CHCAOD001 Readings

Models for Explaining the Etiology of Addiction

Substance use and abuse has been linked to a variety of societal issues and problems (crime and violence, violence against women, child abuse, difficulties with mental health, risks during pregnancy, sexual risk-taking, fatal injury, etc.). Given the impact the abuse of substances can have on society in general and the toll it often levies on individuals and families, it seems reasonable to attempt to understand the etiology or causes of addiction so that diagnosis and treatment plans can be as efficacious as possible. There are numerous models for explaining the etiology of addiction (McNeese & DiNitto, 2005); these models are not always mutually exclusive and none are presented as the correct way of understanding the phenomena of addiction. The moral, psychological, family, disease, public health, developmental, biological, sociocultural, and some multicausal models will be described in the subsections that follow.

The Moral Model

The moral model is based on beliefs or judgments of what is right or wrong, acceptable or unacceptable. Those who advance this model do not accept that there is any biological basis for addiction; they believe that there is something morally wrong with people who use drugs heavily.

The moral model explains addiction as a consequence of personal choice, and individuals who are engaging in addictive behaviors are viewed as being capable of making alternative choices. This model has been adopted by certain religious groups and the legal system in many states. For example, in states in which violators are not assessed for chemical dependency and in which there is no diversion to treatment, the moral model guides the emphasis on “punishment.” In addition, in communities in which there are strong religious beliefs, religious intervention might be seen as the only route to changing behavior. The moral model for explaining the etiology of addiction focuses on the sinfulness inherent in human nature (Ferentzy & Turner, 2012). Since it is difficult to establish the sinful nature of human beings through empirically based research, this model has been generally discredited by present-day scholars. It is interesting to note, however, that the concept of addiction as sin or moral weakness continues to influence many public policies connected with alcohol and drug abuse (McNeese & DiNitto, 2005). This may be part of the reason why needle/syringe exchange programs have so often been opposed in the United States.

Although the study of the etiology of alcoholism and other addictions has made great strides in moving beyond the moral model, alcoholics are not immune to social stigma, and other types of addiction have yet to be widely viewed as something other than a choice. But as we move further away from the idea that addiction is the result of moral failure, we move closer to providing effective treatment and support for all those who suffer.

Psychological Models

Another explanation for the reasons people crave alcohol and other mind-altering drugs has to do with explanations dealing with a person’s mind and emotions. There are several different psychological models for explaining the etiology of alcoholism and drug addiction, including cognitive-behavioral, learning, psychodynamic, and personality theory models.

Cognitive-Behavioral Models

Cognitive-behavioral models suggest a variety of motivations and reinforcers for taking drugs. One explanation suggests that people take drugs to experience variety (Weil & Rosen, 1993). Drug use might be associated with a variety of experiences such as self-exploration, religious insights, altering moods, escape from boredom or despair, and enhancement of creativity, performance, sensory experience, or pleasure (Lindgren, Mullins, Neighbors, & Blayney, 2010). If we assume that people enjoy variety, then it can be understood why they repeat actions that they enjoy (positive reinforcement).

The desire to experience pleasure is another explanation connected with the cognitive-behavioral model. Alcohol and other drugs are chemical surrogates of natural reinforcers such as eating and sex. Social drinkers and alcoholics often report using alcohol to relax even though studies show that alcohol causes people to become more depressed, anxious, and nervous (NIAAA, 1996). Dependent behavior with respect to the use of alcohol and other drugs is maintained by the degree of reinforcement the person perceives as occurring; alcohol and other drugs may be perceived as being more powerful reinforcers than natural reinforcers and set the stage for addiction. As time passes, the brain adapts to the presence of the drug or alcohol, and the person experiences unpleasant withdrawal symptoms (e.g., anxiety, agitation, tremors, increased blood pressure, seizures).

To avoid such unpleasant symptoms, the person consumes the substance anew and the cycle of avoiding unpleasant reactions (negative reinforcement) occurs and a repetitive cycle is established. In an interesting review of the literature on the etiology of addiction (Lubman, Yucel, & Pantelis, 2004), it was proposed that in chemically addicted individuals, maladaptive behaviors and high relapse rates may be conceptualized as compulsive in nature. The apparent loss of control over drug-related behaviors suggests that individuals who are addicted are unable to control the reward system in their lives and that addiction may be considered a disorder of compulsive behavior very similar to obsessive compulsive disorder.

Learning Models

Learning models are closely related and somewhat overlap the explanations provided by cognitive-behavioral models. Learning theory assumes that alcohol or drug use results in a decrease in uncomfortable psychological states such as anxiety, stress, or tension, thus providing positive reinforcement to the user. This learned response continues until physical dependence develops and, like the explanation provided within the context of cognitive-behavioral models, the aversion of withdrawal symptoms becomes a reason and motivation for continued use. Learning models provide helpful guidelines for treatment planning because, as pointed out by Bandura (1969), what has been learned can be unlearned; the earlier the intervention occurs the better, since there will be fewer behaviors to unlearn.

Psychodynamic Models

Psychodynamic models link addiction to ego deficiencies, inadequate parenting, attachment disorders, hostility, homosexuality, masturbation, and so on. As noted by numerous researchers and clinicians, such models are difficult to substantiate through research since they deal with concepts difficult to operationalize and with events that occurred many years prior to the development of addictive behavior.

A major problem with psychodynamic models is that the difficulties linked to early childhood development are not specific to alcoholism or addiction, but are reported by nonaddicted adults with a variety of other psychological problems (McNeese & DiNitto, 2005). Nevertheless, current thinking relative to the use of psychodynamic models as a potential explanation for the etiology of addiction has the following beliefs in common (Dodgen & Shea, 2000):

• Substance abuse can be viewed as symptomatic of more basic psychopathology.
• Difficulty with an individual’s regulation of affect can be seen as a core problem or difficulty.
• Disturbed object relations may be central to the development of substance abuse. Readers are referred to Chapter 12 of Slaying the Dragon: The History of Addiction Treatment and Recovery in America by William L. White (1998) for a more extensive discussion of psychodynamic models in the context of the etiology of addiction.

Personality Theory Models

These theories make the assumption that certain personality traits predispose the individual to drug use. An “alcoholic personality” is often described by traits such as dependent, immature, impulsive, highly emotional, having low frustration tolerance, unable to express anger, and confused about their sex role orientation (Catanzaro, 1967; Milivojevic et al., 2012; Schuckit, 1986).

Although many tests have been constructed to attempt to identify the personality traits of a drug-addicted person, none have consistently distinguished the traits of the addicted individual from those of the nonaddicted individual. One of the subscales of the Minnesota Multiphasic Personality Inventory does differentiate alcoholics from the general population, but it may only be detecting the results of years of alcoholic abuse rather than underlying personality traits (MacAndrew, 1979). The consensus among those who work in the addictions counseling arena seems to be that personality traits are not of much importance in explaining addiction because an individual can become drug dependent irrespective of personality traits (Raistrick & Davidson, 1985).

Family Models

As noted in Chapter 14, during the infancy of the field of addictions counseling, addictions counselors were used to working only with the addict. Family members were excluded. However, it soon became clear that family members were influential in motivating the addict to get sober or in preventing the addict from making serious changes. There are at least three models of family-based approaches to understanding the development of substance abuse (Dodgen & Shea, 2000).

Behavioral Models

A major theme of the behavioral model is, that within the context of the family, there is a member (or members) who reinforces the behavior of the abusing family member. A spouse or significant other, for example, may make excuses for the family member or even prefer the behavior of the abusing family member when that family member is under the influence of alcohol or another drug. Some family members may not know how to relate to a particular family member when he or she is not “under the influence.”

Family Systems

There have been many studies demonstrating the role of the family in the etiology of drug abuse (Baron, Abolmagd, Erfan, & El Rakhawy, 2010). As noted in Chapter 14, the family systems model focuses on the way roles in families interrelate (Tafa & Baiocco, 2009). Some family members may feel threatened if the person with the abuse problem shows signs of wanting to recover since caretaker roles, for example, would no longer be necessary within the family system if the member began behaving more responsibly. The possibility of adjusting roles could be so anxiety producing that members of the family begin resisting all attempts of the “identified patient” to shift relationships and change familiar patterns of day-to-day living within the family system.

Family Disease

This model is based on the idea that the entire family has a disorder or disease, and all must enter counseling or therapy for improvement to occur within the addicted family member. This is very different from approaches to family counseling in which the counselor is willing to work with whichever family members will come to the sessions, even though every family member is not present.

The Disease Model

E. M. Jellinek (1960) is generally credited with introducing this controversial and initially popular model of addiction in the late 1930s and early 1940s (Stein & Foltz, 2009). However, it is interesting to note that, as early as the later part of the 18th century, the teachings and writings of Benjamin Rush, the Surgeon General of George Washington’s revolutionary armies, actually precipitated the birth of the American disease concept of alcoholism as an addiction (White, 1998). In the context of this model, addiction is viewed as a primary disease rather than being secondary to another condition (reference the discussion, earlier in this chapter, of psychological models).

Jellinek’s disease model was originally applied to alcoholism but has been generalized to addiction to other drugs. In conjunction with his work, Jellinek also described the progressive stages of the disease of alcoholism and the symptoms connected with each stage. These stages (prodromal, middle or crucial, and chronic) were thought to be progressive and not reversible. Consistent with this concept of irreversibility is the belief that addictive disease is chronic and incurable. Once the individual has this disease, according to the model, it never goes away, and there is no treatment method that will enable the individual to use again without the high probability that the addict will revert to problematic use of the drug of choice. One implication of this philosophy is that the goal for an addict must be abstinence, which is the position taken by Alcoholics Anonymous (Fisher & Harrison, 2005). In addition, the idea that addiction is both chronic and incurable is the reason that addicts who are maintaining sobriety refer to themselves as “recovering” rather than as “recovered.”

Interestingly, although Jellinek’s disease model of addiction has received wide acceptance (Ferentzy & Turner, 2012), the research from which he derived his conclusions has been questioned. Jellinek’s data were gathered from questionnaires. Of the 158 questionnaires distributed, 60 were discarded; no questionnaires from women were used. The questions about the original research, which led to the conceptualization of the “disease” model, have led to controversy.

On the one hand, the articulation of addiction as a disease removes the moral stigma attached to addiction and replaces it with an emphasis on treatment of an illness, results in treatment coverage by insurance carriers, and sometimes encourages the individual to seek assistance much like that requested for diabetes, hypertension, or high cholesterol. On the other hand, the progressive, irreversible progression of addiction through stages does not always occur as predicted, and the disease concept may promote the idea for some individuals that one is powerless over the disease, is not responsible for behavior, may relapse after treatment, or may engage in criminal behavior to support the “habit.”

The Public Health Model

It is interesting to note that the public health model was not originally conceptualized to focus on psychobehavioral ailments since, from its early beginnings, the emphasis has been on promoting healthy behaviors. As noted by Ferentzy and Turner (2012), the 20th-century psychiatrist Paul Lemkau, founding chairperson of the Mental Hygiene department in the Johns Hopkins University School of Public Health, was one of the first to apply a public health model to mental disorders. Lemkau promoted the establishment of community, rather than residential, treatment centers because he believed that mental health, including the treatment of addiction, was a public rather than a private issue. Lemkau believed that when individuals did not engage in healthy behaviors and became addicted, it was because of the impact of social issues. He viewed addiction as a societal disease, in direct contrast to the more dominant, individualistic conceptions associated with the disease model.

The Developmental Model

As noted by Sloboda, Glantz, and Tarter (2012), the etiology of addiction can also be explicated by applying a developmental framework to understand the factors that increase or decrease risks for the individual to use or misuse drugs. They posited that vulnerability is never static or unchanging, but varies across the life span. Sloboda and her colleagues examined some of the key developmental competencies associated with the following developmental stages: prenatal through early childhood, middle childhood, adolescence, late adolescence/early adulthood, and adulthood. This research provided detailed examples of competencies that must be mastered during each of these developmental stages to decrease the possibility of engaging in risky behavior that includes the use and misuse of drugs. Readers interested in exploring the developmental model for understanding the etiology of addiction will find the Sloboda et al. (2012) an article excellent starting point for additional study.

Biological Models

Biophysiological and genetic theories assume that addicts are constitutionally predisposed to develop dependence on drugs. These theories or models support a medical model of addiction, apply disease terminology, and often place the responsibility for treatment under the purview of physicians, nurses, and other medical personnel. Usually, biological explanations branch into genetic and neurobiological discussions.

Genetic Models

Although genetic factors have never really been established as a definitive cause of alcoholism, the statistical associations between genetic factors and alcohol abuse are very strong. For example, it has been established that adopted children more closely resemble their biological parents than their adoptive parents when it comes to their use of alcohol (Dodgen & Shea, 2000; Goodwin, Hill, Powell, & Viamontes, 1973); alcoholism occurs more frequently in some families than others (Cotton, 1979); concurrent alcoholism rates are higher in monozygotic twin pairs than in dizygotic pairs (Kaij, 1960); and children of alcoholics can be as much as seven times more likely to be addicted than children whose parents are not alcoholic (Koopmans & Boomsina, 1995).

Because of such data, some genetic theorists have posited that an inherited metabolic defect may interact with environmental elements and lead, in time, to alcoholism. Some research points to an impaired production of enzymes within the body and yet other lines of inquiry point to the inheritance of genetic traits that result in a deficiency of vitamins (probably the vitamin B complex), which leads to a craving for alcohol as well as the accompanying cellular or metabolic changes.

There have been numerous additional lines of inquiry that have attempted to establish a genetic marker that predisposes a person toward alcoholism or other addictions (Bevilacqua & Goldman, 2010). Studies that examined polymorphisms in gene products and DNA, the D2 receptor gene, and even color blindness as factors have all been conducted and then later more or less discounted. Genetic research on addiction shows potential, but is a complex activity given the fact that each individual carries genes located on 23 pairs of chromosomes. The Human Genome Project, which is supported by the National Institutes of Health and the U.S. Department of Energy, is conducting some promising studies (NIAAA, 2000).

Neurobiological Models

Neurobiological models are complex (Jacob, 2013) and have to do with the neurotransmitters in the brain that serve as the chemical messengers of our brain (Hammer et al., 2012); Kranzler & Li, 2008; Wilcox, Gonzales, & Miller, 1998). Almost all addictive drugs, as far as we know, seem to have primary transmitter targets for their actions. The area of the brain in which addiction occurs is the limbic system or the emotional part of the brain. The limbic part of the brain refers to an inner margin of the brain just outside the cerebral ventricles, and the transmitter dopamine is key in its activity in the limbic system and the development of addiction. As a person begins to use a drug, changes in brain chemistry in the limbic system begin to occur and lead to addiction. Current thinking is that these changes can also be reversed by the introduction of other drugs in concert with counseling and psychotherapy.

Sociocultural Models

Sociocultural models have been formulated by making observations of the differences and similarities between cultural groups and subgroups. As noted by Goode (1972), the social context of drug use strongly influences drug definitions, drug effects, drug-related behavior, and the drug experience. These are contextual models and can only be understood in relation to the social phenomena surrounding drug use. A person’s likelihood of using drugs, according to these models, the way he/she behaves, and the way abuse and addiction are defined are all influenced by the sociocultural system surrounding the individual.

Supracultural Model

The classic work of Bales (1946) provided some hypotheses connecting culture, social organization, and the use of alcohol. He believed that cultures that create guilt, suppress aggression and sexual tension, and that support the use of alcohol to relieve those tensions will probably have high rates of alcoholism. Bales also hypothesized that the culture’s collective attitude toward alcohol use could influence the rate of alcoholism. Interestingly, he categorized these attitudes as favoring (1) abstinence, (2) ritual use connected with religious practices, (3) convivial drinking in a social setting, and (4) utilitarian drinking (drinking for personal reasons). The fourth attitude (utilitarian) in a culture that produces high levels of tension is the most likely to lead to high levels of alcoholism; the other three attitudes lessen the probability of high alcoholism rates. Another important aspect of Bales’ thinking is the degree to which the culture offers alternatives to alcohol use to relieve tension and to provide a substitute means of satisfaction. A culture that emphasizes upward economic or social mobility will frustrate individuals who are unable to achieve at such high levels and increase the possibility of high alcoholism rates.

In 1974, Bacon theorized that high rates of alcoholism were likely to exist in cultures that combine a lack of indulgence toward children with demanding attitudes toward achievement and negative attitudes toward dependent behavior in adults. An additional important factor in supracultural models is the degree of consensus in the culture regarding alcohol and drug use. In cultures in which there is little agreement, a higher rate of alcoholism and other drug use can be expected. Cultural ambivalence regarding the use of alcohol and drugs can result in the weakening of social controls, which allows the individual to avoid being looked upon in an unfavorable manner.

Culture-Specific Models

Culture-specific models of addiction are simultaneously fascinating and hampered by the possibilities inherent in promoting stereotypes and overgeneralizing about the characteristics of those who “seem” to fit the specific culture under consideration. For example, there are many similarities between the French and Italian cultures since both cultures are profoundly Catholic and both cultures support wineries and have populations that consume alcohol quite freely (Levin, 1989). The French drink both wine and spirits, with meals and without, at home as well as away from the family. The French often consider it bad manners to refuse a drink, and the attitudes toward drinking too much are usually quite liberal. The Italians drink mostly wine, with meals and at home, and they strongly disapprove of public misconduct due to the overconsumption of wine. They do not pressure others into accepting a drink.

As the reader might expect from prior discussion, the rate of alcoholism in France is much more problematic than that which exists in Italy. Although the authors would agree that the prevailing customs and attitudes relating to the consumption of alcohol in a specific culture can provide insight and have usefulness as a possible explanation of the etiology of addiction in the culture under consideration, readers should be cautious about cultural stereotyping and make every attempt to address diversity issues in counseling as outlined in the current version of the Code of Ethics of the American Counseling Association (ACA) as well as the ACA guidelines for culturally competent counseling practices. (See the ACA website at www.counseling.org).

Subcultural Models

It should also be briefly noted that there have been many investigations of both sociological and environmental causes of addiction and alcoholism at the subcultural level. Factors related to age, gender, ethnicity, socioeconomic class, religion, and family background can create different patterns within specific cultural groups (McNeese & DiNitto, 2005; White, 1998). They also can be identified as additional reasons why counselors and other members of the helping professions must vigilantly protect the rights of clients to be seen and heard for who they really are rather than who they might be assumed to resemble.

Multicausal Models

At this point in your reading you may be wondering which of these etiological models or explanations of addiction is the correct model. As you may have already surmised, although all of these models are helpful and important information for counselors beginning their studies in addiction counseling, no single model adequately explains why some individuals become addicted to a substance and others do not. An important advance in the study of addiction is the realization that addiction is probably not caused by a single factor, and the most likely models for increasing our understanding and our development of treatment options are multivariate (Buu et al., 2009; McNeese & DiNitto, 2005; Stevens & Smith, 2005).

Even though there may be some similarities in all addicted individuals, the etiology and motivation for the use of drugs varies from person to person. For some individuals, there may be a genetic predisposition or some kind of a physiological reason for use and later addiction to a drug. For others, addiction may be a result of an irregularity or disturbance of some kind in their personal development without a known genetic predisposition or physiological dysfunction. The possible debate over which model is the correct model is valuable only because it assists the practitioner to see the importance of adopting an interdisciplinary or multicausal model.

An interesting example of a multicausal model that has been proposed is the syndrome model of addiction (Shaffer et al., 2004). This model suggests that the current research pertaining to excessive eating, gambling, sexual behaviors, shopping, substance abuse, and so on does not adequately capture the origin, nature, and processes of addiction. The researchers believe that the current view of addictions is very similar to the view held during the early days of AIDS awareness when rare diseases were not recognized as opportunistic infections of an underlying immune deficiency syndrome.

The syndrome model of addiction suggests that there are multiple and interacting antecedents of addiction that can be organized in at least three primary areas: (1) shared neurobiological antecedents, (2) shared psychosocial antecedents, and (3) shared experiences and consequences. Another promising example of a multicausal model is the integral model(Amodia,Cano, & ¬Eliason, 2005). This integral approach examines substance abuse etiology and treatment from a fourquadrant perspective adapted from the work of Ken Wilbur. It also incorporates concepts from integrative medicine and transpersonal psychology. Readers are referred to the references cited in this subsection for more complete information about both the syndrome and integral models.

The multicausal model is similar to the public health model recently adopted by health care and other human service professionals. This model conceptualizes the problem of addiction as an interaction among three factors: the “agent” or drug, the “host” or person, and the “environment,” which may be comprised of a number of entities. When the agent or drug interacts with the host, it is important to realize that there are a variety of factors within the host, including the person’s genetic composition, cognitive structure and expectations about drug experiences, family background, and personality traits, that must be taken into consideration as a treatment plan is developed. Environmental factors that need to be considered include social, political, cultural, and economic variables. When a counselor or therapist uses a multicausal model to guide the diagnosis and treatment planning process, the complex interaction of several variables must be taken into consideration.

Summary

This chapter provided an overview of the historical evolution of approaches to the prevention of addiction in the United States. It chronicled the movement from the rudimentary and unregulated approaches of early practitioners to the more carefully regulated, credentialed, and evidence-based methods in use today. The social and political influences on the attitudes toward the use of drugs for both recreational and medical purposes were also addressed.

A brief review of the federal government’s role in funding agencies focused on the prevention of drug abuse as well as the provision of treatment for addicted individuals provided the background for some of the current policies influencing the prevention of addiction. Descriptions of the moral, psychological, family, disease, public health, developmental, biological, sociocultural, and multicausal models for understanding the etiology of addiction provided the reader with the background to understand topics covered in subsequent chapters of the text.

Cell Activity of the Human Brain

Cells of the brain are known as neurons. Figure 2.1 illustrates the structural features of a presynaptic and postsynaptic neuron. It should be noted that this figure depicts only two neurons and thus is quite simplistic. In the brain, each neuron forms synapses with many other neurons and, in turn, receives synaptic connections from an equally large number of neurons.

The brain’s signaling functions are primarily conducted by the neurons of the brain. There are approximately 86 billion neurons in the human brain (Azevedo et al., 2009) that provide the capacity for sensation, movement, language, thought, and emotion. Although neurons in different parts of the brain vary in size, shape, and electrical properties, most share the common features that appear in Figure 2.1. The cell body containing the nucleus holds the cell’s genetic information. Dendrites are the treelike projections that integrate information from other neurons. Many neurons have a single axon that conducts electrical signals away from the cell body. At the end of each axon, branches terminate at a microscopic, fluid-filled gap known as the synapse. Thus, this electrochemical system consists of neurons that are separated by very small synaptic gaps (see Figure 2.2).

Vesicles located at presynaptic axon terminals release brain chemicals, known as neurotransmitters, into the synapse in response to electrical stimuli. Homeostatic mechanisms attempt to maintain the appropriate concentration or balance of particular neurotransmitters in the synapse. One mechanism involves the action of enzymes that break down available neurotransmitters. (Enzymes are specialized proteins that serve as a catalyst for a specific chemical reaction.) When the concentration of a neurotransmitter becomes too great, enzymatic activity in the synapse increases to reduce it. A second mechanism is known as reuptake. Here, presynaptic “pumps” draw neurotransmitter molecules back into vesicles located at presynaptic terminals. This reabsorption process intensifies when the concentration of neurotransmitter in the synapse becomes too great. In tandem, the processes of enzymatic activity and reuptake work to maintain optimal neurotransmitter concentration.

Postsynaptic axon terminals (see Figure 2.2) receive and respond to the particular neurotransmitter they are designed to operate. There are target areas for the neurotransmitter molecule at the postsynaptic terminals. These target areas are known as receptor sites or just receptors. Typically, each neurotransmitter has an affinity for a specific type of receptor, and their relationship has often been described as akin to that of a key (the neurotransmitter) to its lock (the receptor). In some cases, a receptor may recognize more than one chemical.

Nevertheless, the design of the receptor is such that it usually responds only to the specific molecular structure of its neurotransmitter. The postsynaptic terminals respond to the diffusion of neurotransmitters across the synapse by sending an electrical signal toward their cell body. In this way, the neurons “communicate” or relay information to one another in a highly rapid manner.

