASAC, 2018).
Training for counselors not specializing in addiction ✔✔counselors who are not specializing in addictions may not receive any training beyond one course (Chasek & Kawata, 2016). Though CACREP programs require addiction coursework, there continues to be a lack of standardization regarding content taught, as some courses focus only on information education rather than practice and treatment (Iarussi et al., 2013). The most effective method of training counselors for addictions specific competencies is to incorporate training that includes both constructive methods for understanding addictions-related knowledge and experiential practice to solidify the ability to use the new skills
Recovering counselors ✔✔Recovering counselors are more likely to diagnose substance use disorders, use a wider range of interventions and techniques, and report higher levels of commitment to their work (Nielson, 2016). Counselors who are in recovery often report that becoming a helper was a significant part of their recovery process as a shift in identity (Racz et al., 2015). Additionally, clients may feel more connected to counselors who understand addiction personally and that can help with an expedited rapport-building process (Racz et al., 2015). However, the dynamic of being in recovery can create dual relationship challenges beyond the normal experiences of counselors (Veach, 2015). Counselors in general struggle with burnout in the profession due to the intensity of the environment and the exposure to the trauma and suffering of clients (Dreison et al., 2018). For addictions counselors in recovery, there is an added stressor of shared experiences or understanding that may be difficult for counselors to manage.
Ethical concerns related to counselors in recovery ✔✔There are multifaceted ethical concerns related to counselors in recovery, and one in particular includes boundary issues. Perhaps as a way to mitigate this concern, the Alcoholics Anonymous (AA; 2003) guidelines for AA members employed in the alcoholism field specifies that counselors in recovery should have at least 3-5 years of abstinence before working as an addictions counselor. Although the AA guidelines are geared toward those in recovery from alcohol, they can be extended to recovery from all mind-altering substances. Additionally, the AA guidelines suggest maintaining strict boundaries between one's clients and those one sponsors, should a counselor participate in both processes.In terms of counselors in recovery, there are two other key issues impacting this population. These include countertransference issues and self-disclosure.
Alcoholics Anonymous (AA) ✔✔a voluntary support group located in 180 countries for individuals who wish to stop drinking alcohol. Its companion group for those who use other drugs is Narcotics Anonymous. AA was founded in 1935 by a New York stockbroker and an Ohio surgeon, and it is estimated there are currently over 2 million members worldwide. The only requirement for membership is the desire to stop drinking or using other substances. There are no fees or costs associated with membership, and AA is self-supporting through member donations. The philosophy behind AA is that alcoholism is an illness that cannot be cured, but can be controlled through hard work and perseverance "one day at a time." Therefore, one is always in "recovery" unless one has relapsed. The goal is to help one another through fellowship, understanding, and by working the 12 steps and 12 traditions. Each step and tradition helps the individual make changes to behaviors, beliefs, and emotions so he or she can obtain sobriety and good health.
Countertransference with recovered counselor ✔✔Depending on the populations reviewed, anywhere from 37% to 75% of addictions helpers are themselves in recovery (Racz et al., 2015). Given this high percentage, what are the implications if an addictions counselor is working with someone who may be struggling with the same addiction from which the counselor, or a member of the counselor's family, is recovering? Given counselors' own history of struggle with
lack of nationwide continuity; therefore, requirements, education, and certification may vary, contingent upon each state's standards
The National Board of Certified Counselors certification ✔✔provides a voluntary certification of National Certified Counselor for state licensed counselors who want to demonstrate a high commitment to education and standards in their profession. In addition to the general certification, NBCC offers additional certifications for counselors to choose, including Master Addictions Counselor (MAC). Counselors who want to obtain this credential must pass the Examination of Master Addictions Counselors exam and commit to following the NBCC guidelines for continuing education in addictions-related topics for recertification
NAADAC certifications ✔✔According to the NAADAC (2018a), the National Certification Commission for Addiction Professionals recognizes three levels of substance addiction certifications, including National Certified Addiction Counselor Level I (NCAC I), National Certified Addiction Counselor Level II (NCAC II), and Master Addictions Counselor (MAC). In 2013, the NAADAC announced the addition of more credentials, including the co-occurring competency and the peer-recovery support specialist credential (Brys, 2013). Currently, NAADAC acknowledges additional specialties, such as National Certified Adolescent Addiction Counselor, National Endorsed Co-Occurring Disorders Professional, and Nicotine Dependence Specialist, among others.
NAADAC certification tests ✔✔All NAADAC (2018b) certifications require the passing of an examination that requires the tester have strong knowledge of the following topic areas: (1) treatment admission, (2) clinical assessment, (3) ongoing treatment planning, (4) counseling services, (5) documentation, (6) case management, (7) discharge and continuing care, and (8) legal, ethical, and professional growth. Though each exam contains 200 multiple-choice questions, the distribution of questions are diverse related to the content areas of pharmacology of psychoactive substances, counseling practice, theoretical bases, professional issues, and co- occurring disorders
Criteria for credentialing between states and certification agencies ✔✔Credentialing agencies and states differ in opinion regarding just how many competencies are needed. When examining the criteria for credentialing between states and certification agencies, it is evident that standards and requirements vary. In making a case for standardized national credentials, NAADAC (2018a) suggests that that type of standard would (1) provide a national standard for knowledge and competence, (2) ensure that standards exceed state standards and encourage professionals to seek continued education, (3) offer a way to measure and monitor professional requirements, and (4) offer clients, agencies, and communities a credential that signifies a quality counselor.