Mesolimbic Dopamine Pathway: The Brain’s Reward Center

Many drugs stimulate reward circuitry in the brain known as the mesolimbic dopamine pathway (Lingford-Hughes, Watson, Kalk, & Reid, 2010; Pierce & Kumaresan, 2006). This pathway extends through several regions of the brain and is composed of a system of neurons that operates primarily on a type of neurotransmitter known as dopamine. From an evolutionary perspective, the forces of natural selection are thought to have fostered development of this reward circuitry to reinforce those behaviors most necessary for survival, such as eating food and having sex. The mesolimbic system can be considered the neurobiological substrate that produces pleasure. Unfortunately, many drugs also commonly stimulate reward centers in this system. Thus, the mesolimbic dopamine system is implicated in addiction. Other chemical pathways, using serotonin and glutamate, also are implicated in the reinforcing effects of particular drugs, but these are not reviewed here.

As can be seen in Figure 2.3, the mesolimbic system arises in the ventral tegmental area in the brainstem and projects to the nucleus accumbens in the ventral striatum and the frontal cortex. The system then consists of the nucleus accumbens, frontal cortex, and the amygdala. The nucleus accumbens is implicated in the expectation and pursuit of rewards, such as the “high” accompanying drug use. The frontal cortex supports the human abilities to evaluate stimuli, weigh the pleasure produced by an action, and activate impulse control. The amygdala is responsive to the intensity of pleasure and pain, and is involved in the human ability to associate pleasurable experiences with neutral environmental stimuli.

Most drugs of abuse directly or indirectly alter the brain’s reward circuitry by flooding it with the neurotransmitter known as dopamine. The pleasure associated with dopamine release reinforces the act of drug self-administration, that is, drinking, smoking, injecting, and so on. Thus, without thinking about it, users want to repeat taking a drug because they quickly learn that pleasure will follow. Over time, this motivation to use a drug strengthens while interest in other natural rewards weakens. For these reasons, addiction can be thought of as an overlearned behavior or activity driven by dopamine release.

Elevated levels of dopamine in the nucleus accumbens are associated with the rewarding effects of all common drugs of abuse, with the possible exception of the benzodiazepines (Koob & Le Moal, 2001). In the ventral striatum, the euphoric effects of stimulants are associated with dopamine increases (Volkow, Fowler, & Wang, 2003). Elevated dopamine levels have also been observed in relation to nicotine and alcohol use, but these findings are not consistent (Boileau et al., 2003; Montgomery, LingfordHughes, Egerton, Nutt, & Grasby, 2007).

The Neurobiological Basis for Development of Tolerance

In nonaddicts, repeated drug exposure is associated with elevated levels of dopamine, which make the mesolimbic reward pathway more sensitive, that is, effective at producing euphoria (Boileau et al., 2003). However, in a chronic addictive state, dopamine levels gradually decrease over time, making the mesolimbic system less sensitive and thereby producing deficient rewards. The user often responds by attempting to increase his or her dopamine release by using larger and larger doses of the drug, which only exacerbates the addiction. This is the process of increasing tolerance. These changes in reward circuitry sensitization may be the neurobiological basis for addicts “wanting,” but no longer “liking,” the effects of a drug (Berridge & Robinson, 2016; Blum, Gardner, Oscar-Berman, & Gold, 2012).

The biological purpose of the mesolimbic system probably is to mediate reward and pleasure and to create motivation to engage in life-sustaining tasks (e.g., eating and reproduction). However, it should be noted that motivation has both cognitive and emotional dimensions. Cognitive expectations in the form of anticipated reinforcement arise from previous life experiences and influence motivation. It is likely not an accident that our expectations of future events are formed in the prefrontal cortex, which is linked to the nucleus accumbens.

Previous drug “highs” may be preserved as memories, and they may motivate the user to engage in repeated selfadministration of a euphoric substance. Furthermore, as this region of the brain becomes increasingly exposed to excess dopamine during a period of substance abuse, its natural production may decline, resulting in fewer and less sensitive receptors for the neurotransmitter. This is one mechanism for the development of drug tolerance.

As a result of these changes to the brain, the addicted person gradually relies more and more on the drug as the source of gratification and pleasure. In this process, addicts tend to develop the perception that they have an inability to regulate their desire for the drug (i.e., perceived loss of control). As interest in nondrug activities diminishes, involvement in drug-related behaviors increases. Drug seeking, intoxication, and recovering from the deleterious effects (e.g., hangover) typically become the central activities in the addict’s life.

The National Drug Strategy 2017-2026 at a Glance

Purpose

To provide a national framework which identifies national priorities relating to alcohol, tobacco and other drugs, guides action by governments in partnership with service providers and the community, and outlines a national commitment to harm minimisation through balanced adoption of effective demand, supply and harm reduction strategies.

Aim

To build safe, healthy and resilient Australian communities through preventing and minimising alcohol, tobacco and other drug-related health, social, cultural and economic harms among individuals, families and communities.

A Balanced Approach across the Three Pillars of Harm Minimisations

Demand Reduction	Supply Reduction	Harm Reduction
Preventing the uptake and/ or delaying the onset of use of alcohol, tobacco and other drugs; reducing the misuse of alcohol, tobacco and other drugs in the community; and supporting people to recover from dependence through evidence- informed treatment.	Preventing, stopping, disrupting or otherwise reducing the production and supply of illegal drugs; and controlling, managing and/or regulating the availability of legal drugs.	Preventing, stopping, disrupting or otherwise reducing the production and supply of illegal drugs; and controlling, managing and/or regulating the availability of legal drugs.

Underpinning Strategic Principles

• Partnerships
• Coordination and Collaboration
• National direction, jurisdictional implementation
• Evidence-informed responses

Priority Actions	Priority Populations	Priority Substances
Enhance access to evidence informed, effective and affordable treatment Develop and share data and research, measure performance and outcomes Develop new and innovative responses to prevent uptake, delay first use and reduce alcohol, tobacco and other drug problems Increase participatory processes Reduce adverse consequences Restrict and/or regulate Availability Improve national coordination	Aboriginal and Torres Strait Islander people People with mental health conditions Young people Older people People in contact with the criminal justice system Culturally and linguistically diverse populations People identifying as lesbian, gay, bisexual, transgender, and/or intersex	Methamphetamines and other stimulants Alcohol Tobacco Cannabis Non-medical use of pharmaceuticals Opioids New psychoactive substances

Measuring Success

Assess progress by reviewing and reporting against the following headline indicators, using existing published and well-established data sources:

• Average age of uptake of drugs, by drug type;
• Recent use of any drug (people living in households);
• Arrestees’ illicit drug use in the month before committing an offence;
• Victims of drug related incidents; and
• Drug-related burden of disease (including mortality).
• Reporting will also consider new and emerging data sources, research and evaluation findings both nationally and internationally to ensure progress is monitored according to best available evidence

Introduction

Since its first iteration in 1985, Australia’s National Drug Strategy has been underpinned by an objective of minimising the harms associated with alcohol, tobacco, illicit drug and pharmaceutical drug use. Throughout the Strategy, the term ‘other drugs’ is used in reference to illicit drugs and pharmaceutical drugs.

The concept of harm minimisation is again central to this, the seventh iteration of the National Drug Strategy (the Strategy).

This consistent approach to the national drug policy framework has earned high international regard for its progressive, balanced and comprehensive approach and has made considerable achievements. However, alcohol, tobacco and other drug problems continue to impact individuals, families and communities through negative health, legal, social and economic outcomes.

Importantly, for the first time, the Strategy will have a ten year lifespan, reflecting Australia’s consistent and ongoing approach to national alcohol, tobacco and other drug policy.

The Strategy provides a national framework for action that is able to accommodate new and emerging alcohol, tobacco and other drug issues when they arise, and provides a guide for jurisdictions in developing their individual responses to local alcohol, tobacco and other drug issues. It is expected that each jurisdiction will develop their own accompanying strategy action plan which details the local priorities and activities to be progressed during the Strategy lifespan.

The ongoing cooperation between the law enforcement and health sectors is a key success of the previous National Drug Strategy. In addition to providing a national framework to guide coordinated action to minimise the harms to all from alcohol, tobacco and other drugs, this iteration saw the development of a number of sub-strategies to provide direction and context for specific issues.

During the period of the National Drug Strategy 2010-2015, evidence-informed demand, supply and harm reduction strategies yielded positive results. Some examples include:

• In 2014-15, police reported a record 105,862 national illicit drug seizures, and issued 11, 809 diversions for cannabis-related offences;
• The 2014 survey of Australian secondary students shows that the prevalence of smoking in the past month, past week and on at least three of the past seven days among 12- to 15-year-olds was the lowest it has been since 1984; and
• The National Drug Strategy Household Survey reported a decline in the proportion of people exceeding lifetime risk guidelines for consuming alcohol from 20.5% in 2010 to 17.1% in 2016, and declines in the use of some illicit drugs between 2010 and 2016, including methamphetamine and ecstasy and a decrease in the proportion of people injecting drugs during this period.

Why Do We Need a National Drug Strategy?

The harms from alcohol, tobacco and other drugs impact (directly and/or indirectly) on all Australian communities, families and individuals. Impacts can include:

Health Harms such as:

• injury;
• chronic conditions and preventable diseases (including lung and other cancers; cardiovascular disease; liver cirrhosis);
• mental health problems; and
• road trauma.

Social Harms including:

• violence and other crime;
• engagement with the criminal justice system more broadly;
• unhealthy childhood development and trauma;
• intergenerational trauma;
• contribution to domestic and family violence;
• child protection issues; and
• child/family wellbeing.

Economic Harms associated with:

• healthcare and law enforcement costs;
• decreased productivity;
• associated criminal activity; and
• reinforcement of marginalisation and disadvantage.

Alcohol, tobacco and other drug problems are also associated with social and health determinants, such as discrimination, unemployment, homelessness, poverty and family breakdown.

The Strategy recognises this whole of government impact and while driving cooperation between law enforcement/policing/justice and health sectors to deliver effective responses, it also reflects the need to build and improve the collaboration between agencies responsible for alcohol, tobacco and other drug policy and service delivery, with agencies and providers working in other social service areas working with vulnerable people, including family intervention, child protection and out-of-home-care agencies.

The Strategy identifies nationally agreed priorities which governments will work collaboratively in coordinated, multi-agency approaches to develop and deliver jurisdictional responses that seek to prevent and minimise the harms from alcohol, tobacco and other drugs.

Policy Context

Development of the Strategy

The Strategy was informed by a national consultation process throughout 2015, which included key informant interviews, online survey feedback and stakeholder forums. The consultation process was invaluable in shaping the direction and priorities for the Strategy, as well as confirming strong support for Australia continuing its commitment to harm minimisation underpinning its national drug policy approach.

Harm Minimisation

Australia’s long standing commitment to harm minimisation considers the health, social and economic consequences of drug use on individuals, families and communities as a whole and is based on the following considerations:

• drug use occurs across a continuum, from occasional use to dependent use;
• a range of harms are associated with different types and patterns of drug use; and
• the response to these harms requires a multifaceted response.

A harm minimisation policy approach recognises the clear recognition that drug use carries substantial risks, and that drug-users require a range of supports to progressively reduce drug-related harm to themselves and the general community, including families. This policy approach does not condone drug use.

Implementation of the approach presented in this strategy, including funding, legislation and programs, is the responsibility of relevant agencies in Commonwealth, state and territory jurisdictions. The mix of actions adopted in individual jurisdictions and the details of their implementation may vary to reflect local and/or national circumstances and priorities.

This approach reduces the harms of use through coordinated, multi-agency responses that address the three pillars of harm minimisation. These pillars are demand reduction, supply reduction and harm reduction. Strategies to prevent and minimise alcohol, tobacco and other drug problems should be balanced across the three pillars.

Harm minimisation includes a range of approaches to help prevent and reduce drug related problems, and help people experiencing problems (including dependence) address these problems, including a focus on abstinence-oriented strategies.

The relative impact of strategies implemented under demand reduction, supply reduction and harm reduction varies for alcohol, tobacco and other drugs, due to differences in legality and regulation, prevalence of demand and usage behaviours. Strategies are also more effective in combination than separately, and should be tailored to meet the varied needs of individuals, families, communities, and specific population groups.

Demand Reduction

Alcohol, tobacco and other drug use is a multi-determined behaviour, influenced by a range of biological, psychosocial and environmental factors, including socialising, experimentation, excessive availability, coping with stress or difficult life situations, trauma, peer pressure and/ or acceptability, desire to enhance pleasure experiences or intensify feelings and behaviours. Demand reduction strategies influence these factors to delay, prevent or reduce use.

While the percentage of Australians reporting using any illicit drug in the last year has reduced since 1998, 15.6% of the population have used at least one illicit drug in the last year.

Prevent Uptake and Delay First Use

Prevention of uptake reduces personal, family and community harms, allows better use of health and law enforcement resources, generates substantial social and economic benefits and produces a healthier workforce. Demand reduction strategies that prevent drug use are more cost-effective than treating established drug-related problems.

Delaying first use can also lead to improved health and social outcomes. The earlier a person commences use, the greater their risk of harm. This includes mental and physical health problems and a greater risk of continued drug use. Strategies that delay the onset of use prevent longer term harms and costs to the community.

Reduce Harmful Use

Effective demand reduction approaches that reduce harmful consumption levels over time, or the amount taken on one occasion, can reduce harms. Harmful consumption can arise with the volume consumed, the nature of the drug, the way in which it is used, frequency of use, the context of that use and individual risk factors such as health conditions and age.

Support People to Recover from Drug Related Problems

Treatment options and support services have shown to be highly effective in helping reduce risky alcohol, tobacco and other drug use as well as related problems for individuals and the broader community. Alcohol, tobacco and other drug services and support are available within a wide spectrum ranging from peer-based community support, to brief interventions in primary care and hospital services through more intensive specialist treatment services. The best course of action is determined on the nature, complexity and severity of problems. It is critical, therefore, to ensure a range of services and agencies that are appropriately connected through established referral pathways.

It is critical that Australia’s strategy enhances and maintains access to quality evidence-informed treatment. Integrated care is critical to Australia’s response and this includes approaches that allow individuals to connect to services which will address barriers to recovery, which might lead to issues such as physical and mental health needs, social, economic, legal or accommodation considerations. It is important that these services are accessible and tailored to the diverse needs of individuals affected by drug use.

It is important to also ensure that there is investment in strategies that are critical to long term maintenance of recovery.

Evidence indicates that maintenance of recovery is strongly associated with quality of life. Quality of life factors include issues such as family life, connection to community, employment and recreational opportunities. Therefore, investing in strategies to enhance social engagement, and where indicated, re-integration with community, is central to successful interventions that can reduce alcohol and drug demand and related problems, including dependence.

Approaches that seek to build protective factors and address issues underpinning social determinants of health in order to prevent the initial uptake of drugs can also enhance community health and wellbeing and reduce health inequalities among population groups who experience disproportionate risk of harm from alcohol, tobacco and other drugs. This includes social services and community groups collaborating to improve access to housing, education, vocational and employment support, as well as developing and enhancing family and social connectedness, and strategies to reduce the availability, accessibility and demand for drugs.

Evidence of Good Practice

Demand reduction requires a comprehensive approach involving a mixture of regulation, government initiatives, community services and treatment services. Strategies that affect demand include:

• reducing the availability and accessibility (such as price mechanisms for alcohol and tobacco);
• improving community understanding and knowledge, reducing stigma and promoting help seeking;
• restrictions on marketing, including advertising and promotion;
• programs focused on building protective factors and social engagement;
• treatment services and brief intervention;
• targeted and culturally appropriate approaches to high prevalence population groups and regions at increased risk of exposure to and harm from alcohol, tobacco and other drugs;
• addressing underlying social, health and economic determinants of use; and
• diversion initiatives.

Supply Reduction

Supply reduction strategies aim to restrict availability and access to alcohol, tobacco and other drugs in order to prevent or reduce alcohol, tobacco and other drug problems. Controlling who can use, as well as when, where and how use occurs reduces the harm experienced by both the consumer and the broader community.

More than 17.1% of Australians consume alcohol at a level that puts them at risk of harm from alcohol-related disease or injury over their lifetime and 25.5% drink at levels on a monthly basis that pose a risk in terms of short-term harms, such as injury.

Control Licit Drug and Precursor Availability

Harm from alcohol, tobacco and other drug use is associated with when, where and how it occurs and who is using it. The harm from products that are legally available, including tobacco, alcohol and pharmaceuticals, can be reduced by regulating supply. This can include working with industry and informing communities to prevent misuse, enforcing existing regulations, and introducing new restrictions or conditions where required.

Regulating supply also includes ensuring that substances such as pharmaceuticals, precursors, and volatiles are available for legitimate uses, but not diverted for illicit uses.

Prevent and Reduce Illicit Drug Availability and Accessibility

Preventing or disrupting illicit supply of drugs and precursors reduces availability, leading to a reduction of use and consequential harms. Illicit supply of drugs includes drugs that are prohibited, such as cannabis, heroin, cocaine and methamphetamine, and those diverted from legitimate use, such as pharmaceuticals. It also includes illicit supply of substances that are legitimately available, such as alcohol, tobacco, solvents and those precursors used in illicit drug manufacture.

Preventing illicit supply includes dismantling or disruption of distribution networks and manufacturing and cultivation facilities or locations. It can be closely associated with policing activities aimed at organised crime.

Over the last five years there has been an increase in the availability and purity of methamphetamine (as indicated by more domestic seizures, border detections and arrests). As a consequence, states and territories are reporting an increase in the harms associated with its use including increased presentations to drug treatment services, ambulance attendances and presentations / admissions to Australian public hospitals.

Evidence of Good Practice

Supply reduction requires regulation, working with industry, intelligence and coordination between enforcement agencies, within jurisdictions, across jurisdictions, nationally and internationally.

Strategies that affect supply include:

• regulating retail and wholesale sale;
• age restrictions;
• border control;
• regulating or disrupting production and distribution; and
• implementation of real-time monitoring of prescription medications so that prescribers can prevent patients inappropriately accessing harmful and substantial quantities of medications.

Harm Reduction

Harm reduction strategies identify specific risks that arise from drug use. These are risks that can affect the individual who is using drugs, but also others such as family members, friends and the broader community. Harm reduction strategies encourage safer behaviours, reduce preventable risk factors and can contribute to a reduction in health and social inequalities among specific population groups.

The cost to Australian society of alcohol and other drug use in 2004–05 was estimated at $55.2 billion, including costs to the health and hospitals system, lost workplace productivity, road accidents and crime. Of this, tobacco accounted for $31.5 billion (56.2%), alcohol accounted for $15.3 billion (27.3%) and illegal drugs accounted for $8.2 billion (14.6%).

Reduce Risk Behaviours

Harms from alcohol, tobacco and other drugs can arise from risky behaviours associated with drug use in addition to directly from use. These behaviours can be positively influenced through public policy and programs. Strategies that encourage safer behaviours reduce harm to individuals, families and communities.

Effective public policy has included drink driving laws that have reduced the incidence of driving while intoxicated, smoke-free area laws that have reduced exposure to second hand smoke and needle and syringe programs that have reduced the incidence of people sharing injecting equipment.

Safer Settings

Environmental changes can reduce the impacts of alcohol, tobacco and other drug use. Examples include smoke-free areas, chill out spaces, providing food and free water at licensed venues and the opportunity for the safe disposal of needles and syringes. Strategies that create safer settings reduce harm.

Evidence of Good Practice

Harm reduction requires commitment from government and non-government programs, industry regulation and standards, and targeted communication strategies. Strategies that affect harm reduction include:

• reducing risks associated with particular context, including creating safer settings;
• safe transport and sobering up services;
• protecting children from another’s drug use;
• protecting the community from infectious disease including blood borne virus prevention;
• reducing driving under the influence of alcohol or other drugs; and
• availability of opioid treatment programs.

The Appendix to the Strategy provides a comprehensive summary of examples of harm reduction approaches.

Although Australia has achieved significant reductions in drink driving since the 1980s, it continues to be one of the main causes of road accidents, responsible for 28% of the burden due to road traffic injuries in Australia. Research shows between 20-30% of drink drivers reoffend and contribute disproportionately to road trauma. Alcohol-attributable road accidents in Australia cost an estimated $3.1 billion in 2004-05.

Priority Areas of Focus

The National Drug Strategy 2017-2026 identifies three different types of priority areas of focus for consideration in implementation: actions, populations and substances. These priorities reflect current available evidence of harms, as well as the views presented through the consultation processes undertaken to support the development of the Strategy.

This is not to say that only the actions, populations and substances identified will be addressed over the lifespan of this strategy, but rather that any policy responses aimed at minimizing the harms of alcohol and drugs should have reference to these priority areas of focus as they represent the areas where it is agreed the biggest gains can be delivered and the largest risk of harm currently exists.

It is also important to note that the examples of evidence-informed approaches highlighted against the priority actions is not exhaustive (a more comprehensive summary is provided in the Appendix to the Strategy), but are provided as an illustration of the types of approaches that could be considered, potentially enhanced and/or further promoted in implementing this Strategy through national collaboration and/or individual jurisdictional implementation. Where relevant, these example activities have been mapped to the applicable harm minimisation pillar.

The priority actions for the Strategy have been identified for specific coordinated action between and across jurisdictions. To achieve the goal of the Strategy, jurisdictions will work together. The priorities for the Strategy are complementary to this approach. They have been identified through a series of national consultations and by reviewing available data and evidence.

Actions

• enhance access to evidence-informed, effective and affordable treatment services and support;
• develop and share data and research, measure ep
• develop new and innovative responses to prevent uptake,
• delay first use and reduce alcohol, tobacco and other drug problems;
• increase participatory processes;
• reduce adverse consequences;
• restrict and/or regulate availability; and
• improve national coordination.

Populations

• Aboriginal and Torres Strait Islander people;
• people with mental health conditions;
• young people;
• older people;
• people in contact with the criminal justice system;
• culturally and linguistically diverse populations; and
• people identifying as lesbian, gay, bisexual, transgender and/or intersex.

Substances

• methamphetamines and other stimulants;
• alcohol;
• tobacco;
• cannabis;
• non-medical use of pharmaceuticals;
• opioids; and
• new psychoactive substances.

Priority Substances

The Strategy also identifies a number of specific priority drug types. These priorities are not just as a result of prevalence among the population, but also the increased harms that these substances bring to an individual and/or the community.

Identifying these substances should not imply that all other drugs should be ignored. It is important for governments and communities to maintain strong surveillance and data collection efforts to stay aware of emerging trends or drugs with concentrated use in specific communities.

It is also important to remember that priority drug types change over time and differ due to local circumstances. Priority drug types should be reviewed and policy responses informed by evidence as it develops. Poly-drug use is also a significant concern and strategies that address this can be very effective at reducing harm.

Current priority drug types include alcohol; tobacco; cannabis; methamphetamines and other stimulants; new psychoactive substances; opioids including heroin; and the non-medical use of pharmaceuticals. These are the drug types associated with the most harm in Australia.

Methamphetamines and Other Stimulants

Methamphetamine comes in a range of forms, including powder, paste, liquid, tablets and crystalline. Methamphetamines are part of a broader category of stimulants that also includes cocaine, and 3,4-Methylenedioxymethamphetamine (MDMA). Stimulants can be taken orally, smoked, snorted/inhaled and dissolved in water and injected. Some of the harms that can arise from the use of methamphetamines and other stimulants include mental illness, cognitive impairment, cardiovascular problems and overdose.

According to the 2016 National Drug Strategy Household Survey, 1.4% of Australians aged 14 years and over had used methamphetamine in the past 12 months. However, among those who use meth/amphetamine, the use of powder as the main form of the drug used decreased significantly from 50.6% in 2010 to 20.2% in 2016, while the use of crystal-methamphetamine more than doubled since 2010 (from 21.7% to 57.3% in 2016). There was also a significant increase in the percentage of users consuming methamphetamine daily or weekly (from 9.3% in 2010 to 20.4% in 2016). In addition, 39.8% of Australians identified methamphetamine as the illicit drug of most concern to the community (an increase from 16.1% in 2013). Violent behaviour is also more than six times as likely to occur among methamphetamine dependent people when they are using the drug, compared to when they are not using the drug.

In 2015, the Council of Australian Governments (COAG) released the National Ice Action Strategy (NIAS). The oversight of the implementation of the NIAS and the impact of measures will need to be a key priority of governments over the lifespan of the National Drug Strategy.

Alcohol

Alcohol consumption has resulted in significant fiscal and health costs in Australia. In 2010, the cost of alcohol-related harm (including harm to others) was reported to be $36 billion. Alcohol is also associated with over 5,000 deaths and more than 150,000 hospitalisations every year.

Alcohol related harm has a significant impact on Australian society with almost 250,000 Australians estimated to have been the victims of an alcohol-related physical assault in 2015-16. Alcohol also has an impact on frontline police and health workers, for example in Victoria in 2014-15 alcohol was by far the most common substance recorded for alcohol and drug related ambulance attendances with more than double the number of cases for all illicit drugs combined.

The consumption of alcohol during pregnancy can result in birth defects and behavioural and neurodevelopmental abnormalities known as Fetal Alcohol Spectrum Disorder (FASD).

The symptoms of FASD can persist into adulthood and can vary between individuals. The relationship between the consumption of alcohol during pregnancy and the expression of FASD is complicated as not all children exposed to high levels of alcohol during gestation are affected to the same extent. There is no accurate data available on the prevalence of FASD, and it is likelythat current estimates underestimate the prevalence in Australia. Research indicates that there are higher rates among Aboriginal people than non-Indigenous Australians and that certain groups such as children in out-of-home care and children in contact with youth justice services have higher rates of undetected FASD than the rest of the community.

Heavy alcohol use amongst parents is a significant cause of child neglect, lack of responsive care and understimulation. This is one of the major cause of unhealthy early childhood development for many children.

A new National Alcohol Strategy is under development, and is expected to provide a guide for governments, communities, organisations and industry for reducing the harms of alcohol on the Australian community.

Tobacco and Nicotine

Tobacco remains a significant cause of death and disability in Australia. Around 2.6 million Australians smoke and each year, smoking is estimated to kill almost 19,000 people. Tobacco smoking also carries the highest burden of drug-related costs on the Australian community.

Australia’s implementation of a range of multifaceted tobacco control measures has been effective in reducing smoking rates over recent decades, with daily smoking for those aged 18 years or older declining in Australia from 16.1% in 2011-12 to 14.5% in 2014-15. This decrease is a continuation of the trend over the past two decades.

However, challenges remain for tobacco, including addressing the inequality in smoking rates between some disadvantaged populations and the broader community. In 2014-15, 21.4% of people living in areas of most disadvantage smoked daily, compared with 8% of people living in areas of the least disadvantage. Recent estimates show that tobacco use is the greatest contributor (23%) to the gap in the disease burden between Indigenous and non-Indigenous Australians. Indigenous Australians were 2.5 times more likely to smoke daily (32% compared to 12.4% for non-Indigenous Australians) and approximately 32% of people reporting a common mental illness smoked daily, more than double the rate in the total Australian population.

Cannabis

Cannabis is a group of substances from the plant cannabis sativa and is available in three main forms: flowering heads, cannabis resin (hashish) and cannabis oil. It is usually smoked, either in a hand-rolled cigarette or through a water-pipe.

In 2016, 10.4% of Australians over the age of 14 had used cannabis in the last 12 months and 34.8% had used cannabis in their lifetime. As the most widely used of the illicit drugs in Australia, cannabis carries a significant burden of disease. The use of cannabis can result in various health impacts, including mental illness, respiratory illness, and cognitive defects. In particular, cannabis dependence among young adults is correlated with, and probably contributes to, mental disorders such as psychosis.

Non-Medical Use of Pharmaceuticals

The range of pharmaceutical drugs commonly used for non-medical reasons include opioids (such as oxycodone, fentanyl, morphine, methadone, pethidine and codeine), benzodiazepines (such as diazepam, temazepam and alprazolam), and other analgesics (such as paracetamol and ibuprofen in preparations combined with codeine) and performance and image enhancing drugs (such as anabolic steroids, phentermine and human growth hormones). The harms that can arise as a result of the use of pharmaceutical drugs depend on the drug used, but can include fatal and non-fatal overdose. Harms also include infection and blood vessel occlusion from problematic routes of administration, memory lapses, coordination impairments and aggression.

Opioids including Heroin

The negative health consequences of heroin and other opioids use include dependence, infectious disease transmission (primarily through risky injecting practice) and death from overdose.

Heroin use ‘in the last 12 months’ has declined from 0.8% in 1998 to 0.2% in 2016. However, Australia has seen an increase in the prescription and use of licit opioids. In particular, the supply of oxycodone and fentanyl increased 22-fold and 46-fold respectively between 1997 and 2012 and the number of prescriptions for opioid prescriptions subsidised by the Pharmaceutical Benefits Scheme increased from 2.4 million to 7 million between 1992 and 2007. Consistent with these trends, hospital separations associated with prescription opioid poisoning have increased substantially.

New Psychoactive Substances

New psychoactive substances (NPS) are a range of drugs that have been manufactured to mimic other illicit drugs such as cannabis, cocaine, ecstasy and lysergic acid diethylamide (LSD). They include, but are not limited to, synthetic cannabis, mephedrone and methylenedioxypyrovalerone (MDPV). While the effect of the drugs may be similar to other illicit drugs, their chemical structure is different and the effects are not always well known.

One of the principal concerns with the use of NPS is that the products, and their chemical compounds or makeup, are constantly evolving. The rate at which NPS are emerging poses challenges for health and law enforcement responses, as well as traditional scheduling methods for illicit drugs.

The toxicity of each drug is also not often well understood and can be harmful in microgram quantities. The use of NPS is often linked to health problems. NPS users have frequently been hospitalized with severe intoxications. There have also been a number of unexplained suicides associated with preceding use of NPS. In addition, substances like 4-methylmethcathinone (mephedrone), methylenedioxypyrovalerone (MDPV), 4-methylamphetamine (4-MA) have been associated with fatalities. Domestically, several Australian states have moved quickly to place controls on the manufacture, sale and marketing of NPS, in light of the identified risks to public health.

In 2015, the Australian Government introduced laws to ban the importation of NPS on the basis of their psychoactive effect or appearance, rather than their chemical structure. These laws protect against untested and potentially dangerous substances being imported into Australia for use as alternatives to other illicit drugs.

Appendix – Examples of Evidence-Based and Practice-Informed Approaches to Harm Minimisation

Demand Reduction

Tobacco

Approach	Strategies
Price mechanisms	Excise tax increases
Build community knowledge and change acceptability of use	Sustained, high volume social marketing campaigns that encourage tobacco cessation Labelling and health warnings
Restrictions on promotion	Plain packaging Advertising bans Retail display bans
Treatment	Cessation support counselling Pharmacotherapies Subsidised medications, including smoking cessation aids

Alcohol

Approach	Strategies
Price mechanisms	Excise tax increases Volumetric excise tax Minimum floor price Regulate price discounting and bundling
Build community knowledge and change acceptability of use	Social marketing strategies, including campaigns, as part of a comprehensive response Promotion of National Health and Medical Research Council’s Australian Guidelines to Reduce Health Risks from Drinking Alcohol
Restrictions on promotion	Enforced advertising standards and restrictions Regulate price promotion Regulate promotion at point of sale Regulate promotions in key settings, such as those aimed at young people
Treatment	Outpatient, inpatient and community based treatment services Medication assisted treatment for alcohol dependence Family-support programs that can positively impact on patterns of drug use (including intergenerational patterns) Post treatment support programs to reduce relapse

Illicit and Illicitly Used

Approach	Strategies
Price mechanisms	Influence the market price of illicit drugs by law enforcement and border control activities
Build community knowledge and change acceptability of use	Targeted social marketing campaigns as part of a comprehensive response Peer education networks
Treatment	Outpatient, inpatient and community based treatment services Medication assisted treatment of opioid and other drug dependence Access to community pharmacies and GPs for drug treatment to support both community participation and long term treatment outcomes Family-support programs that can prevent patterns of drug use (including intergenerational patterns)
Diversion	Diversion from the criminal justice system to treatment services

All Drugs

Approach	Strategies
Build community knowledge and change acceptability of use	School programs, policies and curriculum Support programs targeting life transition points Build parenting and family capacity to support the positive development of children Social competence training Increased engagement in community activity (education, employment, cultural, sporting)
Treatment	Assessment and brief intervention by GPs, nurses, allied health professionals and in other settings Treatment guidelines that support evidence based approaches
Targeted approaches to priority populations, including Aboriginal and Torres Strait Islander people	Supporting the Aboriginal Community Controlled sector to provide treatment services within and for Aboriginal communities Capacity building for health services and training for key workers Targeted social marketing strategies
Social determinants of health	Address underlying determinants of alcohol, tobacco and other drug problems for individuals, communities and priority populations
Workforce	Building the capacity of the workforce to deliver services and respond to emerging issues

Supply Reduction

Tobacco

Approach	Strategies
Regulating retail sale	Retail licensing schemes, supported by strong enforcement and retailer education Restrictions on temporary outlets and vending machines Detect and disrupt sales of prohibited products
Age restrictions	Ban sales to people under 18
Border control	Interrupt illegal importation and enforce payment of excise tax Duty free restrictions
Regulating or disrupting production and distribution	Regulating production Regulating wholesaler distribution Detect and disrupt illegally grown or produced products

Alcohol

Approach	Strategies
Regulating retail sale	Retail licensing schemes supported by strong enforcement and retailer education Coordinated medication management system Restricting the type of retailers or venues that can sell Limiting the density of licensed retailers and venues Limiting trading hours Responsible alcohol service schemes Liquor licensing restrictions Detect and disrupt sales of prohibited products Declaration of dry communities Lower strength alcohol sale requirements
Age restrictions	Ban sale to people under 18 Secondary supply restrictions
Border control	Interrupt illegal importation and enforce payment of excise tax Duty free restrictions
Regulating or disrupting production and distribution	Regulating production Regulating wholesaler distribution Detect and disrupt illegally produced products

Illicit and Illicitly Used

Approach	Strategies
Regulating retail sale	Licensing schemes for pharmacists, veterinarians and other health professionals that sell pharmaceuticals Coordinated medication management system Electronic prescriptions to minimise the risk of dispensing errors and fraudulent alteration of prescriptions Substitution of low aromatic fuel in vulnerable locations for volatile substance abuse
Supporting workers at the point of supply	Supporting workers at the point of supply of licit drugs, chemicals and equipment to reduce their misuse or diversion Real time reporting of prescribing and dispensing events
Age restrictions	Restricting sale of volatiles to people under 18
Supporting prescribers and dispensers	National guidelines for treatment of conditions commonly indicated in problematic use Professional peer review mechanisms Increase training and support for prescribers and those at the point of supply of pharmaceutical drugs to reduce the inappropriate supply, misuse and diversion Provide and promote use of Medicare Benefits Schedule items that remunerate and target medication review and non-pharmacological management of certain conditions Increase training and support for those at the point of supply of pharmaceutical drugs to reduce the inappropriate supply, misuse and diversion Real time national monitoring of precursor chemicals and equipment
Border control	Prevent or disrupt transnational supply of prohibited substances and precursors
Regulating or disrupting production and distribution	Prevent, stop, disrupt or reduce production and supply Disrupt and dismantle criminal groups involved in production, trafficking and supply of illicit drugs and precursors Target financial proceeds and the confiscation of assets arising from illicit supply activities Regulate the legitimate trade of pharmaceuticals, precursors and equipment used in the manufacture of illicit drugs
Enforcing legislation	Asset confiscation Search, seize and destruction powers

All Drugs

Approach	Strategies
Regulating or disrupting production and distribution	Regularly review legislation and scheduling to capture emerging substances, production mechanisms, devices and distribution methods Timely enforcement of legislation with meaningful penalties Implement Australia’s obligations under international treaties
Intelligence	Cooperation and collaboration between law enforcement and forensic agencies, across jurisdictions Build and maintain strong relationships with international partner agencies and bodies Gather intelligence on all aspects of drug supply markets including identifying emerging drugs and manufacturing techniques Effectively utilising trend monitoring and data collection
Workforce	Building the capacity of the workforce to deliver services and respond to emerging issues

Harm Reduction

Tobacco

Approach	Strategies
Safer settings	Smoke-free areas
Smoking cessation aids	Nicotine Replacement Therapy

Alcohol

Approach	Strategies
Safe transport and sobering up services	Sobering up facilities Mobile assistance patrols
Safer settings	Access to public transport Promotion of responsible venue operations Dry areas Mandatory plastic glassware in high risk venues Availability of free water at licensed venues Lock out times Emergency services responses to critical Incidents Maintenance of public safety

Illicit and Illicitly Used

Approach	Strategies
Safer settings	Chill-out spaces Availability of free water at licensed venues Information and peer education Emergency services responses to critical incidents Maintenance of public safety
Diversion	Diversion from the criminal justice system to treatment services
Blood borne virus prevention	Hepatitis B vaccination BBV and STI testing, prevention, counselling and Treatment  Peer education
Safer injecting practices	Diversity and accessibility of needle and syringe programs Medically supervised injection centres and drug consumption rooms Peer education Prevent and respond to overdose including increased access to naloxone Police policy to exercise discretion when attending drug overdoses Non-injecting routes of administration
Replacement therapies	Pharmacotherapy for opioid maintenance and other drug use

All Drugs

Approaches	Strategies
Periods of increased risk	Programs to reduce alcohol, tobacco and other drug use during pregnancy Peer education and support
Reduce driving under the influence of alcohol or other drugs	Random drink and drug driver testing Zero blood alcohol concentration requirements on novice drivers Penalties and intervention programs for recidivist drink or drug drivers
Workforce	Building the capacity of the workforce to deliver services and respond to emerging issues

The Strengths Perspective

The strengths perspective, which cannot be considered a theory because it lacks explanatory power, is a way of perceiving people in their struggles to rise above difficult circumstances. In combination with the empowerment theoretical perspective, the strengths approach is the predominant approach in social work today. Positive psychology that focuses on well-being and resilience is a parallel perspective that is achieving a large following in psychology. Positive psychologists such as Biswas-Diener (2010) focus on mental health rather than mental illness and working with clients collaboratively to recognize and reinforce strengths and in so doing “to promote energy, effectiveness, productivity, and a sense of meaning” (p. 38).

Like the harm reduction approach, the strengths perspective is decidedly pragmatic. The word pragmatic is used here in the dual sense of being realistic and having relevance to direct practice. Of what use is theory, after all, without practical application? The focus on the strengths perspective in the treatment of addicts and alcoholics, accordingly, is not chosen because of some ideology of “looking at the bright side of things.” Rather, it comes from the practical understanding that a focus on capabilities rather than defects fosters hope (where there is despair), options (where there is a perceived dead end), and increased self-efficacy (where there is a feeling of helplessness). In her review of the literature on strengths-based treatment, Cynthia Franklin (2015) reviewed updates on the scientific research. She found that the studies show that the strengths-based model performs as well as other psychotherapies, such as cognitive-behavioral therapy, in treating depression. In mental health school settings, child protection, and youth and family services, this client-centered approach has been found to work especially well as in the substance use treatment field with adult mental health clients with mild substance use issues. Chapter 8 addresses the specifics of strengths-based therapy with addictive populations and describes interventions directed at the individual, group, and community levels.

Related to the strengths perspective is the motivational interviewing approach originally introduced by psychologist William R. Miller. For working with people with addiction problems motivational psychologists, such as Miller, emphasize bolstering client self-efficacy. This is done, they inform us, in normal conversation through exploring successful changes the clients have made in the past. Mobilizing clients’ own strengths and social support systems are important, Miller & Rollnick (2013) suggest, in promoting rehabilitation and recovery maintenance.

Motivational interviewing is defined by Miller and Rollnick (2013) as “a collaborative conversation style to strengthening a person’s own motivation and commitment to change” (p. 12). In their recent formulation, the authors emphasize the spirit of this approach as its most important aspect. This spirit is evidenced through collaboration with the client, acceptance, and compassion. Compassion is defined by Miller and Rollnick as a deliberate “commitment to pursue the welfare and best interests of the other” (p. 20). This spirit, which is central to the way that this therapeutic technique is taught and utilized, is best described by the notion that motivational interviewing is done with someone, as opposed to something that is done to someone (Smith, 2015).

One other discipline turning toward the use of strengths-based concepts to help people turn their lives around is criminology. Admittedly in its infancy, a form of positive criminology is being developed, according to Israeli social scientists Ronel and Elisha (2010). A new conceptual approach, positive criminology is geared to the study of “factors that may help at-risk individuals desist from deviance and crime” through positive experiences and connections (Ronel & Elisha, 2010, p. 306). In the introduction to their groundbreaking book, Positive Criminology, Ronel and Segev (2015) state that “rather than focusing on negative causes, consequences, and risks, positive criminology suggests placing emphasis on integrating and unifying forces that enhance the good [in people]” (p. 4).

In all these disciplines, the strengths perspective is primarily a philosophy or way of interpreting information about bio-, psycho-, and social factors in people’s lives that are forces for the good. These belief systems link human flourishing to following humanistic values and are rooted in Aristotle’s writings on human striving to reach one’s potential (Gray, 2011). In therapy, Carl Rogers operated from the premise that a nondirective, nurturing relationship would bring out the best in people. Similarly, the strengths perspective in social work favors an inductive approach whereby insights emerge through relationships with clients and the stories they tell (Gray). This approach to client treatment was pioneered and popularized through the writings of Dennis Saleebey (1992) and Charles Rapp (1998) in their books The Strengths Perspective in Social Work Practice and The Strengths Model: Case Management with People Suffering from Severe and Persistent Mental Illness, respectively.

Although there is much overlap between traditional and strengths-based approaches to the conceptualization of substance disorders and the treatment thereof, for the sake of distinction, we have constructed Table 1.1. Concepts from traditionally based treatment are derived from van Wormer’s alcoholism treatment practice experience with this 12-Step approach, from White’s (1998) history of substance abuse treatment, and from Peele and Bufe’s (2000) critique. On the opposite side of the table, we list concepts central to the strengths perspective as drawn from the writings of Saleebey (2011, 2013), Rapp and Goscha (2012), and Miller & Rollnick (2013).

Table 1.1 Comparative Approaches to Addiction

	Traditional Counselling Approach	Strengths-Based Therapy
Biological	Looks to the individual for specific causes of disease	Stress on multiple, interactive levels of influence
	Dichotomises reality, for example, alcoholic vs. non-alcoholic	Addiction-like behaviours seen as existing along continuum
Psychological	Problem focused	Strengths focused, looks to possibilities
	Uses labels such as alcoholic, codependent	Tries to avoid use of negative labels
	Assesses problems and losses	Assesses and builds on strengths
	Client seen as typically resistant, in denial	Client seen as active participant in collaborative, health-seeking effort
	Client motivation unimportant	Intervention geared to level of client motivation to change
	Focus to prevent slip or relapse	Focus to maintain moderation or abstinence as client wishes
	Expulsion from treatment for relapse	Client self-determination stressed; meet client where he or she is
	Uses confrontation to elicit change	Rolls with the resistance, redefines resistance as challenge
	One size fits all	Individualised treatment stresses client choice
Social	Encourages identity as member of self-help group	Holistic approach
	Identifies pathologies from upbringing in chemically dependent home	Seeks strengths in upbringing
	Looks for codependence in family members	Perceives family as potential resource

As an inclusive approach, the biopsychosocial framework allows us to use the learning developed across disciplines and to employ a strengths-based approach to work with addicted individuals, their families, and communities (Corrigan, Bill, & Slater, 2009). Whereas the biopsychosocial-spiritual model helps us gain a holistic understanding of the roots and intransigence of addiction, the strengths perspective is geared toward direct practice, although it can shape our appreciation of particular treatment modalities (or aspects of these modalities) as well. This perspective represents a paradigm shift away from the treatment industry’s emphasis on psychopathology, disease, and disorder, a focus on personal deficits rather than resilience. Harm reduction alone is not enough; the client caught in the mire of addiction and personal pain needs help in developing a healthy outlook on life and even a dramatically altered lifestyle.

Given the horrendous grip of addiction for certain individuals—the self-defeating behavior, guilt feelings, broken relationships—it is clear that the treatment modality used must offer hope and a way out of the morass of the addiction cycle. Hope, guidance, and relationships are three key ingredients in successful recovery. Finding a spiritual connection can help tremendously as well.

Although most recovery does not stem from formal treatment, the incentive for sobriety can very well be an outgrowth of a treatment experience. And for the family of the person with an alcohol or other drug problem, family counseling can be a lifesaver.

The strengths approach, as its name implies, builds on clients’ strengths and resources. This is “a versatile practice approach, relying heavily on ingenuity and creativity, the courage and common sense of both clients and their social workers” (Saleebey, 2013, p. 1). The root principles of strengths-based practice are disarmingly simple, as Saleebey (2011) indicates, but they are difficult to put into practice “because they run counter to some of the thinking that characterizes some practices and agency mandates today” (p. 482). Traditionally, work in the substance abuse field has focused on breaking client resistance and denial (Rapp & Goscha, 2012). According to this more positive framework, however, client resistance and denial can be viewed as healthy, intelligent responses to a situation that might involve unwelcome court mandates and other intrusive practices.

Themes in Recovery

The treatment of addictive disorders differs from other mental disorders, in that it has historically required one to give up completely a valued part of one’s daily life (Slutske, 2010). Perhaps this is why recovery is more common for addictive than for other mental disorders because it is, to a greater degree, more under the individual’s control. When a person with alcoholism stops drinking without getting treatment, it is called natural recovery. A study of such recovery is vital to treatment research so that we can discover what works. Because we now recognize, based on studies such as the comprehensive National Epidemiologic Survey on Alcohol and Related Conditions, that most recovery is natural recovery, the people we need to study are those whose recovery took place without any formal treatment or membership in a self-help group (Slutske, 2010). Respondents to the survey stated that they were strong enough to quit drinking on their own, or wanted to do it at their own pace. Perhaps from them, we can learn about the process by which they managed to control their consumption. We can ask the same research question of former smokers: What is the secret of their success? In the past, research has focused on the most severely addicted populations—people who sometimes went through treatment programs several times before they could shake the destructive habit.

Here is a summary of the findings of the National Epidemiologic Survey. The highest risk for alcohol use disorder was found among people without advanced education, at lower socioeconomic levels, and among those with co-occurring mental health and personality disorders. The findings indicated a lower risk for black, Asian or Pacific Islander, and Hispanic than white or Native American respondents. Factors associated with recovery included participation in a 12-Step group, a brief intervention at an early stage of problems, use of effective medication at the most severe levels of alcohol use disorder, and receiving cognitive behavioral or motivational enhancement therapy.

Information on such factors associated with what is sometimes termed natural recovery can be used to improve the prospects for treatment. From the reverse standpoint, through identifying those subpopulations at greatest risk for a particular alcohol-related problem, public health professionals can target prevention strategies to intervene early to prevent more serious problems from developing. But we still have a lot to learn for more effective preventive work.

Researchers at the Center for Addiction and Mental Health in Toronto, in a review of the findings in the treatment literature on the prevalence of self-change efforts, concluded that most of the people who are in trouble with alcohol and other drug use can successfully reduce their consumption to much more acceptable levels and do this on their own (see Arkowitz & Lilienfeld, 2008; Slutske, 2010). And natural recovery may be preferable to formal treatment for an addictive disorder because one can quit at his or her own pace or even reduce one’s use, rather than quit completely. Self-change for addictive disorders may become less common, as Slutske suggests, when treatment approaches that offer a broader range of treatment goals become more widely available.

The strengths perspective is highly consistent with such a research approach, which is geared toward an investigation of what people do right—how they protect themselves— rather than what they do wrong. This approach, moreover, does not entail set rituals or dogma but is informed by certain basic principles that transcend treatment modality or style. To learn about how recovery is conceptualized from this perspective, we can turn to Rapp and Goscha’s (2012) text on the strengths model for case management. Six critical elements are singled out by these authors as conducive to recovery. These are (1) identity as a competent human being; (2) the need for personal control or choice; (3) the need for hope; (4) the need for purpose; (5) the need for a sense of achievement; (6) and the presence of at least one key supportive person. The experience of illness and recovery is unique to each person, but these common themes emerge in the stories of recovery. Although Rapp and Goscha’s focus was on mental illness, these recovery themes pertain equally well to all biochemical disorders. In the following pages, we draw on firsthand narrative accounts to illustrate each of these strengths-based recovery themes.