Licensure ✔✔the most rigorous form of professional regulation. Historically, the movement to license addictions counselors was not as advanced as that of certification, but this has changed in recent years. Unlike certification, which can be granted nationally (e.g., national certified
counselor), state law establishes licensure, and each state determines the requirements for licensure. Each state has differing names and requirements for licensure, so determining how to find information can be confusing. States use different terms for addictions counselor licenses, including Licensed Chemical Dependency Counselor (LCDC), Chemical Dependency Counselor (CDC), Certified Alcohol Drug Counselor (CADC), Substance Addiction Counselor (SAC), Alcohol and Drug Counselor (ADC), Addiction Counselor, and Substance Addiction Professional
Relationship between addictions counseling and professional counseling ✔✔Historically, the relationship between addictions counseling and professional counseling has been distanced. It was 2009 before CACREP standards required addictions education for professional counselors and added addictions counseling as a specialized program within accredited programs (Bobby, 2013). Even in modern texts that provide an overview of the counseling field, addictions counseling is covered in the chapters on credentialing and licensure (Neukrug, 2017). A final note regarding the licensure process for addictions counselors is the fact that professional counselor licensures, marriage and family therapy licensures, and clinical social work licensures offer the holders the credentialing to treat clients with SUDs without specialized licensure or credentialing. These nuances provide evidence that, though great strides have been made to connect the counseling field to addictions specializations, there is much work to be done for the establishment of continuity between the professions.
Accreditation ✔✔Accreditation applies to the specific counselor education program within colleges and universities that educates and trains addictions counselors. It does not apply to individual counselors in the way that licensure and certification does. Accreditation procedures are intended to ensure the quality and standardization of graduate education for the academic preparation of addictions counselors
Managed care ✔✔The advent of managed care has changed the way health care provisions are administered in this country (Quinn et al., 2017). Managed care refers to any type of intervention aimed at the financing of health care and focused on elimination of unnecessary and inappropriate care and reduction of costs (Hines, Raetzman, Barrett, Moy, & Andrews, 2017). While the managed care system has been successful in lessening short-term costs, many consider that it has been at the price of long-term consequences for clients and practitioners (Hines et al., 2017). For example, managed care has not always covered addiction treatment equally to that of other types of medical care and there has been a perception that those individuals who suffer from addictions use more resources than others (Quinn et al., 2017). The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) has helped to rectify this discrepancy in treatment provision (Quinn et al., 2017)
Ethical concerns regarding managed care ✔✔The core of these concerns regard cost-containment practices of setting session limits, restricting provider availability, and issues relating to conflict of interest, confidentiality, informed consent, client abandonment, pressures to breach fiduciary
Move toward evidence-based treatments ✔✔along with other counseling and medical specialties, a move toward evidence-based treatments has taken root within the addictions field (Kidd et al., 2014). Professional associations and governmental agencies have also issued practice guidelines and treatment algorithms, which support selected treatments or levels of care for specific conditions (Horvath & Yeterian, 2012). Empirically based practices are developed through clinical trials, consensus reviews, and expert opinions
Scientifically based treatment approaches ✔✔These include (1) cognitive-behavioral therapy, (2) community reinforcement approaches, (3) motivational enhancement therapy, (4) the 12-step approach, (5) contingency management techniques, (6) pharmacological interventions, and (7) systems treatment (Smith & Liu, 2014).
Concerns that exist about the implementation of evidenced-based practice ✔✔The role of ethical values in shaping practice Disagreement about the supporting evidence needed to validate some treatment protocols Lack of therapist adherence to treatment protocols Difficulty of implementation Lack of availability of some treatment manuals Lack of availability of training, consultation, technical assistance, and supervision Difficulty in learning the treatment protocol Cost of implementation Lack of insurance reimbursements Concern about how the new model impacts existing practices How well the clients like it and will adhere to it
Disconnect between research and clinical practice ✔✔To address this concern, an alliance has been formed among researchers and addictions specialists, called the National Drug Abuse Treatment Clinical Trials Network (CTN). The purpose of this alliance is to not only research current treatments, but also to formulate and empirically validate new ones
Future trends in addictions counseling ✔✔positive psychology, unity among self help groups, changes in US drug laws
Positive psychology ✔✔Some in the field are increasingly calling for the addictions field to forgo the labels and pathological perspective and take a wellness and positive psychology and recovery approach in treating those with addictions. Positive psychology focuses on client strengths and supports over the lifespan and embraces the notion that there is more than one way to obtain sobriety and recovery
Unity Among Self-Help Groups ✔✔Rather than standing alone and working in parallel lines, more and more self-help groups are joining forces and pooling resources, including combining
advocacy efforts, which has led to a greater public voice (Krentzman, 2013). The national advocacy group that came out of these collaborations is the Faces and Voices of Recovery and the Association of Recovery Community Organizations (Krentzman, 2013).