The first critical element of recovery, which has important implications for treatment, occurs when the person moves from an all-consuming identification with the illness to a position of managing the symptoms of the disorder. From a harm reduction perspective, Brad Karoll (2010) contends that for many seeking recovery, “labeling oneself only continues to erode one’s self-esteem, self-confidence, and self-efficacy” (p. 275). Accordingly, Karoll recommends that clinicians and persons affected focus on the premise that one has an alcohol or drug disorder rather than that the person is the disorder; terms such as addict and alcoholic, therefore, should be avoided in favor of terminology indicating a person has a particular disorder. The National Association of Social Workers (NASW) has issued a strong policy statement on the subject: “‘Disease first’ language, as opposed to ‘people first’ language, obliterates individual differences and depersonalizes those to whom the label is applied” (p. 25).

Sometimes sobriety brings with it a change in identity that can be inferred through one’s behavioral changes. Consider this description of John Cheever, a famous writer, by his daughter Susan Cheever (1999), who observed the following change in her father upon his return from treatment:

The second theme concerns the need for personal control, or choice. As we hear from a former methamphetamine addict, “four years clean and sober,” whose family had earlier disowned her:

Social work professor Michael Beechem (in personal correspondence with van Wormer of August 26, 2015) shared that he had tried AA to no avail and eventually was referred by his college administrator for treatment. This is how he maintains his sobriety:

Choice is the hallmark of the harm reduction model; its task is to help clients find their own way and to carve out their own paths to sobriety. In Britain, this is the predominant model for treatment, considered to be the most effective with young persons who express willingness to work on controlling their drinking and other drug use. The focus is on prevention, not cure. In his textbook, Understanding and Working with Substance Misusers, Aaron Pycroft (2010) of the University of Portsmouth in England discusses how a client-centered strategy would work. In practice, we must be agents of hope. In the early stages of treatment, a harm reduction approach is more appropriate than a requirement for abstinence, Pycroft suggests, as the latter may deter people from seeking help. “The client centered approach is obviously in keeping with a working relationship that seeks to build motivation rather than impose it” (p. 113).

Ralph Campbell, a substance abuse counselor from Minnesota, similarly tells us:

The third theme, hope, is a quality emphasized throughout the literature on substance abuse counseling. Without hope, of course, there can be no effort on working toward a meaningful goal. At the societal level, as Saleebey (2013) informs us, the strengths-based counselor’s goal is forever searching the environment for forces that enhance human possibilities and resiliencies. Rather than focusing on problems, your eye turns toward possibility. “Like social caretaking and social work, the strengths perspective is about the revolutionary possibility of hope: hope realized through the strengthened sinew of social relationships in family, neighborhood, community, culture, and country” (Saleebey, 2013, p. 8). Saleebey stresses the power that stems from membership in community organizations. Membership in mutual support groups such as AA offers hope to alcoholics through the fellowship of shared experience. Sayings such as “I can’t do it alone, but together we can” reinforce the strength of mutual help.

A sense of purpose is the next critical ingredient in recovery. Many of van Wormer’s clients expressed a sense of purpose or meaning, saying, in essence, “Now I know this all happened for a reason. So I could help people who are going through the same thing.” The 12th Step of AA involves taking the message of what has been learned to others. As people hear personal stories from others who have achieved sobriety and a happy outlook on life, they too may think change is possible.

Spirituality is a cornerstone of the many mutual-support groups, a connection with a Higher Power that gives life meaning. Pat Coughlin, a substance abuse counselor from Marshalltown, Iowa, who once suffered from multiple drug addictions (including meth and cocaine), describes the change that came over his life following a bar fight. In inpatient treatment for the third time, Coughlin says:

A sense of achievement is a healthy counterpart to wrestling with the feelings of grief and loss that accompany the early period of recovery. Common types of achievement listed by Rapp and Goscha (2012) are helping others, personal success at work, and self-expression through hobbies and/or the arts. In reflecting on his life, Coughlin, the speaker in the preceding passage, described how his sister, so estranged from him in the past, now has turned to requesting help with her daughter who has started to drink. “To go from a drug-dealing nothing to being called to help with a drinking child—that is the miracle of AA, the power of The Program.”

The final element in recovery delineated by Rapp and Goscha is the presence of at least one key person—a friend, professional helper, teacher, or family member. This element parallels the focus on relationship in all client-centered therapies (see Carl Rogers, 1931, for the classical formulation). Genuineness, empathy, and nonpossessive warmth are the key components of the effective therapeutic relationship. Through warmth (and caring), many tough-minded spokespersons from AA, NA, or GA (Gamblers Anonymous) have guided the seemingly most recalcitrant addict through the rough periods of early sobriety. Whatever the personal style of the helper, it is sincerity and caring that are key. Central to all these stories of recovery is the theme of personal empowerment. Both harm reduction and mutual-help programs are based on a voluntary commitment to change. The greatest weakness of The Program—its dogmatism—is possibly also its greatest strength. The Program gives people, who are highly vulnerable and clutching for support something concrete, something more faith-based than scientific, to latch on to. One is hard put to fault the kind of personal support that so many recovering alcoholics and other drug addicts have derived from what is commonly referred to as The Program (see Chapter 11 on mutual-help groups for an in-depth analysis).

For persons with co-occurring disorders—those with both substance use and mental health disorders—a more flexible approach than one based on total abstinence may be required (Green, 2015; Mancini, Linhorst, Broderick, & Bayliff, 2008). Many persons with co-occurring disorders are unable to negotiate the demands of highly structured, abstinence-only programs, a fact that results in low retention rates in such programs. Harm reduction approaches are therefore essential for persons of such high vulnerability. Still, only one in seven persons who have both a substance use disorder and only one in three of persons with a mental health disorder receive the treatment they need (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). According to the SAMHSA website, 21.2 million Americans ages 12 and older could have benefited by treatment for an illegal drug or alcohol use problem in 2014. Although most of these people did not wish to have treatment, lack of access was a problem for many others. And we also know from surveys that around 45% of Americans seeking substance use disorder treatment have been diagnosed as having a mental health disorder; this indicates that the presence of co-occurring disorders is common. Of those who do get treatment, most receive mental health treatment only, and only a fraction receive integrated treatment geared to their special needs.

Within this context, the work of clinicians such as Catherine Crisp (2011) is rare. Crisp differentiates chemical dependence theory, which takes “a hard-lined approach,” from mental illness theory, which stresses client nurturance. The following passage describes the approach that she has found most effective when working with clients with co-occurring disorders:

Rosenberg and Davis (2014) surveyed 432 members of a national addiction counselor organization online to gauge their attitudes toward nonabstinence-based treatment goals. They found that when set as an intermediate goal, almost half of the respondents were positive for clients diagnosed with alcohol abuse or cannabis abuse than for clients using the harder drugs. As far as a final goal for clients, the respondents rated nonabstinence as acceptable for alcohol misuse (30%) and cannabis misuse (24%) and much less for other drugs. Few believed that moderate use of an addictive substance was appropriate for clients who were addicted to that drug, but 20–30% viewed such use as acceptable in the short-term. These results reveal a shift in thinking from previous years in the direction of counselors being much more open to harm reduction approaches. Rosenberg and Davis suggest that individuals with alcohol and drug problems who avoid treatment because they are ambivalent about abstinence should know that their interest in moderating their consumption will be acceptable to many clinicians, especially those working in outpatient and independent practice settings.

The shift in thinking toward acceptance of less traditional, more pragmatic approaches is closely related to familiarity with the harm reduction model. Fillmore and Hohman (2015) surveyed 259 students of social work and a comparison group of 30 substance abuse counselors working in a drinking-and-driving program. They found that the social work students were less accepting of alternative treatments than were the substance abuse counselors. Their explanation was that many of the students were unfamiliar with the philosophy and methods of harm reduction. The social work curriculum needs to be expanded to include education regarding effective methods of substance abuse treatment to reach people who are put off by a one-size-fits-all, total abstinence approach.

Masters of Incarceration

Chris Sheppard, Effective AOD transition worker

I first entered the justice system as a person who used amphetamines; I left as a person using opiates. In a unit of 50 men with a fair percentage of people using gear, there might have been two syringes in the whole unit—catching a blood borne virus was a certainty. There seems to be a big gap—which I take as political reasoning—between harm minimisation in the justice system, with inmates having no access to needle syringe programs, compared to the amount of money being spent on treatment inside for hepatitis C.

The justice health system was hit and miss. It was always a long wait to see a health worker after you put a request form in. Sometimes the request form didn’t even make it to the health services, adding to your anxiety and frustration, while the reason you wanted to see a health worker would escalate. Sometimes to the point where people become very unwell, to even losing their life.

A lot of people in prison have been victims of crime as children, but there never seemed to be any therapeutic services in prison to deal with such issues, and if there is, they are few and far between. People are ordered into doing group work and sometimes a person’s trauma just does not allow them to sit comfortably in groups. There is an overpopulation of people living with trauma in prison and no one to help people to address what is going on for them around this. I had been living with trauma from when I was a ten-year-old boy into my early forties before I even knew what the word trauma meant. You are constantly triggered by staff in correctional centers who don’t understand the effect trauma has on people.

There seems to be sayings like ‘that’s how it was back in the day’, ‘child abuse was a common thing’, ‘DV was as common as having dinner’, ‘it’s just how it was’. But abuse that happened 40 years ago, no matter what excuses people say, is abuse, just as it is for someone to go through now. People need to be treated with dignity and respect and given the chance to heal no matter their age, race or gender.

People often come out of prison in good health with certificates of some training they did inside, but they face a lot of barriers when trying to find work. Housing needs to come first so people can feel safe, clean and feed themselves, so they can be healthy enough to find or go to work. We need programs to be funded and run that are big enough to support people upon their release to get them into work, as well as using these same programs for an alternative to sentencing a person to prison.

My advice for services supporting people post release from custody is:

• Be bloody patient. Yes, we need to understand trauma and how it works and the effect it has on a person, but we need to understand the person we are working with EQUALLY, to how we understand what trauma means.
• Put yourself in their shoes and ask yourself, ‘How would I feel if I had to go through this—what effect would this have on me?’ ‘How does a lifetime of disconnection from community affect a person?’ ‘What have they gone through to get to using ice or other drugs?’ Because then you will understand more about the person and their drug use and how to best support them.
• Reassuring a person that you are there for them and that you care for them is as important as lifesaving medication in my books.
• Make referrals that suit the person’s needs and follow up with the service after making the referral. Build solid relationships with other services and workers, like GPs prescribing opioid treatment, the pharmacists who are dosing people in your area, and staff in government drug health clinics.

I am now working as an effective AOD transitional worker. Unfortunately, there is a stigma that comes with the title of a peer worker in our sector. I believe it is good for people like myself and all of the others out there that have done their PHD of lived experience, to be known for what we actually do, and how effective we are at supporting people in the community to rebuild and restore normality and peace in their lives.

The Female Experience

Jenny Valentish and Rosemaree Miller, NADA

Over the last decade, less than 40% of Australian clients receiving treatment for their own substance use identified as female. On the surface, this uneven ratio of female to male clients could suggest that more men than women experience problematic substance use in Australia. However, a growing body of evidence indicates that there are differences in the experience of problematic substance use for individuals who are female or male. Moreover, an individual’s gender may also impact the trajectory of their recovery from problematic substance use.

In her 2017 book, Woman of substances, Jenny Valentish explores the female experience of AOD use. In this research-memoir hybrid, Jenny artfully intertwines discussion of her own experiences with the factors known to contribute to problematic substance use for individuals who identify as women. I sat down with Jenny to discuss some of the social determinants that affect the female experience of AOD use, and how this knowledge can be used to inform treatment, evidence based practice and research in the non-government service sector.

How is the female experience of AOD use unique, and how does this impact women in treatment for problematic substance use?

• Experience of trauma: ’Nothing is completely unique to women in treatment; however, women are perhaps more likely to have experienced sexual trauma.⁵ So, that means if there are no gender specific treatment options, talking about traumatic experiences in a mixed setting can be uncomfortable for women in treatment.’
• Child-care responsibilities: ’Even if a woman is in a stable relationship when she has children, she may still be discouraged from seeking help because of childcare responsibilities. A woman could initially engage in treatment, but she may not be able to sustain this if, say, her partner or family are unable to assist with child-care. Alternatively, she might feel that leaving her children with a partner, or even her family, is not a safe option.’
• Eating disorders: ‘Eating disorders and substance use go hand in hand, especially for women. It’s quite hard to find treatment services that tackle both at once. If these comorbid issues are severe, it can mean that some people may fall between the cracks. Is a detox ward going to take on a client who needs to be properly fed and monitored for their eating disorder? And how likely is it that an eating disorder ward would take on a client who is in withdrawal? In either scenario, the client might feel they have to lie and pretend that the withdrawal, or the eating disorder, isn't happening, which can be dangerous.’
• Stigma around substance use: ‘There’s a lot of judgement around female clients, especially mothers, which can lead them to conceal their drug use a lot more. This can create what’s called ‘telescoping’, when it appears that women become addicted much faster than men. In actual fact, that severity of dependence could be partly because some women conceal their substance use for a longer time before seeking treatment.’

What are three ways in which services could better support their female clients in treatment?

• Provide gender-sensitive treatment: ‘I think there need to be options available for women to seek women-only treatment, and there are options, but there aren’t enough— particularly if you have a child that you need to have with you. It’s harder to find that kind of service. Treatment is usually considered to be gender-neutral, but is this true if the experiences of men are used to judge what is normal? Because more men than women are in treatment as a direct result of there being more barriers for women to access treatment than men, so, unfortunately, any statistics you get from treatment services can feed into the old idea that substance use is primarily a male problem.’
• Ensure trauma informed care is available: ‘Staff would need to understand that women who have reached the stage of needing treatment are very likely to have experienced cumulative trauma. Not understanding how cumulative trauma works can make it harder for staff to support female clients. Say, if you’ve experienced sexual abuse as a child, and then start using drugs to self-medicate, you might increase your likelihood of being in unsafe situations. This can lead to the mindset where an individual may think they are a bad person, and that bad things always happen to them. When, in fact, the way cumulative trauma works is that when you add something like drug use to the experience of trauma, that itself predisposes an individual to being preyed upon by opportunists and predators.’
• Practical support with safety and resources: ‘The woman’s safety has to be a priority. Use your discretion and take any safety concerns she may have seriously. Be careful with the privacy of these clients and if there isn’t an option for trauma informed care at your service, then refer the woman to an appropriate service that can provide this care. It is important to make the referral process as streamlined as possible, though. A woman may be juggling child-care with other responsibilities while seeking treatment, and she may not be able to follow up with more than one referral at a time, particularly if she’s being bounced around town.’
• Summary and next steps: Individuals who identify as women, men or another gender face many of the same challenges when receiving treatment for problematic substance use. However, considering some of the social and practical barriers that women may face in accessing treatment could improve the retention of female clients with your service. You can achieve this by creating an environment in which female clients will be more likely to engage with and continue their treatment.

There’s No Place like Home

Michelle Ridley, NADA

Every night, almost 120,000 people are homeless in Australia. Before COVID-19 there were already 50,000 people on the waitlist for social housing in NSW, and with unemployment growing due to its impact, an increasing number of people will become at risk. This predicted rise is overwhelming to consider, because homelessness was already one of the main issues impacting people’s access and retention to AOD treatment in NSW.

In NSW, people are most likely to experience homelessness due to domestic and family violence, accommodation issues (housing crisis, inadequate or inappropriate dwellings) and financial difficulties (housing stress, unemployment). Research suggests that around 60% of these people had no problematic drug use issues before they were homeless. Therefore, as AOD workers, we cannot just focus on the person’s drug use. We need to also explore and support them with their educational outcomes, housing situations and income, as it is these conditions, in which they are born, live and age, that are most significant.

So considering all this, I asked practitioners working on the frontline with people experiencing homelessness for practice advice. And also, ways that we, as community members, help change the housing crisis in NSW.

Elizabeth Gal, Peer Practice Leader at Neami National, suggests: Validate what a client is experiencing and acknowledge that the system may not be set up in a way that currently works for them. This is really important to acknowledge, because from my own personal experience, feelings of low self-worth can come with trying to make changes and having so many barriers in the way.

Being patient with clients and meeting them where they’re at, rather than trying to force my goals. At the same time though, it’s important to have the tough conversations, and I tell my clients what I’m seeing and how I believe they can have/do something different when they’re ready.

Focus on a client’s strengths. Most of the time they don’t see their own strengths, quite often because they use them in ‘negative’ ways. When I’m able to pull a strength out of a ‘negative’ story I’ve been told, clients value that so much.

David Chivers, Senior AOD Transition Worker at Community Restorative Centre, suggests: Be realistic and help your client understand how challenging things can be. We want to engender hope for our client but there are many myths circulating, that gaining social housing can be easy, particularly for people leaving prison. Gaining safe and secure accommodation can be extremely challenging. We try our best to prepare clients for this reality (before their release from custody, where possible), whilst reassuring them that we will be there to assist them in any way possible.

Encourage flexibility. We encourage clients to consider all options available to them. We try to help clients make informed decisions. For example, clients often say they don’t want to consider a boarding house because they’ve heard bad things about them, particularly in relation to the prevalence of drug use. Yet, there are some very good boarding houses and they are certainly preferable to some temporary accommodation places.

Share the responsibility. We encourage clients to persevere. We support them to ‘knock on every door’ possible by completing referrals (we help complete paperwork if needed) and making calls with them. There are services that can help and being persistent in asking for their support is crucial. We don’t do everything for the clients, There's no place like home continued cc by 2.0 Media Evolution rather we empower them to take responsibility and action. We also reassure them that we’re not just leaving them to deal with this alone. Often ‘just being there’ as someone to listen to them can be extremely valuable as well.

And advice for how we can, as community members, help to change this situation?

We can open up solutions based conversations around this topic, in as many arenas as possible. Have conversations with people who don’t necessarily agree that people who experience drug dependence should have housing support, find out what their reasons are, ask them what they think will work and speak to the facts of those reasons, to show them evidence that points differently to how they’re thinking. This is just a small starting point but the more that we talk about it, outside the usual circles, and continue to do so consistently, eventually politicians will have to listen, as it will be on people’s minds when it comes time to vote (Elizabeth Gal, Peer Practice Leader, Neami National).

Released into homelessness By Dale

I was once homeless, unemployable, and whether real or imagined, isolated from society. The hopelessness that I felt led to depression, and very quickly, a dependence on illicit drugs. I was soon financing my habit through crime, and was subsequently arrested, convicted and sentenced to 10 years imprisonment. My last sentence was the seventh or eighth time I had returned to prison for drug related crime, and while it would be convenient to attribute my recidivism to drug use, the truth of the matter was that I felt trapped and disempowered. I wanted help but had no idea how to ask for it, or whether or not help even existed.

Accommodation provides people with security and peace of mind. The data shows, however, that around 4000 people are released from NSW prisons each year into relative homelessness. They are being released with two nights’ emergency accommodation and a social security payment amounting to $550. While it may be possible to feed and clothe oneself on this amount, it is quite simply not enough to pay for three weeks' accommodation, which is the amount of time that you must wait until your next Centrelink payment becomes available.

And so this vulnerable population are forced into homelessness. When in this situation, being told that there is nothing available or that ‘we are doing everything that we can’ is like being slapped in the face. Repeated slaps can not only cause resentfulness, but can also create a sense of otherness. This can unfortunately force people with the best of intentions to make bad decisions.

Providing people with affordable accommodation could reduce the likelihood of people reoffending because of homelessness. Governments should consider this proactive approach.

Hungry for Change

Sharon Lee, NADA

‘Everyone now has a basic understanding of I could not get what I need,’ said Jenna Bottrell, Program Manager of Continuing Coordinated Care Programs in the Central West.

But for some, this experience is recurring.

Food security Food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life.

Food security is a human right, yet food insecurity affects 6.9% of people in New South Wales, and this rate is much higher among asylum seekers and refugees, Aboriginal and Torres Strait Islander people, people receiving social security benefits or experiencing homelessness.

‘Food insecurity is closely linked with income security,’ declares Phary Stamatis, Program Manager of Mission Australia’s Kings Cross Youth Services. Indeed, while a diverse range of groups experience food insecurity, household income is the strongest predictor of risk. For people on low incomes, buying food can be a discretionary expense, to be juggled with rent, medical, and energy bills. When people don’t have enough food, they may skip a meal, or reduce the size. They might bulk dishes with cheap rice, and eat fewer vegetables. They may feel anxious about their food supply or feel deprived by a lack of choice. It may prevent them from joining friends and family to share a meal. They may experience food insecurity periodically, like the day before payday, or each and every day.

Food insecurity can have wide-ranging impacts on a person’s physical and mental health. It has been associated with diet related chronic conditions such as diabetes, metabolic syndrome and obesity alongside the health care costs. When someone doesn’t know when or where their next meal is going to come, finding that often becomes their central focus and can take priority.

‘You can’t expect someone to focus on their mental health or AOD dependence if the biggest stress of the day is that they haven’t got food for the next three,’ says Jenna. ‘You can’t look towards the future if you’re looking for your next meal.’

Where can people turn for food? Since the 1970s, the Australian government has funded emergency relief, which today includes food and voucher programs, as well as other services for emergencies. A variety of food related charity programs exist alongside this.

Charitable food services work to alleviate hunger and provide temporary relief until food security can be improved. This sector comprises suppliers like food banks and rescue services, as well as community food programs, the agencies that directly supply to people through meals, cooking classes, breakfast programs, outreach services or pantries. But only a fraction of people who experience food insecurity access this relief, considering it as an option of last resort; people say they experience stigma, shame, and hopelessness when they use them. While food charities offer critical support, reports on the nutritional, and cultural inadequacy of foods provided are common.

Yet due to government cutbacks in welfare social protection systems, these charities have become an extension of the safety net. And because government support has proved precarious, this net is illusory. Due to COVID-19, food banks are facing challenges with a lack of volunteers because of distancing restrictions and lack of donations due to rising consumer demand. Emergency food assistance do not, in and of themselves, offer pathways out of food insecurity.

A food secure future. Governments, business and the community need to address the four pillars of food security. Following are a few example actions: Access: capacity to acquire a healthy diet Policies that promote full employment and job security are bound to be helpful for our clients and the whole of society. Income support should be raised, to meet the cost of healthy food and the real cost of living. The net should also be widened to support those who currently fall through the cracks. NADA has joined the ACOSS campaign to raise the rate for good seeking a permanent and adequate increase to Newstart, JobSeeker, Youth Allowance and related payments.

Availability: supply of food within a community Community based food system solutions—providing healthy, sustainable, culturally appropriate food with minimal waste—can supplement income support payments. Sustainable funding, flexibility and community ownership are key to success for these innovations. Examples include pop up fresh food markets in low income areas and community gardens (see box, overleaf).

Utilisation: appropriate food use based on knowledge of nutrition and care. The NSW Government should invest more in programs like FoodREDi which build peoples’ skills to cook tasty, healthy meals. NADA members have filled this gap by building upon healthy food supplies. Jenna distributed food boxes to clients in partnership with a greengrocer during the onset of COVID-19; recipes and cooking tips for the more unusual items were included.

Stability: access to adequate food at all times and no risk due to sudden shocks or cyclical events. Diversity is key to building resilience. Australia needs to diversify its large scale monoculture production, supermarket dominated, export oriented system with local, small scale production; growing a range of breeds and seeds; shorter supply chains; and diets comprising a wide variety of fresh, healthy foods. Organisations working towards a better food future include Sustain and the Australian Food Sovereignty Alliance.

Practice tips. Clients need a stable base before they can tackle things like AOD recovery or employment. As AOD workers, we can often go automatically into therapeutic work, but instead we need to firstly support our clients with their basic needs, like housing and food. If your client returns multiple times for emergency relief, have a conversation about their situation to understand the context. Talk with them, ask them what’s happening and most importantly, listen. It could be a crisis or an unexpected bill. If it is a bill, support your client and call the provider together to negotiate, so they can learn the skills to advocate for themselves. Otherwise, ask how you can help them, to prevent this pattern from recurring. This may include helping them with budgeting or referring them to a financial counsellor for extra support.

While people can currently access their superannuation due to COVID-19, there’s nothing in place to develop their skills to manage this, knowing it will end. Counsel them on this to build their financial skills or refer them to a financial counsellor. There are many non-government community organisations that can provide a financial counsellor at no cost.

Culturally and Linguistically Diverse People

Valentina Angelovska CEO—2Connect Youth & Community

What are the barriers for culturally and linguistically diverse (CALD) people, especially young people, to engage with AOD services?

There’s a general lack of knowledge about AOD services and how they may help. Services may not be able to cater for language needs, cultural understanding and sensitivities to the intricacies surrounding cultural community experiences. They may practice a more individual approach whereas a young person can be more family and community orientated. There are help seeking barriers too; people may hide AOD use for fear of isolation from the family, culture or community.

How has 2Connect addressed these barriers?

We provide basic information about AOD services, how they can be accessed, and highlight confidentiality principles. We translate information into different languages, and make it family and community focussed. The language we use is non-clinical, and free from jargon. We reach audiences through platforms like language specific radio, places of worship, or a cultural specific dancing group.

We partner with services (e.g. Nepalese and Macedonian welfare groups) to provide specific presentations to these communities. It helps that our staff come from diverse backgrounds—many are bilingual—we also use interpreters.

We use a holistic family and community approach in our clinical work. For example, we enquire about family, and engage with a parent or other family member, not just the young person. We also provide flexible service delivery e.g. mobile outreach to settings where young people already attend, such as schools.

Describe the outcome for these clients

By breaking down the barriers to access and taboos surrounding help-seeking, we have increased access for culturally and linguistically diverse young people and families. With successful engagement, there’s a greater chance for young people to meet their goals, and young people able to connect with the service to meet their support needs. All in all, we have achieved greater successful therapeutic outcomes.

Gender and Sexuality – Why Do You Ask Them?

Raquel Lowe Health Education Officer, Community Services—Odyssey House

Why does Odyssey House think it is important to ask the gender and sexuality questions?

We know how important it is to get a full and clear picture of all our clients, but because there are still gaps in the data around help seeking behaviour and substance use of sexuality and gender diverse communities, we need to know if, how, and how frequently LGBTIQ communities are accessing our service.

It is important to provide our clients with the opportunity to tell us who they are, in their own words. You cannot rely on stereotypes and the only way to correctly identify someone’s sexuality and gender identity is by asking them. Referring someone as a he or she because of the way they present or asking somebody if they have a boyfriend/ girlfriend rather than partner, are examples of how we may unintentionally make assumptions if we don’t ask the question.

How do you support staff to ask the question?

Gender and sexuality questions have been embedded into our assessment process and are required fields when creating a new file in our client management system. If staff require more support, we educate them on the importance of asking and refer them to NADA’s ‘Asking the question’ eLearning course.

How does it improve outcomes for clients?

Worrying about whether it is safe to disclose their gender identity or sexuality can be a source of anxiety for LGBTIQ clients. Asking the question takes the pressure off them, assuring them that their whole self is welcome.

There may be additional health, mental health, and social concerns for LGBTIQ clients accessing AOD services. For example LGBTIQ clients are more likely to have mental health concerns, more likely to smoke tobacco regularly and may be at greater risk of exposure to blood borne viruses, so asking the question also allows for more holistic care/treatment planning with the client and potentially better outcomes.

Simone Angus-Carr Western Sydney Programs Manager—Noffs Foundation

Why does Noffs think it’s important to ask the gender and sexuality questions?

We need to know our audience—their demographics, sexuality and gender—so we can better equip our service and clinicians to provide clinically relevant and holistic services. Asking questions relating to gender and sexuality helps to create a safe space from the beginning; it normalises the issue so if clients want to talk, the conversation has already been started. It’s also important to us to make a habit of not assuming.

How do you support staff to ask the question?

When clinicians start working with us, we train them on our assessment practices and systems, including the relevance and importance of questions and how to conduct an in-depth psychosocial assessment. We provide them with ongoing and in-depth training, as well as clinical supervision.

How does it improve outcomes for clients?

Asking the question enhances service provision and improves client outcomes, not only from a clinical perspective, but allows for linkages with services. Sexuality and gender are important aspects of identity development during adolescence, so they’re important to outcomes. They lead to conversations about acceptance by self, peers and family and about safe sex, with same gender partners or partners of another gender, something that may not be covered much in mainstream places like schools. Allowing a safe space for these conversations also allows for discussions and education about AOD use in sexual situations.

Services for Women And Mothers

Karen Urbanoski Associate Professor, University of Victoria, Canada
Karen Milligan Associate Professor, Ryerson University, Canada

Women, and particularly mothers, face numerous barriers to seeking help for problematic substance use, including stigma and fear of child welfare involvement. Effective treatment services for women provide wrap-around supports that address these common barriers as well as co-occurring challenges with mental health, histories of trauma, and the social determinants of health. In North America, Australia, and elsewhere, comprehensive and integrated services (that offer coordinated access to primary care, substance use and mental health treatment, pre-natal care, parenting and child welfare services) are becoming increasingly common. While such treatment programs share the goal of reducing fragmentation of health and social services, there is no shared understanding of a service model in practice, leading to wide variability in the supports that women actually receive.

In 2014, we began a system-level study of integrated treatment programs for pregnant and parenting women who use substances in Ontario (Canada’s most populous province). As part of that study, we sought to better define the essential service components of these programs, paying particular attention to how they connected with women’s perceptions of care. The work was guided by a project advisory board that included service providers, managers and agency directors, decision-makers and other women’s health researchers.

When we conducted this study, there were 34 integrated programs operating within Ontario’s publicly funded substance use treatment system. All were outpatient programs, given challenges for mothers to attend residential services where children are not allowed. We purposively selected 12 programs to represent the geographic diversity of the province (rural versus urban), years of operation, and program size. During site visits to these programs, we conducted semi-structured interviews with managers (n=22) and counsellors (n=15). Women who were service recipients (n=106) also completed the Ontario Perception of Care Tool for Mental Health and Addictions (OPOC-MHA). This 32-item scale measures perceptions of treatment access and entry, as well as perceptions of care during treatment (including satisfaction with services, level of participation in care, counsellors, environment, and discharge planning). Open-ended questions are used to obtain feedback on the most helpful aspects of care and areas for improvement. Comparison data were obtained from a provincial database of OPOC-MHA scores for women of child-bearing age (19-44) who attended standard treatment programs (n=207).

Data from the service inventories and interviews yielded insights into service models across programs. All programs were undefined in length, meaning that women could stay for prolonged periods of time. This is in contrast to standard outpatient programs offered in this specialized treatment sector, which are often restricted in the number of sessions a given client can attend. Most (9 of 12) programs also offered the flexibility of home visits to reduce barriers to access (e.g., transportation or childcare). All programs reported embracing a harm reduction philosophy, which they interpreted as “meeting women where they are at’, supporting women’s decisions around their treatment goals, and teaching safer substance use practices. Women receiving opioid agonist therapy (OAT) were welcomed at all programs, which is still not always the case among treatment centres in North America. Most (n=9) also identified as being trauma informed and attended to trauma experiences in service planning and provision. Most programs served only women, although one had some programming for fathers and male partners.

All programs offered individual and group based counselling for substance use and counselling to address maternal mental health needs (primarily mood and anxiety disorders. More intensive psychiatric services (including medication consults) were limited, as was OAT. That is, although programs had resources to offer in-house psychosocial counselling and psychotherapy (including cognitive behavioural and motivational interventions), they tended not to have physicians on-site who could prescribe and manage medications for psychiatric disorders, including substance use disorders, and relied instead on referrals to outside agencies. About half of the programs indicated that they offered primary care and pre-natal services on-site or through a partner (e.g., on-site care by nurse/doctor once a week or month). Children’s mental health services were rarely offered.

All programs offered coordination with child welfare (e.g., attending meetings with women, facilitating supervised access visits with children, helping women navigate the system). Program staff and leaders singled out this aspect of care as particularly important to their ability to meet the needs of women and families. Parenting support was offered by all programs, including manualized parenting interventions in some cases. Where manualized parenting interventions were offered, however, these were designed for a general population. In related work on integrated programs, we have highlighted the need for parenting interventions that are specifically designed to address parenting in the context of substance use and social-structural disadvantages (e.g., poverty, racialization, criminalization).

Ancillary supports for the social determinants of health (e.g., food security, life skills training, housing supports, and transportation supports) were variably provided. Whereas life skills training was part of most programs, only one had an on-site housing worker. Access to food, childcare, and transportation supports were also limited and not able to meet demand. This is reflective of governmental divisions that separate funding and administration of health care services (where substance use services are located) from social services. When unavailable, most programs tried to connect women with services by referral.

Perceptions of care for women who participated in integrated programs were more positive than those of women who attended standard substance use treatment programs. This association did not differ by client age, ethnicity, sexual orientation, or whether treatment was mandated by child welfare or the legal system. Women cited flexibility and tailored services as key strengths of the integrated programs. Others singled out support with childcare, food, transportation, and services beyond substance use treatment as being key. Consistent with studies that show an association between strong therapeutic relationships and outcomes, the importance of counsellors and the quality of the therapeutic relationship/ environment was emphasized:

'I find this is the only place where there is no judgment, so I am free to present my true being and voice any and all concerns because if they don't understand, I know they will try to figure out a way to help me deal with whatever it is.’

While the therapeutic process appears to be critical to positive perceptions of care in integrated programs, less is known about the role of specific services in this relationship and in shaping outcomes. In the next phase of this study, we are exploring how maternal and child health outcomes differ between integrated programs and standard treatment, and whether this varies across programs depending on the number and types of services offered.

For treatment programs that are working to improve access and services for women and mothers, this research suggests:

• The delivery of comprehensive and integrated services can improve women’s experiences of care processes.
• Tangible supports, such as for childcare and transportation, and flexibility in location of services (e.g., home visits), can help to address challenges that prevent women from attending appointments and making use of other services.
• In jurisdictions (such as Ontario) where substance use services were established and evolved quite separately from medical care, additional efforts may be warranted to ensure that there is meaningful integration.

Engaging Aboriginal and Torres Strait Islander People

Jolene Mokbel Clinical Co-ordinator Salvation Army Youthlink AOD/Mental Health Programs

What are the barriers for Aboriginal and Torres Strait Islander people to engage with AOD services?

Aboriginal and Torres Strait Islander people may find difficulties in accessing the relevant support services, especially when they are experiencing multiple needs in addition to AOD use (e.g. physical and mental health, social, economic and housing needs). Many Aboriginal and Torres Strait Islander young people have also found medical clinics to be unwelcoming and stigmatising. As a result, it is common for young people from Aboriginal and Torres Strait Islander communities to have experienced unpleasant experiences when accessing clinical support.

How has Salvation Army addressed these barriers?

The Salvation Army has designed a program to help address the alienating experience which many Aboriginal and Torres Strait Islander young people feel in traditional clinical settings. Our program includes a care co-ordinator who not only builds rapport with Aboriginal and Torres Strait Islander young people, but also helps the young person navigate through a range of services. The care coordinator works collaboratively with our program’s clinician to help the young person receive the AOD/mental health treatment they need along with support to address social and structural concerns. This in turn provides the young person with greater accessibility to seek holistic support that focuses beyond their AOD treatment.

Describe the outcome for these clients

We have seen more Aboriginal and Torres Strait Islander young people express willingness to seek AOD treatment along with other support to improve their quality of life. Many times, the young person makes one life change (e.g. securing accommodation, engaging in work/study, seeing a medical professional etc.) which then leads to a positive impact on their overall wellbeing (including reducing or avoiding AOD use).

Code of Ethics

Introduction

Most professions expect their members to meet a standard of ethical behaviour and this requirement is often formalised through a code of ethics which then informs practice. In the case of community work this is essential because practitioners often work with the most vulnerable and marginalised groups of people in our society. This practitioner-client relationship may be defined in a number of ways but in this document, is taken to mean that which has resulted through the engagement of an individual, group, or community with the services of a community worker.

The Australian Community Workers Association (ACWA) code of ethics sets the foundation for exemplary community work practice and is the benchmark for all practitioners. As the professional association for community workers ACWA has defined a community work practitioner as a person who holds a relevant qualification and has the values, knowledge and skills to work independently or with others in an agency or program intended to facilitate or ensure social inclusion. The community worker is therefore expected to acknowledge and respect the worth of all individuals regardless of their race, religion, age, gender, sexual and gender diversity, and other individual differences.

Conduct opposed to the full recognition of human dignity and individual rights within the community worker’s professional practice shall be considered improper and unacceptable within the community work profession and to the Australian Community Workers Association.

Principles Underlying the Code of Ethics

1. Every human being, regardless of race, religion, gender, age, sexual and gender diversity, or other individual differences has a right to maximise his or her potential providing it does not infringe upon the rights of others.
2. Social inclusion is a human right where every individual has an active role to play in society and has the expectation of full social, educational and economic participation. An inclusive society is based on the fundamental values of equity, equality, social justice, and human rights and freedoms, as well as on the principles of tolerance and embracing diversity.
3. Every society has an obligation to provide for and deal equitably with all its members and to make extra provision for those who are excluded or disadvantaged.
4. Every person is legally protected against discrimination on the basis of age, sex, race and disability and their universal human rights are inviolable.
5. The Australian Community Workers Association recognises Australia’s first people and their right to self-determination.

Responsibility to Clients

1. The community worker:

• Shall determine with the client or client group the exact nature of the relationship, the role of the community worker, and clarify the expectations of the client shall regard all information concerning clients as confidential except where:
  • Eith the permission of the client, referrals are to be made or other professional consultation, opinion or advice is sought;
  • Failure to disclose information would breach the terms of the community worker’s employment (such exceptions must be notified to the client); or where
  • Failure to disclose information would contravene mandatory reporting requirements or other legal obligations
• Has an obligation to treat clients with dignity and to safeguard, promote and acknowledge their capacity for self-determination
• In exercising certain powers and using information, is accountable to the client to ensure that:
  • They are fully informed of their rights;
  • Have choices; and
  • Can access information about themselves
• Will improve their skills and knowledge for the benefit of the client
• Will establish and maintain professional boundaries with clients at all times and not form personal relationships that compromise the primary practitioner-client relationship.

Responsibility to Employers

2. The community worker, as an employee, is expected to:

• Carry out the duties and responsibilities of the role as outlined in their terms of employment by adhering to the stated aims, policies and procedures of the employing body
• Achieve the aims of the employing organisation without denying clients their rights
• Bring to the employer’s attention where organisational expectations or practices contravene the profession’s code of ethics
  • Particularly in the area of client rights
  • Maintain a professional relationship with clients at all times and disclose any out-of-hours contact or social media contact
  • Act responsibly in the expenditure of public monies

Responsibility to Colleagues

3. The community worker is expected to:

• Share professional knowledge and insights with colleagues
• Respect the skills, knowledge and experience of colleagues including volunteers
• Be generous in using their skills and knowledge to enhance the practical fieldwork education of students
• Discuss any unethical behaviour that may have been observed in a colleague directly with their colleague unless to do so would pose a risk to a client or the practitioner
• Acknowledge and observe the legal rights and protections of colleagues, including, but not restricted to, confidentiality and privacy, workplace health and safety, and anti-discrimination legislation.

Protecting The Reputation of the Profession

4. The community worker will:

• Maintain, through ongoing education and training, the standards required for exemplary and contemporary practice
• Address in a timely manner and through an appropriate channel any behaviour in a colleague or an employer that is either incompatible with this code, or impinges on the rights of clients and their families, or contravenes the law
• Seek advice when unsure of a course of action and make informed decisions
• Participate in any complaint process if a public complaint is brought against them
• Distinguish in public statements, for example on social media, whether acting as an authorised spokesperson of their organisation or in a private capacity
• Respect the rights and legal protections of others
• Act responsibly in the expenditure of public monies
• Disclose any improper relationship between a colleague and client
• Meet the expectations of this code and the practice standards at all times.

Practice Guidelines

These guidelines define a standard of practice to which the Australian Community Workers Association holds its members accountable. They are, however, relevant to all community workers including those involved in intake, support, case work, crisis intervention, team management, community development and advocacy roles across all fields of practice. The guidelines have been developed in consultation with practitioners, industry partners, and education providers, and exemplify what is generally considered to be good practice in the sector.

All community workers, regardless of qualification, industry experience or specialisation, need to demonstrate throughout their career that they meet a recognised and ethical standard of practice, which protects the client, the community, and the practitioner.

These practice guidelines are underpinned by a code of ethics, and it is within this ethical framework that exemplary community work practice occurs.

Values Underpinning Ethical Practice

Like all other professions, community work is shaped by a code of ethics and a set of values that guide the qualified practitioner. For the community worker, a commitment to social inclusion and social justice is fundamental to their practice, along with a respect for the individual and his or her right to self-determination.

How to Use the Guidelines

These guidelines, along with their indicators, have been written to provide a framework for community work practice. Originally conceived as standards, the new guidelines expand upon the Australian Community Workers Code of Ethics and provide a benchmark for experienced practitioners, as well as a guide for new community workers entering the profession. The guidelines are not intended to conflict with the requirements of an employing organisation but they do set out a minimum acceptable standard. The guidelines are written in such a way that practitioners can assess themselves against the indicators and plan their professional development accordingly.

The Guidelines

• Guideline 1 Ethical practice
• Guideline 2 Provision of service and supports
• Guideline 3 Confidentiality in the workplace
• Guideline 4 The regulatory framework
• Guideline 5 Diversity
• Guideline 6 The workplace
• Guideline 7 Professional development
• Guideline 8 Professional standing

Guideline 1 Ethical Practice

A community work practitioner, in providing services to individuals and communities, should work in accordance with a code of ethics and in agreement with the principles of individual worth and the individual’s right to social inclusion.

Indicators
To comply with the intent of this guideline a community work practitioner will be required to:

1.1	Apply the principles of social justice, equity, individual worth, human dignity and self-determination in all day to day professional practice.
1.2	Practice ethical behaviour in every situation in accordance with the Australian Community Workers Code of ethics.
1.3	Seek advice, if required, when confronted with an ethical dilemma.
1.4	Challenge policies and practices that are unjust or fail to meet accepted community standards such as human and legal rights, social inclusion and self-determination.
1.5	Reflect on personal beliefs and values and identify those that might impact on the rights of others.
1.6	Base relationships with service users or groups on the principles of respect and human dignity regardless of a service user’s own attitudes or behaviour.
1.7	Identify and appropriately address ethical issues, such as breaches of confidentiality, privacy, and professional boundaries that may occur when using online tools for service provision.
1.8	Use resources and public monies responsibly and for their specified purpose.
1.9	Use knowledge and skills for the benefit of the service user, the employing organisation and the common good.

Guideline 2 Provision of Services and Supports

A community work practitioner should base her or his professional practice on the theory of community work and the principle that individuals, families, groups and communities have a fundamental human right to access appropriate services and support.

Indicators
To comply with the intent of this guideline a community work practitioner will be required to:

2.1	Provide services that meet the needs of individuals and communities and facilitate their right to social inclusion or social justice.
2.2	Encourage service users to actively provide feedback on the effectiveness or otherwise of services.
2.3	Routinely advise service users of their right to complain and how to access the organisation’s complaints policy.
2.4	Ensure that they do not discriminate against or in any way disadvantage a service user who has made a complaint.
2.5	Use appropriate research, planning and evaluation methodologies when providing community and human services.
2.6	Facilitate effective outcomes by routinely monitoring, evaluating and improving upon services, programs and projects.
2.7	Retain currency in theory and practice to underpin all service provision.
2.8	Advocate for service users and needed services.
2.9	Recognise the sometimes imbalance of power between themselves and service users and take care to not abuse that authority.

Guideline 3 Confidentiality in the Workplace

A community work practitioner should understand and comply with all legislation and guidelines that provide for confidentiality and privacy of service users, colleagues and employers.

Indicators
To comply with the intent of this guideline a community work practitioner will be required to:

3.1	Be familiar with the relevant legislation and the organisational policies relating to confidentiality and privacy.
3.2	Inform service users as to who has access to his or her file and under what circumstances the information contained therein is or may be shared.
3.3	Provide service users with access to their own files and make them aware of the process to record or amend any representation, notation or omission with which they disagree.
3.4	Protect a service user’s privacy through secure record keeping.
3.5	Seek informed consent from service users before any confidential information is shared, unless required by law.
3.6	Advocate for non-disclosure of confidential information where a practitioner believes that disclosure would adversely affect a service user.
3.7	Provide privacy to service users who wish to discuss sensitive matters.
3.8	Destroy obsolete confidential information or records in a secure manner.
3.9	Apply the principles of confidentiality to information that pertains to colleagues and employers.
3.10	Remind colleagues, who disclose confidential information, of their obligations under the various legislation and policy requirements that govern the workplace.

Guideline 4 The Regulatory Framework

A community work practitioner often works within complex organisational structures governed by legislation or statute. The practitioner must, therefore, understand the sometimes seemingly contradictory frameworks that impact either on service provision or the service users with whom they work.

Indicators
To comply with the intent of this guideline a community work practitioner will be required to:

4.1	Comply with legislation and statutory provisions, for example, mandatory reporting, which affect professional practice.
4.2	Alert their employer of relevant legislation not observed by the organisation.
4.3	Deal with service-user information in accordance with the principles and requirements of legislation including that which governs privacy, confidentiality and freedom of information.
4.4	Work within the legal limitations around the right to confidentiality.
4.5	Inform service users about the legal limitations to their right to confidentiality and privacy.
4.6	Ensure information systems relating to service users, resources, programs and projects are in place, and kept in accordance with legislation and organisational policy and procedural requirements.
4.7	Ensure that the fundamental human rights of an individual are not impinged through the misuse of authority granted through law.
4.8	Understand which pieces of legislation govern organisational behaviours, for example, workplace health and safety, and inform the service user group wherever necessary.

Guideline 5 Diversity

A community worker works within diverse communities and should demonstrate in all of her or his professional practice an understanding and sensitivity to diversity in all forms and her or his compliance with all relevant legislation.

Indicators
To comply with the intent of this guideline a community work practitioner will be required to:

5.1	Respond appropriately to diversity in all its forms.
5.2	Acknowledge and promote the rights of culturally and other diverse groups.
5.3	Challenge organisational behaviours and services that discriminate on the basis of individual or group characteristics including ability, age, beliefs, economic, employment and housing status, ethnicity, faith, gender and gender identity, and sexuality.
5.4	Recognise personal values and bias and takes steps to safeguard against any adverse impact these might have on a service user’s right to a service. Recognise and declare conflicts of interest.
5.5	Gain information from relevant individuals and Indigenous and culturally diverse communities to ensure professional practice, policy, or service development is appropriate to community and service user needs.
5.6	Engage in individual and collaborative knowledge building to ensure professional practice with culturally or otherwise diverse or minority groups is appropriate and effective.
5.7	Adapt communication means and methods to effectively connect with a diverse range of people.
5.8	Use culturally appropriate verbal and non-verbal communication when engaging with individuals and community members.

Guideline 6 The Workplace

A community work practitioner rarely works alone and should treat her or his workplace with respect and take personal responsibility to ensure that it is a productive, safe and healthy environment within which they, service users, colleagues or residents can work or live.

Indicators
To comply with the intent of this guideline a community work practitioner will be required to:

6.1	Understand and respect the nature and context of the workplace, which may also be the residence or home of service users.
6.2	Continually develop and use knowledge and skills within the workplace for the benefit of service users, colleagues and employers.
6.3	Maintain professional boundaries with service users and colleagues.
6.4	Acknowledge and protect confidential, sensitive or commercially valuable workplace information and intellectual property.
6.5	Treat colleagues with respect, honesty and consideration.
6.6	Deal with conflict in a timely manner.
6.7	Report discriminatory, bullying or otherwise adverse behaviour by a colleague toward clients or another staff person.
6.8	Recognise and act upon individual responsibility for workplace health and safety.
6.9	Understand and implement organisational policy and procedures.
6.10	Take up any areas of concern, either regarding policies, service provision or workplace behaviors with the appropriate supervisor, manager or employer.

Guideline 7 Professional Development

The education of a community work practitioner does not cease upon graduation. It is incumbent on the community worker to undertake relevant professional development throughout her or his career to ensure their knowledge remains current and informs their everyday practice.

Indicators
To comply with the intent of this guideline a community work practitioner will be required to:

7.1	Identify skill and knowledge gaps and remedy through training, supervision or other means.
7.2	Seek appropriate professional support, mentoring or advice to address personal and professional limitations.
7.3	Critically analyse the profession, human service agencies and organisations, and social institutions in all aspects of the community work role.
7.4	Acknowledge personal responsibility and accountability for actions, decisions and professional development.
7.5	Increase new knowledge and information about the profession, the sector or areas of practice through active engagement with research and enquiry.
7.6	Keep abreast of current research, models of practice, and theory.
7.7	Supervise students, staff and volunteers in an ethical manner and from an appropriately qualified knowledge base.
7.8	Share information and knowledge with colleagues.

Guideline 8 Professional Standing

Community work practitioners not only represent the interests of service users and employers but are also representatives of the community work profession. Community workers should therefore, practice with integrity and not engage in any behaviour that brings the profession or other practitioners into disrepute.

Indicators
To comply with the intent of this guideline a community work practitioner will be required to:

8.1	Know, understand and work within the ethical norms of the profession.
8.2	Maintain appropriate professional and personal boundaries with service users and colleagues.
8.3	Seek support and guidance when personal issues are affecting professional conduct or practice.
8.4	Recognise and redress inadequate knowledge and experience is through professional development, training, support or supervision.
8.5	Promptly address the inappropriate, unethical or illegal behaviour of a colleague through suitable means.
8.6	Exhibit awareness of social, political, legal, cultural and organisational contexts and systems, and how they might impact on the community work profession.
8.7	Acknowledge and support the right of service users, carers, members of the public and colleagues to make a complaint against the unethical, unprofessional or inept practice of a community work practitioner.
8.8	Demonstrate an understanding of relevant legislation and legal frameworks which specify responsibilities towards clients, colleagues, employers or community members in the workplace.
8.9	Promote, take pride in, and advance the profession of community work.
8.10	Recognise that private behaviour should not have an adverse impact on professional practice or the profession.

So far you have taken a personal inventory and used its implications to protect your clients and you have explored the concept of client welfare, reviewing how to keep your clients’ needs in focus. The welfare of your clients also depends on your ability to respect your clients by understanding and accepting their cultural background. When you don’t accept your clients, you are in danger of discriminating against who they are, which violates all four of the ethical pillars. Our world offers a rich diversity that has implications in our profession (Pope & Vasquez, 2007). The addiction population we are treating is becoming more diverse. Even good clinicians can be at a loss in treating clients with other backgrounds. Clinicians must know their own limitations when treating clients (Venner & Bogenschutz, 2008). You can’t possibly promote goodness if you are discriminating against some aspect of a client’s character, and you will certainly cause harm to your patient with your discrimination.

While clinicians will undoubtedly agree that discriminating against clients is unethical, it occurs regularly in the profession, often by good clinicians just like you, reader. Discrimination can be big and blatant, but it can also be very small and subtle. If you are not aware of your thoughts and actions, it can even escape your attention. Understanding and accepting the cultural diversity that will make up your client caseload and interprofessional relationships is a necessary task in building an ethical practice. Avoiding discrimination is not the only important aspect of cultural diversity. Understanding a client’s cultural influences can give clues to both how his or her addiction developed and what treatment interventions may be suggested in each case. Let’s begin by exploring the definition of culture and how it can play a role in your client’s addiction and recovery.

Culture refers to a group in which one is a member, that holds rules, values, and norms agreed on and upheld by all members of the shared culture. Traditionally many people view culture as synonymous with ethnicity (Venner & Bogenschutz, 2008), but that is only one type. Culture is so much more. In ethics, we define culture to include age, gender, race, ethnicity, national origin, religion, sexual orientation, disabilities, language, and socioeconomic status (Venner & Bogenschutz, 2008). Most of us have several other cultures to which we belong. The family that raises you provides its own culture, complete with rules, values, and norms. Your age, gender, religion, political affiliation, sexual identity, race, ethnicity, national origin, profession, and workplace are also cultures. Some cultures require an action for membership, such as requiring a credential to be an addictions counselor. Other cultures have no requirements.

Clinicians are taught that clients’ culture plays an important role in their identity (Nassar-McMillan & Niles, 2011; Venner & Bogenschutz, 2008), and that it is important to assess culture in the intake interview, namely their ethnicity, religion, and sexual orientation (Corey, Corey, & Callanan, 2007; Pope & Vasquez, 2010). Age and gender are typically obtained from what the client wrote down on the screening form. Because clients will be representing many different cultures, understanding and addressing that diversity is an important part to any clinical practice. Therefore, many cultural diversity courses are offered to clinicians throughout their training. Historically, many classes and books on diversity teach certain culture-specific rules, such as avoiding eye contact with Asian clients as a sign of respect, and clinicians often treat clients based on what was learned in the class or book. We do so feeling confident that we are being culturally competent in our work.

But being culturally competent does not entail taking a workshop on a specific culture and then using that information to automatically treat clients within that culture in a certain way (NassarMcMillan & Niles, 2011). The problem here is that your clients may not fall under the stereotypes of the culture of which they are a member. What if they are members of two or more distinct cultures and they take bits from each one to make up who they are? How will you know how to treat them if you are only looking at cultural norms? Think about yourself: What cultures are you a part of and what are the stereotypes? Do you fit in perfectly with those stereotypes? You may adhere to some, but I would guess that you don’t comply with all stereotypes. Your clients won’t either, so don’t assume that you know anything about them based on whatever they have written on their intake documents.

Patricia may be a married, heterosexual, African American Christian from the south, but to you she is just Patricia, someone you need to get to know. Any of those labels that Patricia carries are going to mean nothing unless she tells you they mean something to her. Professional education is vital, but you want to use it as background information that informs what questions you will ask your client, not as an excuse not to ask the questions. Close your eyes and say with me, “Tabula Rasa.” Your client is a blank slate when you step into that intake assessment, and it is your job to learn everything you can about him or her in order to effectively help him or her. You want to acknowledge each client’s independence, uniqueness, and allow each the respect to teach you about themselves, according to the pillar of autonomy. The moral of the story is: Never assume anything about who is sitting in front of you; ask.

Cultural competency is “a lifelong process with no endpoint” (Venner & Bogenschutz, 2008, p. 68). You want to connect with all clients regardless of their personal history, according to the pillar of justice. Counselors must recognize that cultural factors exist with each client and influence the counseling process (Nassar-McMillan & Niles, 2011), according to the pillar of beneficence. “The good will of the clinician is not enough for a culturally competent practice.… Clinicians must be aware of general cultural knowledge and their own beliefs, biases, and ability to be open-minded” (Venner & Bogenschutz, 2008, p. 68) in order to achieve nonmaleficence.

We live in a world where the concept of being politically correct is in our vernacular, yet our actions don’t always reflect our vocal assertions. People will say they don’t discriminate against others, and you may be one of them, but when we think of discrimination, we usually think of gross violations of someone’s characteristics. We can easily state that not admitting someone into a program because they are a person of color would be hideously inappropriate on every level. But there are more subtle snags that remain undetectable for even seasoned clinicians that must be examined when evaluating your potential risk of cultural discrimination.

Clinicians violate the principle of cultural diversity in one of two ways, by errors of omission and errors of commission (Venner & Bogenschutz, 2008). Errors of omission include not asking the right questions, or assuming that clients’ cultures are not involved with their presenting problems or solutions. Errors of commission include prejudice and discrimination (Venner & Bogenschutz, 2008). Let’s consider how prejudice and discrimination take place by first examining who typically suffers discrimination and how it can play out in the clinical arena. Characteristics that are often fertile ground for errors of commission are race, ethnicity, national origin, religion, age, gender identity and expression, sexual orientation, disabilities, economic condition, drug(s)/behavior of choice, psychiatric diagnosis, and recovery status of the clinician.

Race/Ethnicity/National Origin

These three categories are distinct and should not be confused with each other. Race refers to physical characteristics, such as the color of a person’s skin, and ethnicity refers to learned behavior, particularly traditions and customs, based on the region in which a person is from. If three people with dark, black skin, are from America, Haiti, and Kenya, they would be members of the same race, yet part of significantly different ethnicities. Similarly, three people with white skin from America, Germany, and Ireland would have the same race but with significantly different ethnic backgrounds.

National origin refers to the nation that clients identify as their home, in which their cultural norms, rules, and traditions were learned and upheld. This is significant because many clients may move into one country, but continue to adhere to the culture of another country. Countries will vary on which generations will be eligible to claim origin; some may welcome people with grandparents born in the country, some may go back further generations. In our own country, different Native American tribes use the term blood quantum to define acceptance into the tribe, which vary from one-half to one-16th degree of blood. Regardless of these rules, an individual client will choose with which country and culture he or she identifies.

It is not the responsibility of the clinician to dictate the appropriate memberships for the clients, or to tell them that their identification is faulty. How a person looks to you may be vastly different than how that person identifies him- or herself.

The three questions you must ask every client are:

1. With which race and ethnic groups do you most identify?
2. How has your race, ethnicity, and national origin played a role in your experiences (positive and negative)?
3. Do you expect your race, ethnicity, or national origin to have a positive or negative effect on your recovery efforts, or has it already had an effect? Tell me more.

Additional questions may emerge from these basic questions.

Spirituality and Religion

The concept of religious identification is similar to race, ethnicity, and national origin. People vary not only in their specific religious membership, if they have one, but also in what they specifically believe. In other words, two Catholics may have very different views. Many people are born into a religion but do not continue their religious membership, or they do to varying degrees. Many people are not members of any organized religion, either because they are agnostic or because they are atheist.

Many people do not subscribe to a formal religion but do have a spiritual connection that serves the same benefits as a formal religion. This spiritual connection can mean many different things to different people. Whether your client identifies as spiritual, religious, or both, clients further vary on the degree to which this identification can aid them in recovery. Some people feel strongly connected and believe this connection can be a great tool in their recovery program; others feel strongly connected but believe this connection to be unhelpful. Asking a client if they are religious is not a sufficient inquiry. You must ask them to describe their spiritual beliefs (Venner & Bogenschutz, 2008).

Specifically, the four basic questions you want to ask every client are:

1. Do you have a sense of spirituality? If so, describe it.
2. Do you belong to any organized religion (if it was not clear from their first answer)?
3. Does your spirituality help you, or do you expect it to help, in your efforts to reach your goals (in the past and in the future)? If so, describe how.
4. Does your lack of spirituality act as a barrier in your efforts to reach your goals (in the past and in the future)? If so, describe how.

Age

Although age can vary between 0 and about 100, you may work at a place that narrows down the age range of your clients and the degree to which you witness age discrimination. People may be treated differently according to where they are on the spectrum of life. Stereotypical examples include treating an adolescent as foolish and immature, or treating a senior citizen as archaic and inflexible. There are many adolescents and older adults who would fit those descriptions, but there are many in these age groups who would not; thus assuming these roles is unfair.

Age can have an impact on how we perceive the world and what our goals might be. Age can determine how people perceive the clients and how the client perceives him or herself. For example, an 18 year old, a 48 year old, and an 80 year old may have different motivations to complete treatment. An 18 year old may want to please his or her parents, a 48 year old may want to keep his job, and an 80 year old may want to die sober. It is also possible that the same motivations can apply to different ages. Assuming the 80-year-old client has the goal to die sober is a subtle way we can make errors of commission.

Three questions to ask every client:

1. Have you ever been treated a specific way based on your age? If so, describe it and how you felt about it.
2. Does your age help you, or do you expect it to help, in your efforts to reach your goals (in the past and in the future)? If so, describe how.
3. Does your age act as a barrier in your efforts to reach your goals (in the past and in the future)? If so, describe how.

Gender Identity and Expression

Gender is a characteristic that has evolved to include male, female, transgender, or transsexual (or intersex). I assume the options of male and female are obvious to you, reader. “Transgender” refers to a person who was born one gender, but identifies with the other gender. People vary in how they express this identification: some may wear clothes congruent with their perceived gender, or adopt mannerisms, or surgically change their anatomy to better reflect the gender with which they identify. Transsexuals refer to people who are born with characteristics of both genders. Formerly referred to as hermaphrodites, and often referred to as intersex, transsexuals typically choose with which gender they would like to identify, but some clients may have not been able to make a choice, or some may opt not to decide. In some cases, the parents of the child decide at birth which gender the child should adopt, and surgically alter the child to only develop as one gender. Some clients feel their parents chose the wrong gender, and may identify more with the gender that was altered at birth.

Gender is a common influence in both addiction and recovery for some. Others will feel it has no effect. Clinicians must watch their own perceptions of gender to avoid making errors. For example, some clinicians will focus on issues related to children with their female clients only, neglecting the reality that many male clients are also interested in child issues.

A good way to get at the role gender plays in your client’s life, as well as a way to keep your own gender biases in check, is to ask the client five questions:

1. With which gender do you most identify?
2. How has gender been addressed in your family growing up and/or now? Were there any stereotypes or gender specific expectations that you felt? What was/is your reaction to those expectations?
3. What role, if any, has gender played in the situation that brought you to my office today?
4. Does your gender help you, or do you expect it to help, in your efforts to reach your goals (in the past and in the future)? If so, describe how.
5. Does your gender act as a barrier in your efforts to reach your goals (in the past and in the future)? If so, describe how.

Sexual Orientation

There are three generally accepted types of orientation: heterosexual, homosexual, and bisexual. “Heterosexual” refers to those who are attracted to members of the opposite gender, “homosexual” refers to those attracted to members of their own gender, and “bisexual” refers to those who are attracted to more than one gender. Your clients may strongly identify or may be questioning, unsure as yet with which sexual orientation to identify. It is important to note that someone can inwardly identify with one orientation, but outwardly act in a different orientation. For example, Jerry could be married to a woman but actually be attracted to other men and would identify as a homosexual. Thus, one cannot assume a person’s sexual orientation without directly asking him or her.

A person’s orientation, how accepting and comfortable he or she is, and how accepting and supportive the client’s family and friends can be vital pieces to understanding a client’s addiction development and can be suggestive in how to treat it. Clinicians can create errors of commission based on personal views of sexual orientation, which continues to be a hot topic today in our society. Where you personally fall may clash with your client’s views. You will need to put aside your personal opinions. Your job is no place to educate a client on your views.

A good way to get at the role sexual orientation plays in your client’s life, as well as a way to keep your own biases in check, is to ask the client four questions:

1. With which sexual orientation do you most identify?
2. What role, if any, has your sexual orientation played in the situation that brought you to my office today?
3. Does your sexual orientation help you, or do you expect it to help, in your efforts to reach your goals (in the past and in the future)? If so, describe how.
4. Does your sexual orientation act as a barrier in your efforts to reach your goals (in the past and in the future)? If so, describe how.

Disabilities

The term “disabilities” is vast and encompasses many people. Types of disabilities range from mild learning disabilities to severe developmental disabilities and everything in between. The ways people discriminate against persons with disabilities is equally varied, from failing to recognize that a disability is present to neglecting to make a program accessible. Learning disabilities are tough because they can easily go unrecognized, or be mistakenly diagnosed as something else, and therefore left untreated. We know more now about these types of disabilities than we used to, but it remains more obscure on the surface than other, more obvious conditions, and therefore discrimination can often come by errors of omission, in the form of neglect or failure to recognize. For example, a client may come to abuse substances because it helps them cope with symptoms of disabilities that are otherwise unrecognized.

Five questions to ask the client:

1. Have you ever been told you have a disability, or do you believe you have a disability? If so, describe your disability.
2. How has your disability been addressed in your family growing up and/or now? With your peers as a child and as an adult?
3. What role, if any, has your disability played in the situation that brought you to my office today?
4. Does your disability help you, or do you expect it to help, in your efforts to reach your goals (in the past and in the future)? If so, describe how.
5. Does your disability act as a barrier in your efforts to reach your goals (in the past and in the future)? If so, describe how.

Economic Condition

Economic condition refers to the status of a person’s economy, or his or her wealth and resources. This includes finances, employment status, dwelling, access to nutrition, transportation, and insurance. This may seem an irrelevant form of discrimination, but people are often discriminated against based on their socioeconomic status. Assessing one’s economic condition is a bit trickier than assessing the other demographics we have discussed because so many different factors make up the economic condition and to ask may seem impolite or irrelevant. This discomfort can easily lead to errors of omission.

Awareness of socioeconomic differences is an important aspect of working with diversity (Pope & Vasquez, 2007). A good way to ask the client about his or her economic condition is to ask five questions:

1. How would you describe your economic condition growing up, meaning your wealth and resources (finances, employment, dwelling, nutrition, transportation, insurance, childcare)? What was the experience like for you?
2. How would you describe your economic condition now, including how you feel about what you describe?
3. What role, if any, has your economic condition played in the situation that brought you to my office today?
4. Does your economic condition help you, or do you expect it to help, in your efforts to reach your goals (in the past and in the future)? If so, describe how.
5. Does your economic condition act as a barrier in your efforts to reach your goals (in the past and in the future)? If so, describe how.

The fourth question is important because it can help clients begin to feel grateful for what they have, a vital part of any recovery program and very effective in fighting the “poor me” attitude that often is a part of addiction. The fifth question is helpful because it will give you a list of barriers you will need to address with your clients to ensure they meet their treatment needs.

Drug and Method of Choice

What? Drug of choice is not a discrimination category, you say? Au contraire! Surprisingly, discriminating against someone’s drug of choice is a blunder that even substance abuse counselors make. Drug of choice refers to the specific drug that, if given a choice of all drugs, is the drug a client would choose to use. Some call it a favorite drug, others call it the drug that the client struggles with the most, still others refer to it as the drug that is the hardest to quit. It is usually the drug that your client will identify when they are asked what they are needing treatment to address, although some may hide it and present another drug in its place.

There is a lot of stigma associated with problem drug users (Lloyd, 2012). How we discriminate is quite simple; it works like this: Say you have a cocaine addict walk through your door. What are you going to assume about his cocaine experience? Would you expect that he used cocaine to gain energy? Would you expect stories of feeling ultraproductive, of staying up for hours on end, of neglecting to eat or drink? If you expect these things, you will be correct much of the time, as cocaine is a stimulant that typically gives those outcomes. However, not every cocaine user has that experience. Many cocaine users have a paradoxical experience, cocaine slows or calms them down and focuses them. Let’s say you have a heroin addict walk through your door. What are you going to assume about her heroin experience? Would you expect that she uses heroin to numb her pain? Would you expect stories of nodding out or sleeping much of the time, of slowing down and letting the days pass without much productivity? Again, you will be correct much of the time, as heroin is an opiate that typically gives those outcomes. However, not every heroin user has that experience. Many heroin users also have a paradoxical experience; heroin gives them energy and productivity, allowing them to focus on completing necessary tasks. We can also assume experience of drug use, such as heroin use by criminals and cocaine use by the wealthy.

A good way to get at this dynamic in your client’s life is to ask the client four questions:

• Which drug do you identify as your drug of choice?
• What is your experience when you use the drug: What benefits do you enjoy; what side effects or outcomes annoy you?
• Does your drug of choice help you, or do you expect it to help, in your efforts to reach your goals (in the past and in the future)? If so, describe how.
• Does your drug of choice act as a barrier in your efforts to reach your goals (in the past and in the future)? If so, describe how. For example, an alcoholic who has to pass three bars between his train stop and his home.

Diagnosis

A diagnosis is a label that is given to a client by one who is trained and licensed, which indicates the illnesses and chronic conditions that clients have or with which they struggle. Each label denotes a collection of signs and symptoms that make up each illness or condition. All current psychiatric diagnoses, including the addictions, are listed in the Diagnostic Statistical Manual (DSM).

Historically, addiction diagnoses were teased out of the other psychiatric diagnoses and treated separately (Whitter et al., 2006). Technically, a Substance Abuse Disorder is a psychiatric disorder, even though it continues to be treated as a separate condition, and few are diagnosed with only a Substance Disorder these days. Most are labeled dually diagnosed, and treatment efforts are significantly enhanced when addiction counselors include the psychiatric and medical diagnoses and necessary medical treatment in the clients’ clinical picture. We cannot treat their medical diagnosis, but we can ensure they have a physician who is able to treat them, and we can discuss their care with that doctor to ensure the best treatment of the client.

Dually diagnosed clients should be an “expectation instead of an exception” (Cline & Minkoff, 2008, p. 55). In reality, most of our clients are triple-diagnosed with an addiction, another psychiatric illness, and a medical disorder (Katzman & Geppert, 2008). They are often not viewed as a priority for care, and are described as misfits to the system, often as if they have “dared to have more than one disorder” (Cline & Minkoff, 2008, p. 57). With programs that are poorly equipped to help the dually diagnosed, this population often suffers poor outcomes with an increased risk of death (Cline & Minkoff, 2008). Clinicians must anticipate this will be the reality and work hard to accommodate their needs. Stigma against the mentally ill, including discrimination and prejudice is an unfortunate reality for many clients. Clinicians are susceptible to the same errors of commission. We are also at risk of committing errors of omission.

One simple way we do this is to assume the diagnoses the client has been given are accurate and supported by the client. Or if not supported by the client we assume they are wrong. Don’t assume, ask questions. The first step is assessing the client’s diagnoses and the effects they are experiencing.

Five questions to ask to assess the effect of diagnosis on your client’s life include:

1. What, if any, diagnoses have you been given in your lifetime? With which of those do you agree and disagree?
2. How has your diagnosis(es) been addressed in your family growing up and/or now? What was/is your reaction?
3. What role, if any, has your diagnosis(es) played in the situation that brought you to my office today?
4. Does your diagnosis(es) help you, or do you expect it to help, in your efforts to reach your goals (in the past and in the future)? If so, describe how.
5. Does your diagnosis(es) act as a barrier in your efforts to reach your goals (in the past and in the future)? If so, describe how.

Now that we have a good idea of the different groups that are discriminated against, let’s consider how we specifically discriminate in our practices. There are several ways we can discriminate against our clients, some more overt than others, among them access to treatment, judging, forwarding the stereotype, assumptions, language, and humor. Access to Treatment Withholding or changing access to treatment services for certain people based on a specific characteristic or membership in a group is an example of professional discrimination. People may not have equal access due to their beliefs (Venner & Bogenschutz, 2008). We have mentioned that the pillar of justice requires us to give equal treatment across a group. This includes the ability to access that treatment. For example, access to treatment is a common way that people with varying economic conditions experience discrimination. People are unable to access needed treatment either due to a lack of funds or a lack of good insurance based on their income level. Access to resources can be another form of discrimination: for example, if a client cannot utilize the resource because of a lack of transportation or a lack of child care.

The second step is to ensure that clients have the best treatment that fits their needs. There is no single best practice for those dually diagnosed; often we try to bend the patient to fit the program, or we bend the program to fit the client (Cline & Minkoff, 2008). The most important aspect of our treatment planning is that we ensure beneficence by treating the dually diagnosed as desirable clients (Cline & Minkoff, 2008).

Judging

Judging someone, or an aspect of someone, because of a characteristic is another example of how we discriminate. People can judge in blatant or subtle ways. We can judge a person based on the psychiatric label with which they arrive. It is acceptable to be frustrated with someone’s symptoms—the client most certainly is at times—but it is not ethically fair to judge clients as frustrating because of their illness.

One tactic that can be beneficial and combat discrimination is to encourage clients to separate themselves from the label of their mental health diagnosis. A person is not a diagnosis, a person is a person with a diagnosis, meaning that he or she is a person first who happens to also have these extra symptoms that are impairing. Regardless of what is written on paper, you can diagnose him or her in a few seconds, stating:

As clinicians, we also need to see each client as Sally with her symptoms, rather than Borderline Sally. If we can separate the two, we have a better chance of treating Sally as Sally, and her symptoms as her symptoms, without mashing them together. It will also help us not have visceral reactions whenever we see a client who has been challenging in the past. If we focus our frustrations on the symptoms and not the person, we should be more amiable when we see him or her, which allows us to give better treatment and to better protect the client.

Forwarding the Stereotype

Forwarding the stereotype occurs when you buy in to an existing stereotype and treat a client as if it is true. For example, there is a hierarchy of drug use that most users adopt as they develop their addiction. It goes something like this: “Well, I may use pot or alcohol, but at least I’m not messing with pills. Serious addicts use those.” Until the user begins to use pills; then it is “Well, I may use pills, but at least I don’t use meth. Seriously messed up people use meth.” But then the user finds meth is not too shabby, so then he or she may say, “Yeah I dabble in meth, but at least it’s not snorting cocaine or smoking crack. Those people are wack.” And then you hear, “Yeah, stimulants are my thing, but it’s not that bad, could be worse. I could be doing heroin. That stuff makes you a serious addict and there is no turning back.” And last but not least, most people hold out for IV use, saying “At least I’m not shooting my drugs. Those people are all sorts of messed up.”

This same hierarchy can be used by clinicians without realization. We may see pure alcoholics (if we can even find them anymore) as lower maintenance, lower severity, fewer issues, not as hardcore, and more likely to adhere to treatment and succeed in recovery. Those of you who have worked with alcoholics, is any of this true? No, alcoholics have the same pitfalls, challenges, and success rates as any other drug user. Drug addicts lie, steal, cheat, manipulate to get their drugs. Well, wait, so do alcoholics! So do nicotine addicts! Just because the drug itself is legal does not mean the associated behavior is legal or less severe. We certainly don’t help by separating out alcohol from the other drugs we treat, as we do in the very title of our credential. Treating clients addicted to heroin as more “hardcore” or sicker than clients addicted to alcohol is forwarding a stereotype.

The best thing to do is challenge it. Sometimes we have to challenge discrimination clients have in themselves. For example, Ashley is the only girl in a family with six children. Having five brothers influenced her life in that she adopted a “tomboy” attitude and avoided “girly” things when she was growing up. Sadly, all of the children developed addictions and other illnesses in young adulthood. Yet while Ashley’s parents give their sons unending support in their treatment efforts, viewing their addictions as illnesses they could not control, they judge Ashley for her addiction, viewing it as a moral character flaw. Although they see the need for their sons to obtain treatment, they believe Ashley simply needs to “grow up and snap out of it.” As a clinician charged with treating Ashley, challenging the damaging views she has weathered will be vital to her treatment success.

Another example is the attitude toward Alcoholics Anonymous (AA) versus Narcotics Anonymous (NA) meetings. AA is thought to be filled with more serious recovery and NA is seen as filled with more drama. This could be true, depending on what the meetings are like where you live, but this is not always true. Sometimes the opposite is true. As a clinician, you will not only need to educate clients, particularly in the group setting, about this faulty discrimination, you will also need to check yourself to make sure you are not making the same assumptions and teaching a client that more serious recovery can be found in AA meetings and more drama in NA meetings.

Assumptions

When we make assumptions about our clients, we are automatically at risk of making blunders and of discriminating against them even if our intentions are positive. For example, those who are dually diagnosed are often assumed, even by clinicians, to be med seeking (Venner & Bogenschutz, 2008). Clients with a criminal past are assumed to be more severe, tricky, and slippery (Venner & Bogenschutz, 2008). When a client exhibits denial of a problem, we can judge them as noncompliant, forgetting that denial is a fundamental aspect of addiction (Powell & Brodsky, 2004).

A subtle way we can discriminate is by lumping all people together and denying the importance of their differences. For example, Mary is a devout Catholic who believes God is telling her not to use drugs ever again. She also believes He is telling her that all she needs to do is trust in Him and He will remove all her compulsions to use. She is denying any need for formal treatment or self-help, believing instead that attending church services is all she needs to obtain and maintain recovery. Clive is an atheist who bristles at the concept of using religion in the treatment of his addiction. He is staunchly against 12-step programs, the attendance of which is a required component of the treatment program he is attending. Both Mary and Clive are influenced by their religious beliefs and are using their beliefs to inform how they pursue the treatment they need to address their addictions. Can you see how unsuccessful treatment could be in both cases if the clinician did not learn these important client perspectives? If you do not address these viewpoints, and help clients navigate through their restrictions, they will not get the treatment they need. Simply stating the program is not religious, but is spiritual, will not address their needs.

People may use legal and illegal substances as a social lubricant in social settings. This may occur even more often if people are engaging in social situations that access their sexual orientation. Many people use alcohol and drugs simply to make a good time even better. And then many people have no correlation with alcohol, drugs, and their sexual orientation. Remember not to assume the nature of the correlation or that there is a correlation at all. The only way to avoid making erroneous assumptions is to ask your client. Anytime we assume to believe how our clients’ addictions work for them, particularly how they intersect with an aspect of their demographics, we are violating the principle of cultural diversity.

We run the risk of missing vital information if we assume and neglect to ask the simple questions: What did the drug do for you? What was your experience like, what did you like and dislike about using? These are the questions that are going to guide your treatment plans because whatever benefits they received from using are going to be the benefits you have to find in other, healthier avenues. If we assume an ecstasy user wants the stereotypical social benefits of the drug, we are going to focus on finding other ways to enhance the client’s social life without the drug. But what if we are wrong? What if the client’s social life is just fine, but he or she uses the ecstasy to help in a crumbling marriage? Helping a client’s social life without assessing the marital distress is going to leave this client with the probability of relapse since we are not giving focus to his or her needs. Ask the questions. You also may get clues about other treatment modalities that are indicated by how they respond to these questions. For example, if you have that cocaine addict who is telling you that cocaine calms him down and allows him to focus and complete tasks, you may want to refer the client to someone who can evaluate him for a type of attention deficit, as there is a correlation suggested in the research between children with ADD or ADHD who later become stimulant addicts (Jaffe et al., 2005). If that is true with your client, you will have to address other ways of coping with those symptoms in order for long-term recovery to be successful.

Language

In addition to making assumptions, the language we use with clients can also reveal judgments based on demographics. The language we use can be subtle and seemingly innocent, but it can also be damaging and unethical. Be careful with the vocabulary you use, the tone of your voice, and the nonverbal language you communicate when asking a client to describe his or her disability. If you clue in the client to your feelings or assumptions you can be quite offensive to your clients, even if unintentionally. Use a neutral tone and ask them to talk a bit about their experiences and how their cultures have affected their life, both enhancing it and challenging it.

For example, Ronald is a competent clinician, and clients seem to benefit from his counseling overall, but he consistently uses language that his co-workers find troubling. Specifically, he speaks with an informal, stereotypically slang speech to clients he perceives have a similar ethnic background to his own. If he walks by a client whom he perceives has a different ethnic background, he calls out “Hello” cheerfully, but if he walks by someone he believes to be of a similar background, he calls out “Wassuuuup!” If he has to admonish a client for breaking a rule, he uses a stern voice with a client of a perceived ethnicity other than his own and a tender voice with a client of a perceived ethnicity similar to his own. If Ronald was asked, he would probably not realize the difference in his language, and would likely believe he treats all of his clients in the same manner. Here’s the tricky part. Many may appreciate his style as welcoming and bondforming, but others may not like it. And what of the other clients who witness this friendly language, noticing it is not how they are treated? Remember the pillars of justice and nonmaleficence.

One of the ways we misuse language seems like a compliment, when really it is a judgment. Here is how it happens: Counselor John comes in to staff meeting and says, “I just met my client Judy. She comes from a wealthy upper-class background. With all her advantages, it is surprising that she ended up a meth addict in this place. Meth knows no boundaries.” Now, while this last statement is true, drugs do affect people of all classes, he just judged Judy in the process, stating that because she is wealthy she never should have turned to drugs, as if wealth and advantage should have steered her away from this life. Why would it? Similarly, John is making a judgment if he comes into the meeting and says, “I just met my client Judy. She is from poor crime-infested projects. I can’t believe she made it to treatment.” Again, this seems like a compliment, but don’t you feel the same way about all your clients? It is always a miracle when clients walk through our doors seeking help, no matter what their background. It is not easier to walk into treatment if you are wealthy. It may be easier to access treatment (i.e., pay for it), but walking through those doors for the first time is an extremely hard step no matter who you are.

Another way we discriminate is to joke with people about their characteristics without establishing a rapport that allows for such joking. This is a fast way to laugh at someone, not with someone, and it makes all the difference. How many times have you sat in a group of clinicians and one says “Oh that Jane is so borderline,” or “I can’t deal with Bipolar Paul today, can someone else talk to him?” Symptoms of various illnesses can be particularly challenging to us, especially on those days when we are not at the top of our game. We need to blow off steam and humor can be a great way to relieve stress. But humor at a client’s expense is unethical. The language we use and the attitude we allow toward our clients is of utmost ethical importance.

We discriminate against someone when we fail to accept them, or when we have a visible reaction when learning about him or her. As a clinician, you must train yourself to keep your personal views hidden from view when you are at work with clients. If you know this is an issue for you, do not feel badly. We all have different ways our personal views can snag us at the workplace. But it is your responsibility to walk into your supervisor’s office, sit down, and discuss how to address the issue at the workplace, perhaps role modeling so that you can ensure that your reactions are nondiscriminatory.

How you ask questions of your clients makes a difference. For example, Bob, a client in his seventies, was quite upset about his experience the previous day with the intake coordinator on duty. The counselor, on learning his age, said, “Bob, tell me why you are here for treatment. You are so much closer to the end of your life…why don’t you just enjoy it?” Bob took this to mean “Why don’t you keep drinking since you have so little time left?” This may scream “offensive” to you, but when the intake coordinator was approached, she was surprised that anyone would be ruffled. She said, “I didn’t mean to offend him at all, I was just trying to understand why he was electing to start treatment now. I was trying to be affirming of his circumstances, and not to assume anything about him, but to ask questions instead.” Her intentions were quite right, in that we teach clinicians to meet the client where they are, and to ask many questions to understand their specific circumstances. Her mistake was in asking a closed question; a better way to ask the same thing would be: “Tell me why you chose to come to treatment now.” And either then or at a different time in the interview, “Do you expect your age to have a positive or negative (or both) impact on your recovery efforts, or has it already? If so, tell me more.” This is an open-ended question, and truly allows exploration from the client on all sides of the possible issue, while also allowing him to say that it has no impact at all. It is better because it doesn’t assume there is an impact. Let’s take a look at some examples:

Taylor, a client in her early twenties, was sitting in an early recovery group, which was largely skewed to an older (midlife) crowd. There were two other clients in their twenties in the room, and about 13 clients older than 40 years. Taylor there for opiate pill use, and the counselor asked whether she had ever used heroin. Taylor replied that she had never touched heroin, nor had any interest in using it. The counselor then rattled off several statistics she had read in a newspaper about the percentage of young adults and teens who were using heroin these days, and implied that there was a good chance she would use it before committing to recovery for the rest of her life. The other adults in the group nodded their heads, one saying, “Yeah, you still got time to hit bottom.” The client was so mad she left group, and expressed a desire to leave group treatment altogether. When the clinician was told the client was upset and wanted to leave, her reply was “Yes, she is a young, heated thing, headstrong, hard to educate. I’m not surprised she wants to quit when the heat turns toward her.” The clinician saw nothing wrong with her own behavior. When pressed, she stated that she often uses clients in group as examples in what she called “teaching moments.”

The clinician is not entirely incorrect: Groups are often filled with teaching moments that come from an interaction with a specific participant. But few people enjoy having statistics spewed at them, especially when loaded with assumptions. It turns out that this particular client, Taylor, felt strongly about not using heroin specifically because her brother had overdosed using it, a fact that the clinician would have known if she had merely asked the client why she had no interest in heroin, rather than retorting with the number of youth using the drug as evidence that she would walk the same path. The statistic may be well bolstered in the general public, but that certainly does not prove that the client sitting in front of you will fall into the same fate. Statistics can be used in education, but are better used if you explain the statistic and then ask participants to comment with reactions to the statistic. You are likely to get better results when you allow them a voice. Even if your assumptions prove to be correct, it is better to allow the client to apply the principle, or statistic, to his or her own life.

The other factor in this example is the necessity of scanning your group for the daily demographic before starting in on anything that can single out a few members. If the clinician had realized that the group was skewed toward older adults, one would hope she would have been more sensitive to calling out youth as an issue knowing how it would isolate a few members against the rest. The fact that there was nodding and comments related to age should have given her a clue. She could have covered herself by throwing in a statistic about another age group so that the discussion became more about age in general and not solely teens and young adults, which would have evened the playing field and diversified the topic. If your group has one male and 13 females it would not be a good day to introduce the topic of relating to the opposite gender. If 13 people are talking about men and there is only one man in the room, he is going to feel isolated and perhaps attacked simply by the demographic. You would be better served by waiting until you have a more even gender demographic in the group to bring up that topic.

Charlotte attends addiction treatment at an outpatient clinic in a city. She attends AA in a neighboring affluent town, close to where she lives. The meeting has excellent recovery and attendees show a strong commitment to helping each other “work the steps.” Lincoln is also in her treatment program and lives in the city, in the poorest section. John, the group counselor, overhears Lincoln asking Charlotte about these AA meetings she talks about, and whether he could attend with her sometime. Because the meetings are outside of the city, and Lincoln cannot afford his own transportation, he is at the mercy of Charlotte and others to give him rides, which unsurprisingly causes him to miss out on many meetings and other opportunities, like employment, outside of the city. John notices Charlotte winces slightly when Lincoln asks her, and hears her tell him, “Oh no, Lincoln, I don’t think you would like the meetings. The people are really different there. I’m worried you wouldn’t fit in.” Discouraged and embarrassed, Lincoln slinks away. Charlotte watches him walk away for a moment, and then turns to another group member and asks if he wants to carpool to the meeting.

John suspects Charlotte is less concerned about Lincoln and more worried about herself and how it would look to members of the meeting if she brought him. John knows that Charlotte and Lincoln come from very different backgrounds and socioeconomic statuses. John is not sure if this is the issue, but it appears suspicious. It would be beneficial to both clients if John can help Charlotte see how she is making assumptions about Lincoln and discriminating against his economic condition. John approaches Charlotte and asks why she is not willing to take Lincoln to the meeting. At first, she tries to give other excuses, but John gently refutes each excuse, telling her he saw the interaction occur and what she said to Lincoln. Charlotte then admits that she does not want to bring him to the meeting, that she feels people will make negative assumptions about her and did not know how to tell him that. With this honesty, John has an opportunity to discuss the idea of treating Lincoln differently because of his background and question whether Charlotte is motivated by her own fears. Charlotte may not change her behavior, as it is entirely her choice to act as she sees fit. The point here is not to change the behavior, but that John makes an attempt, that he does not sit idly by after witnessing discrimination in his clients without attempting to educate them. Many clinicians would turn a blind eye, not wanting to address it, but the ethical action is to work through discomfort in order to honor the principle.

Can you see how you will fail this principle at some point in your practice, and most likely numerous times, often without your awareness? Now that we understand who we are at the risk of discriminating against and how we are at risk of doing it, what can we do in our practice to ensure we act ethically? We want to do all in our power to avoid discriminating against our clients, seeking supervision and counsel every chance we get to ensure our ethical practice. We also must include culture not only in our intake assessment, but in treatment planning as well (Venner & Bogenschutz, 2008). How else can we ensure nondiscrimination? Let’s look to the four pillars as a guide.

The pillar of justice suggests that we treat all clients the same. This does not mean that we treat all clients as part of one culture and make assumptions about them based on what we learn of that culture. Hopefully by now it is clear that is not the ethical way to treat your client’s cultural background. Instead, you want to treat all cultures, including ones that are personally similar to yours, with the same degree of curiosity and discover the cultural impact within each client. The pillar of autonomy allows for clients to teach us about how culture works for them. Use a neutral tone and ask them to talk a bit about their cultures and how culture impacts them. It will both benefit the clients and decrease our risk of discriminating against them. The pillar of beneficence has us take care to plan, promote, and practice an accepting attitude that keeps the focus on providing good, ethical health services. This focus helps us refrain from cultural discrimination. Finally, the pillar of nonmaleficence helps us avoid directly causing harm. Be mindful of the interactions you have with clients to ensure you are not subtly harming your clients.

While it should be the absolute aim to refrain from discriminating against clients and colleagues based on their characteristics, it is impossible to avoid completely based on the simple fact that we each have scripts in our head that dictate both how we perceive people (which leads to prejudice) and how we react to people (which leads to discrimination). These scripts can come from both personal and professional influences, both of which can lead us down a dark path to an ethical dilemma. Before we examine that, there is one more important principle that guides us to protect the client: Building a healthy relationship is a critical piece of your ethical practice.

Treatment and Treatment Settings

Counselors working in various settings (e.g., community agencies, colleges, and school settings) should understand the unique focus found in treatment for alcohol and drug-addicted clients. Beyond this, they should also have knowledge of the many aspects associated with treatment. In this chapter, we inform counselors on what alcohol and drug treatment entails, the functions and goals of treatment, how counselors can motivate clients for treatment services, who can benefit from addiction treatment, and the levels of treatment and medical care (i.e., outpatient, partial hospitalization program [PHP], detoxification, inpatient, halfway house) that exist. We provide three case scenarios and an application of the information presented.

What Is Treatment?

Treatment is the external therapeutic process that clients are exposed to through education on addiction including group, individual, and family modalities. White (1998) defined treatment as “the delivery of professionally directed services to the alcoholic or addict, with the primary goal of altering his or her problematic relationship with alcohol and/or drugs” (p. 334). Alcohol and drug treatment, whether conducted through outpatient or inpatient settings, is designed for clients who meet the criteria for alcohol, drug, or both types of dependency as articulated in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). These clients may also be abusing other substances.

Addiction involves the compulsive and excessive use of drugs and alcohol with subsequent negative consequences. As a result of the well-formed defense system (i.e., denial, minimizing, rationalizing), clients are not always aware of how out of control their behaviors are and the resulting impact on others. Treatment provides a setting for addicted clients to identify their defense system. Treatment also provides a means to increase the client’s understanding of emotional problems (both current and historical). These insights connect clients with the consequences of their use, which can have a significant impact on the denial system. Treatment also allows for personal examination of thoughts and behaviors that contribute to the continued use of drugs and alcohol. The power of addiction convinces its victims that alcohol and drugs are not a problem. To address this irrational thinking, the therapeutic modality of group counseling is used in most addiction treatment programs. Through the process of group interaction, clients provide one another feedback and support to draw out painful emotions associated with their drug and alcohol use. As a result of such support, along with education on various aspects of addiction, clients are able to understand the realness of their addiction. This culminates in an increased commitment to a recovery program coupling abstinence with new behaviors and management strategies.

Function and Goals of Treatment

The function of alcohol and drug treatment is to provide structure, feedback (peer and staff), education, counseling (group, individual, family–couples), and coping skills to clients. These entities merge as the client internalizes and creates an abstinent lifestyle. Treatment decreases isolation, encourages useful social connections, and instills hope in a seemingly hopeless situation. Ultimately, the goal for most alcohol and drug treatment programs is to help clients cognitively and emotionally assess their relationship with drugs and alcohol. This new awareness results in the development of a personal recovery program.

It is common for clients to attempt abstinence on their own before entering treatment. The problem for many individuals is not discontinuing (at least for a while) the drug but rather remaining abstinent on a continuous basis without the proper coping skills and support. For some, medical intervention and inpatient detoxification are needed to assist in the process of withdrawal from their drug of addiction (N. S. Miller & Gold, 1998).

This, however, is not the case in methadone treatment where the treatment goal is for clients addicted to narcotics to take their methadone (a narcotic substitute) on a regular basis to avoid withdrawal symptoms from heroin or other narcotic drugs. In this type of treatment the client is maintained on methadone. While in the methadone program, clients agree to three key therapeutic rules:

1. To remain abstinent from all other drugs and alcohol except for methadone,
2. To attend counseling sessions, and
3. To take their prescribed dose of methadone at the clinic.

Some clients remain in a methadone program for years, whereas others use it as a means to wean off narcotics and into a drug- and alcohol-free lifestyle.

How Do Counselors Help Motivate Clients to Enter Drug and Alcohol Treatment?

One of the significant challenges counselors have when working with addicted clients is motivating them to consider alcohol and drug treatment. Just because clients discuss their drug and alcohol use in session does not necessarily mean they are ready to make a meaningful, substantial lifestyle change. The more informed counselors are regarding the treatment structure, location, cost, and time commitment for clients, the better able they are to work with client ambivalence.

Referring a client to alcohol and drug treatment can represent a substantial commitment of time and energy on the part of both the client and the counselor. For example, clients who are ambivalent about treatment may need to discuss their fears and anxieties concerning treatment, where the facility is located, and how much it might cost before they entertain the thought of entering treatment. In this process, counselors want to work with clients to sign a release of information to the receiving facility to help coordinate the admissions process. This usually entails providing the diagnosis, overall counselor impressions, concerns, and recommendations. The more roadblocks to treatment that are addressed by counselors, the greater the likelihood clients will comply with the treatment referral.

For instance, imagine sitting with your client (Dale) who is presenting symptoms of cocaine and alcohol dependency, yet is resistant to the idea of discontinuing his alcohol and drug use. You feel strongly that he could significantly benefit from entering a drug and alcohol treatment program. As you work with him in individual counseling you realize that most of his problems are intertwined with his alcohol and drug use. He does not agree with this perspective. How do you address drug and alcohol treatment with Dale without him discontinuing counseling altogether?

Motivational interviewing can be an effective method of working with client ambivalence, whereby the counseling relationship itself creates the groundwork for a potential referral. Just because treatment resources in the community exist does not mean Dale is prepared to go. What this strongly suggests of counselors is to work on client preparation. Failing to do this will probably result in the client not showing for the referral appointments and possibly discontinuing counseling.

Picture another scenario: You just received a phone call from parents who want their 32-year-old daughter (who lives at home with them) to enter addiction treatment. How do you help these parents motivate their daughter for treatment?

As in the previous case, counselors need to understand the nature of their clients’ motivation and existing therapeutic leverage. An example of therapeutic leverage is found in the court system where judges, in lieu of incarceration, refer clients for assessment and addiction treatment. In these cases, the use of therapeutic leverage suggests counselors might respond to a client in the following manner:

The intention of the previous statement is to help the client recognize there are choices: to comply with treatment recommendations or risk losing a good job and being sent back to court for noncompliance. It is the counselor’s responsibility to remain objective, outline the choices, and explore the consequences of each possible decision. In so doing, the counselor will be practicing in accordance with the ACA Code of Ethics regarding freedom of choice in counseling while emphasizing client responsibility (American Counseling Association, 2014).

Similarly, the mother who is calling for suggestions to motivate her daughter into addiction treatment will need to explore what leverage she could use to assist in the process. She might say to her daughter that unless she attends an addiction treatment program, she will be unable to live in the house, which is a very personal and difficult decision.

Who Can Benefit From Treatment?

Numerous individuals can benefit from alcohol and drug treatment; however, the primary benefactor initially is the addicted client. Others who receive positive effects from the treatment process include family members, friends, and employers. As a result of treatment, the addicted client can stop using drugs and alcohol, develop a personal recovery plan, and begin the process of healing family relationships. Some clients may enter treatment ambivalent about their drug and alcohol use. For these individuals, complete abstinence may not be a primary goal of the initial treatment. However, they can still benefit greatly from treatment by learning about their addiction, defenses, and the turmoil they have put themselves and others through when using drugs and alcohol. Treatment may plant the seeds for both current and future growth.

There are also those who discontinue drug and alcohol use on their own, without treatment. The literature suggests rates of 80%–90% abstinence if patients participate in weekly continuing care or Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings following discharge from an inpatient treatment program (N. S. Miller & Gold, 1998).

Clinical Example

When I (Ford) started as a counselor in the field of addiction in 1984, I interned in a detoxification unit where most of the patients were in the later stages of addiction, and their use of drugs and alcohol had significantly devastated their bodies. Most of the clients entered a 28-day inpatient treatment facility following detoxification. There were very few outpatient programs at the time, and the popular mode of treatment was inpatient. The advent of managed care initiated a reexamination of this length and type of treatment, and as a result, outpatient and PHP increased as quickly as inpatient programs closed down.

When Clients Are Ready for Treatment

Let’s say you know where the best alcohol and drug treatment program is located, you have helped the client understand and coordinate the financial issues, you have met two of the staff in the treatment program and were impressed, and most important, your client is willing to attend an initial screening appointment. The next step is determining which level of treatment your client needs.

Continuum of Treatment Care

This segment outlines the suggested criteria for admission into a variety of treatment settings: outpatient treatment, intensive outpatient treatment, partial hospitalization treatment, inpatient alcohol and drug treatment, and how treatment affects clients. The continuum of treatment care suggests clients are in varying points in the progression of their addiction, and therefore multiple treatment options are necessary.

The American Society of Addiction Medicine (ASAM; 1996; Magura et al., 2003) created criteria that allow for a broader continuum of care and make differentiations between adult and adolescent care. A common set of criteria has been developed to help determine a client’s severity and was designed to place alcoholics in the appropriate level of care. Critics argue that the emphasis on medical aspects of treatment may place clients in a higher level of care than appropriate. Indeed, some patients with severe alcoholism may work better in a lesser level of care rather than in inpatient treatment (ASAM, 1996).

ASAM has four separate levels of care, as listed below, which are evaluated on six other measures of severity in order to assess and refer a client for appropriate treatment.

ASAM Levels of Care
Level 1: Outpatient treatment
Level 2: Intensive outpatient (IOP) and partial hospitalization program (PHP)
Level 3: Medically monitored inpatient (residential) treatment
Level 4: Medically managed inpatient treatment

Dimensions of Severity
Dimension 1: Acute intoxication and/or withdrawal potential
Dimension 2: Biomedical conditions or complications
Dimension 3: Emotional and behavioral conditions and complications
Dimension 4: Treatment acceptance resistance
Dimension 5: Relapse potential
Dimension 6: Recovery environment

Outpatient Treatment

Outpatient treatment allows clients to attend sessions while residing in their own homes. Clients attend sessions either during the day or in the evening, and thereby they are able to maintain regular working hours. A study by Friedmann, Lemon, Stein, and D’Aunno (2003) suggested that outreach programs in the community should liaison with criminal justice and workplace programs to attract clients earlier on in their addiction progression when they are more likely to respond successfully to treatment.

Let’s suppose you refer clients to outpatient treatment. What happens once they begin? Following the initial outpatient assessments and treatment planning, they are provided a schedule of treatment groups, which meet every week. N. S. Miller and Gold (1998) reported that the abstinence-based method is commonly used to treat addiction in 95% of the programs surveyed. Control or cutting down is not the goal in treatment—only total, complete abstinence. This model subscribes to the disease concept of addiction, the process of progression, and the chronic nature associated with it. Both education and group therapy are the primary modes of counseling applied in treatment. Additionally, the Twelve Steps of AA are integrated into the treatment process, and outside attendance is required while in treatment.

Clients entering alcohol and drug treatment may feel scared, apprehensive, and uncertain about the decision to engage in the process. Many clients initially believe that they are the only ones who are suffering from this problem and feel uniquely isolated and alone. This is expressly why most treatment is in the form of group counseling, which addresses the isolation and helps clients recognize the universality of the problem (Yalom, 2005). In outpatient settings, the client is assigned an individual counselor (although most of the therapeutic work is done in a group format).

As clients observe others at various stages of recovery in the group, combined with gaining a sense of trust in the treatment process, they are able to start sharing the pain and consequences of drug or alcohol use in their lives. Through such sharing and self-disclosure arrives, maybe for the first time, a sense of connection with others without the use of chemicals. Patients can experience a profound awareness of the potential for healing in a group. These new therapeutic underpinnings provide clients with the courage to open up and allow others to hear their painful journeys. In turn, these stories help others who are new to treatment.

Outpatient treatment typically consists of weekly individual sessions and multiple group sessions per week. Outpatient programs regularly require family involvement, either through education groups or through family counseling sessions. A sample outpatient schedule might include group counseling on Monday and Wednesday (90 min each); attendance at AA, NA, or both types of meetings on Tuesday and Thursday; and individual counseling on Wednesday (60 min). Saturday and Sunday are for leisure activities, family interaction, and support meetings.

Outpatient treatment staff usually consists of an addiction counselor, a psychiatrist, and a consulting psychologist to provide psychological testing. One of the primary factors for outpatient admission is the limited or nonrisk of clients for severe physical withdrawal. It is also noted that clients should be able to respond positively to emotional support.

Intensive Outpatient Treatment

Intensive outpatient (IOP) treatment differs from outpatient treatment in a number of ways. One place they overlap is that clients are able to attend treatment sessions and maintain employment while living at home. IOP typically consists of three groups per week, 3 hours per session, as well as weekly individual and family sessions. The primary modality in IOP treatment is group counseling.

The increase in treatment contact is in relation to the need for structure given the client’s addictive process. Some clients are able to effectively use outpatient services, successfully meet their treatment goals, and remain abstinent. Other clients may continue to relapse and need significantly greater structure provided through IOP protocol. When counselors are evaluating clients for IOP, the following suggested criteria should be considered in determining the appropriateness for this level of care.

Partial Hospitalization Program

PHP differs from IOP in that it requires increased hours of treatment contact per week. The PHP is for clients requiring regular medical and psychiatric monitoring. PHP clients also do not meet the requirements for outpatient treatment because of their increasing severity of symptoms. At the same time, they are not exhibiting severe enough symptoms for admission into inpatient treatment. Clients typically attend partial treatment activities three to four times per week. Schedules for partial programs may range from 9:00 a.m. to 3:00 p.m. During this time clients are provided with education and skills-based programming in a group format, individual and group counseling, case management, and psychiatric assessment. Staff in these programs may include psychiatrists, nurses, recreational therapists, psychologists, social workers, and addiction counselors.

Detoxification

This medical component of treatment is generally associated with a medical facility. However, within the past 15 years, outpatient ambulatory detoxification has also become a viable alternative to inpatient detoxification for some patients. Appropriate clients, as evaluated by a physician, are those with low risk for seizures and those who have minimal medical complications. In some cases, there are clients who attempt abstinence without medical supervision. In other cases, clients realize the challenge of self-detoxification (and all the associated physical, emotional, and cognitive difficulties) and choose to enter a detoxification program. The process of admission to a detoxification unit is similar to checking into a hospital; however, at the time of admission, patients may be under the influence and less than cooperative. While working in the detoxification unit, there were many times that I (Ford) witnessed patients arriving intoxicated and unable to negotiate the short walk down the hall. Within minutes they would pass out in their beds, then awaken later that night disoriented and nauseated, ushering in the detoxification process.

Detoxification provides structure for patients as they are monitored (e.g., blood pressure, pulse, respiration) by the medical staff while their bodies expel the chemicals through various means (urine, breath, sweat). Physicians create a detoxification protocol depending on the chemicals ingested by the patient. Such interventions may include prescribing continuous fluids, aspirin, phenobarbital, Buprenix, or Librium (Caldiero, Parran, Adelman, & Piche, 2006; N. S. Miller & Gold, 1998).

When patients experience withdrawal, physiological issues such as nausea, fever, or muscle cramps emerge. It is during this time when clients (if they were not in detoxification) would potentially begin using drugs and alcohol to alleviate withdrawal symptoms. Instead, during detoxification, the medications prescribed aid in the management of withdrawal symptoms. While patients are detoxifying, the medications enter the patient’s body, preventing seizures and delirium tremens (DTs). Throughout detoxification, nurses monitor patients’ vital signs and observe for signs of potential seizure activity or respiratory issues. As withdrawal symptoms subside, patients are usually tapered off the prescribed medication before being discharged from the medical unit.

While patients are in detoxification, they are evaluated by nurses, physicians, and counselors. A full biopsychosocial assessment is completed for purposes of referral following detoxification. Although patients may experience physical sickness in detoxification, it is important that they participate in group therapy with other patients during their stay because of the natural tendency to isolate. While these interventions are occurring, the staff counselors (setting the stage for the next step in the process) provide ongoing assessment of clients and involve family, employers, and partners (with appropriate releases signed) in the process. Detoxification, for many, is the first step on the road to recovery.

Inpatient Alcohol and Drug Treatment

In the mid-1930s, when AA was cofounded, few inpatient treatment centers existed. Physicians willing to work with this population found many of their patients in a useless cycle of addiction. Clients engaged in a “revolving door” process where they would be detoxified, leave the hospital, only to get drunk again, and then reappear for help (White, 1998). Throughout the years as Bill Wilson, the cofounder of AA, worked toward his own sobriety, he had a personal physician, Dr. William Silkworth. In his lifetime, Silkworth worked with over 50,000 alcoholics, and as a result he believed two things. The fi rst was that alcoholism was not just a vice or bad habit but rather a disease. The second was that alcoholism was an obsession of the mind that condemns one to drink (Kurtz, 1979). As a result of the development of AA and people like Silkworth, structured inpatient treatment was introduced (White, 1998). Inpatient treatment staff consists of physicians–psychiatrists, nurses, leisure activities counselors, addiction counselors, social workers and/or psychologists, intake counselors, mental health counselors, and family counselors.

A typical inpatient daily schedule consists of group therapy twice a day, lecture education, leisure activity, and employer and family meetings, along with time to complete assignments, meet with counselors, and attend AA and NA meetings. Treatment days usually begin around 6:30 a.m. and end with lights out around 10:00 p.m. The unique feature of inpatient treatment in comparison to partial and outpatient treatment is that patients stay in the facility while they are receiving treatment. Patients’ lengths of stay vary depending on their treatment goals. Patients referred to inpatient treatment many times have failed to meet their goals in outpatient programs and are in need of an intensive structure to intervene on the addiction. Patients admitted to inpatient treatment are first evaluated by physicians for a detoxification protocol, and following that evaluation they may or may not enter detoxification. Although treatment programs are structured in different ways, most programs are anchored to the Twelve Steps of AA as a foundation for a recovery philosophy (N. S. Miller & Gold, 1998).

Halfway House

Following treatment (outpatient, IOP, PHP, or inpatient) clients may continue with structured support through placement in a halfway house. Within the context of a halfway house, individuals live with other recovering clients in a house or residence operated by professional staff. Staff can include a house manager, counselors, a facility director, and food preparation specialists. Clients may enter a recovery house for housing needs following treatment, the need for continuing structure, or both. Clients may live in a recovery house for up to a year, usually with the expectation of completing required work. In these settings, clients have weekly individual sessions with their counselors as well as group sessions. Clients are expected to focus on recovery, first and foremost (White, 1998).

Good candidates for admission into a halfway house are typically clients in the later stages of their addiction, who have had multiple attempts at recovery. These clients typically benefit from structure and ongoing support in the recovery process. Living in a recovery house offers clients the opportunity to attend treatment sessions while living in a recovering milieu. The overarching goal, of course, is for clients to eventually successfully transition back into the community.

There are also recovery houses that have no professional staff, relying instead on resident-determined guidelines. There is an expectation in these recovery houses for residents to attend Twelve Step support meetings on a regular basis and to keep current with their financial responsibilities to the house. They may have weekly house meetings or informal discussions but have no clinical staff to work with residents in individual or group therapy.

Therapeutic Communities

With the closure of many state hospitals around the country and the increased incarceration of those addicted to alcohol and drugs, the advent of therapeutic sprung from community need, whereby inmates were housed in separate units to address their drug and alcohol addiction issues. Given that the charge which brought them to be incarcerated was a symptom of their addiction, it made sense to institute addiction programming while they were incarcerated. It provides rehabilitation to those needing treatment that might not have the resources or access to it. Cost to effectively house an inmate who when released from jail–prison to address recovery and maintain abstinence has the potential to positively affect society, but, sadly, will be an issue of funding in this type of service.

The focus of the TC is to provide information on addiction as an illness, coping strategies, specific issues of employment related to legal status, dealing with cravings, re-engaging in society without the use of chemicals–alcohol, the development of a support group and the therapeutic and support resources in the community once released from incarceration. In this way inmates are serving time as well as learning about their addiction, which ultimately will affect any type of recidivism.

TCs became popular when the courts began to look at the repeat offenders and the substantial increase in alcohol- and drug-related crimes. Although charged with a crime (felony or misdemeanor) for drug possession, distribution, or crime related (check forging), many of the inmates are not criminals but rather are addicts and alcoholics whose symptoms of addiction include a legal charge. This is a hopeful distinction in that those suffering from addiction can make changes and enter into recovery. This is not necessarily true for those who have committed murder or rape.

Clients in the Continuum of Treatment Care

The following are client examples that help the reader understand the continuum of treatment care shown in Figure 6.1. Counselors need to understand how a client proceeds through the continuum and how they can best help clients through the process.

Mental Health Counselor Treatment Scenario

As a mental health counselor you see 25 to 30 clients per week in your office, many of whom are diagnosed with clinical depression. However, on this occasion, you meet with Jeff, a 32-year-old who presents with marital discord as his initial issue. Upon further communication with Jeff, you realize the precipitating event for his visit to your office was related directly to his use of alcohol. Jeff reports he drank 10 beers last Saturday evening then blacked out. He adds that he learned later from his friends and family that he yelled obscenities at his wife and the other couple having dinner at their house. These actions were followed by Jeff taking off all his clothes and jumping into the pool. The following morning he had no recollection of what had happened but realized he must have been out of control because he woke up naked in the bushes.

Jeff presents to you that his wife was very upset but indicates that this was a very rare occasion and that he typically drinks only one or two beers. However, he also states that he drinks “heavily” once or twice a month with his old college friends. He reluctantly admits that he came in for counseling because his wife was at her “wit’s end” and moved out of the house two nights ago. Although he appears remorseful, he doesn’t seem to be connecting his drinking with her moving out of the house. He admits that he has cut down on his drinking in the past because of his wife’s concerns, only to return to his usual pattern. Jeff also reports that he has promised his wife multiple times that he was going to stop altogether but ended up drinking anyway.

What Are the Strategies a Counselor Can Employ at This Point?

• Do you refer him immediately to outpatient treatment, or do you refer him to detoxification services?
• Is he a candidate for inpatient treatment, or are you going to see him individually?
• Will you refer him to an alcohol and drug specialist, or will you focus on his depression because of his wife’s moving out?

These are the questions counselors need to consider when clients like Jeff present for counseling. Let’s begin to review what a counselor could do at this point.

Precipitating Issue and Insight into Problem

At this point, Jeff’s understanding of why he is in your office is more related to his wife moving out and his potential relationship loss than to his drinking. He has not yet begun to connect his drinking with her leaving. His insight into his drinking behavior is minimal at best. However, he admits to tremendous sadness as a result of his wife leaving. Let us review what information Jeff has presented us: He has developed a tolerance to alcohol (by his report), and he has one recorded blackout (by his report). There is patterned drinking and a significant consequence (his wife leaving) of a drunken evening with friends (by his report). He denies experiencing any type of withdrawal symptoms when he stopped in the past.

On the basis of your assessment and using the DSM-5 criteria, you see Jeff’s drinking as an alcohol use disorder—moderate. In terms of the stages of change (Prochaska et al., 1992), he appears to be in the contemplation stage in that he has some understanding of how his drinking has affected others, and his wife’s absence is motivating him to initiate action: “whatever it takes to get her back.”

Creating the Therapeutic Bind

By its very nature, generally speaking, addiction is predictable and progressive. Understanding this construct equips counselors to work with clients. As W. R. Miller and Rollnick (2013) described, the therapeutic bind helps to motivate and work with the resistance rather than against it. In Jeff’s case, you might consider that he will probably drink again. Additionally, he may do so without control during the course of individual counseling with you. Up until this point Jeff is trying to convince himself and you that he can control his drinking. Addicted individuals think they can control their use, which is described fully in the next chapter.

You, on the other hand, realize it is probably only a matter of time before his drinking creates more consequences. As a result, you help Jeff create a contract that stipulates, “Just in case you can’t control or stop your drinking, will you go to treatment?” Jeff is now in a bind. If he refuses, he is admitting right there that he is not in control. If he says yes, you can work with Jeff by creating a plan for him to enter treatment.

What Level of Treatment?

Now that you have determined alcohol is the primary problem and that Jeff has some insight into the problem, the question emerges regarding what direction is best as he proceeds. Jeff might be a good candidate and appropriate for outpatient treatment. This assessment is based on his reported absence of withdrawal symptoms, his motivation to do whatever it takes to remain abstinent, and his diagnosis of alcohol dependence. However, he may not be willing at this point to enter an outpatient treatment program. If he is willing to enter outpatient treatment though, you can provide him resources in the local area, obtain a release of information signed by Jeff to relay the information to the intake counselor, and then encourage Jeff to take full advantage of the treatment process. You could let him know you would be willing to see him for follow-up care after the treatment program.

The other option, if Jeff is not interested in starting outpatient treatment, is to continue working with him in counseling. The primary goal may include helping him make changes so that his wife may return home. Working with this goal you can ask Jeff, “In order for your wife to return home, what do you think she would need to see from you?” More than likely Jeff will say something like, “Not drink or get out of control with my drinking.” Maybe he will say, “Not go out as much with my old college buddies and drink.” Jeff has now identified a pragmatic action-oriented behavior that aligns with the parameters of the primary goal (which will still involve him examining his drinking, the impact it has on others, and the current consequences related to it). Jeff may promise to you that he won’t drink or that he will control his drinking. He may be both convincing and sincere in doing so because he believes he has complete control over his drinking. You, however, understand the predictability of loss of control with addiction. Jeff will discover on his own that he cannot control his use and may experience other consequences while he is in counseling with you. You can also introduce early on the following proposition: If Jeff finds that he is unable to control his drinking and suffers more consequences, would he be willing to enter an outpatient treatment program? After the fourth session Jeff discloses how he got drunk on Saturday night in a local bar and obtained a driving under the influence (DUI) charge while driving home, then spent all day Sunday in jail. In addition to being angry, he also realizes for the first time how alcohol is ruining his life.

Working With Client Consequences in Individual Counseling

At this point you have more therapeutic leverage to help Jeff accept a treatment referral. You could intervene with,

Jeff can now decide to again refuse your referral to treatment, which would go against the promise he made to himself that if he couldn’t control his drinking, he would become willing to accept alternative intervention strategies and follow through with the referral. On the other hand, he could discontinue counseling with you rather than accept your referral, which places the importance of the therapeutic relationship and the development of trust in jeopardy. If the relationship has been built, it places Jeff in a therapeutic bind.

Confrontation or Carefrontation?

Dr. Bernie Siegel (1986), who coined the word “carefrontation,” believed that for helpers or clinicians to confront clients, they needed to do so in a genuine and caring manner for their clients to receive the feedback. Empathic statements help Jeff realize that both his wife and the court system would be supportive of treatment, should he choose to enter it. You are also gently carefronting in reminding him of his agreement to enter treatment, should his way not work. There is always the possibility Jeff will attempt a renegotiation of his initial agreement and once again try to control or abstain. Should the court order him into treatment, it would give him a significant message to move forward in the therapeutic process. Should the court referral occur, it is important that you prepare Jeff for treatment, educate him on what will occur, and offer ideas on how he can gain the most from it.

School Counselor Scenario

An 18-year-old student comes into your office to discuss her father’s alcohol use. Tiffany reports her father drinks at least a 12 pack every night, verbally fights with her mom, and then falls asleep by the television. She states that this has been the pattern for the past 7 years, after her father lost a job because of his drinking. He has been unemployed for more time than he has been employed over the past 7 years. Tiffany says that her home life is affecting her ability to concentrate in school and that on the weekends she sometimes “smokes weed” to “mellow out.” She says it is not a regular thing, but she does it because it makes her feel relaxed and less tense at home. She also said that if her father ever found out she smoked pot, he would kick her out of the house.

As the school counselor, you’ve known of Tiffany from her involvement in school plays and the track team. Because this is her senior year, you inquire about her postgraduation plans, at which point she tells you she is not going to college but will move in with her 25-year-old boyfriend, who also drinks a lot.

Presenting Event and Insight into Problem

Tiffany came to counseling reporting a lack of sleep, poor attention in class, and feelings of depression. She is aware of how her father’s drinking is affecting her life and the rest of the family and realizes how, in turn, this issue affects her involvement with other activities. Given this information, what might you conclude? Does she have a substance abuse or dependency problem? Would she benefit from addiction treatment?

On the basis of the information Tiffany gave you, you conclude that she is aware of how tired and run down she is regarding her father’s drinking. However, it does not sound as if she is as aware of the relationship dynamics that are playing out with her boyfriend. Her use of marijuana at this point would need to be explored. Of particular concern might be the feelings she avoids or copes with by smoking pot.

What Level of Treatment Is Warranted?

In this case, it does not appear that structured, formalized treatment is warranted at this point. However, because of the high risk centered around her family and her father’s alcoholism, it would be recommended that you continue to see her individually and explore how alcoholism affects her life, as well as how it may affect the choices she makes with her partners. Continued evaluation and exploration of her marijuana use would also be important. Furthermore, preparing Tiffany for referral to the alcohol and drug specialist might be warranted. It would benefit both Tiffany and the therapeutic bind to acknowledge her honesty with you in the session about her feelings and drug use. For her to share about her marijuana use is a big step in trust, which is the cornerstone to counseling and to any referrals you might make in the future. An Adult Children of Alcoholics (ACOA) group may be appropriate, should it be offered in the school. A referral could be made to the community for ACOA support groups. Should she continue to use marijuana, questions such as, “What does marijuana do for you that you cannot do when clean?” “What can you do on marijuana that you cannot do when not using?” or “What does marijuana help you avoid or escape from?” would be appropriate to explore.

Preparing Clients to Accept Referrals and Help

It is important for the counselor to be familiar with treatment program resources. It is just as critical to work with clients to help them accept the referral. For instance, let’s say Tiffany mentions marijuana use and immediately you refer her to the alcohol and drug education group. Although it may be helpful for Tiffany to receive the information, she may not yet be prepared for the referral. Quite possibly she will either discontinue counseling or simply not follow through on the referral to group. This failure to prepare Tiffany may also mitigate her reaching out for counseling services in the future. In essence, along with not helping her move toward treatment, you may actually cause harm by setting up conditions that may signal that counseling is deceptive, hurtful, uninformed, uncaring, and so on. Working with her and teaching her how to accept help and the benefits of work in counseling is a goal in itself. Many times with selfreferred clients the referral to treatment by the counselor is too quick from the client’s perspective. Often, the client is simply not prepared or ready to move on the referral.

College Counselor Case Scenario

The 2005 National Survey of Counseling Center Directors (366 centers surveyed) indicated that 90.3% of the directors observed an increase in the number of clients with severe psychological problems. Ninety-six percent of directors believed that the increase of students with more serious problems is a growing concern in their centers, and 78% believed it was a growing concern for the administration (Gallagher, 2005).

As a college counselor you see a variety of clients each day with varied presenting issues. Patti is no exception. Her initial paperwork suggests she is depressed and has contemplated suicide within the past 2 months (though she has no current suicidal thoughts and has no plan). Her precipitating event, or her reason for seeking counseling, is the breakup of a 6-month relationship. Initially she says he was seeing other women and that is why they broke up. She continues to disclose details of her use pattern, including amount and consequences (she experiences periods of lost memory when she drinks). Patti tells you how she would go to a party with her boyfriend, only to wake up in someone’s house early the next morning not knowing how she got there or where she actually was. Her boyfriend would get drunk too and “mess around with other women when I was drunk.” Patti recollects how, for years, she watched her mother take pills, which would make her drowsy and incoherent. Patti says she really “got drunk” this past weekend and it scared her because some of the people she was now associating with also use drugs.

As with Tiffany in the preceding scenario, we have multiple issues to address: Patti’s depression, her significant alcohol abuse, the recent loss of a relationship, the significant consequences (both experienced and possible) related to her blackouts, and the impact her mother’s drug use had on her during her developing years. Should Patti be referred to outpatient treatment? Do you feel she has an alcohol problem? To what degree is there a relationship between her depression and her alcohol use, and does one lead to the other?

These are some of the questions most clinicians ask as they begin to work with a substance abuser. Patti’s depression appears significant and will need to be continually monitored with referral to the staff psychiatrist. Additionally, further assessment of depression in her family and current depression following abstinence is needed. Patti’s report of her alcohol use is of concern, particularly related to the previous weekend.

Might she benefit from outpatient treatment at this point? Yes. Because she is self-referred, she may be at a place where a referral will be accepted. However, it might take you time and effort to facilitate that step in the process. In the meantime, Patti has presented significant information to begin addressing her feelings, her blackouts, her relationship loss, and the previous weekend. All of these issues plus the ongoing assessment of her depression are critical.

Summary

This chapter discussed the various types of treatment sites in the continuum of treatment care and familiarized the reader with criteria for admission into detoxification, outpatient and inpatient treatment, and partial hospitalization. Additionally, scenarios were provided to help readers understand how a client might engage in the treatment process as well as how clinicians can work with them during this journey.

Exploration Questions from Chapter 6

1. What aspect of the continuum might you like to work in?
2. Have you ever worked with a client who has been in withdrawal? If so, how did you approach it?
3. If you haven’t worked with a client in withdrawal, how might you know the person needed detoxification?
4. What counseling skills do you feel would be important in helping clients obtain treatment?
5. Do you believe treatment (outpatient, inpatient, etc.) works or is effective? If so, why? If not, why not?
6. What happens when you have clients who cannot afford treatment but are in dire need?
7. How might you work in developing trust with clients of color who you are trying to refer to treatment but who are very wary of going?
8. If you are facilitating a group of clients, of whom only three out of the 10 are minorities, how will you bring this up as an area for exploration?

Suggested Activities

• Visit various sites of treatment care in your region and become acquainted with the treatment program and staff. Ask questions of the staff about their specific duties and determine how you might refer a client to their facility.
• Talk with patients about their experience in treatment and what was most helpful and least helpful.