ERIC Identifier: ED435893
Publication Date: 1999-00-00
Author: Sales, Amos
Source: ERIC Clearinghouse on
Counseling and Student Services Greensboro NC.
Substance Abuse and Counseling: A Perspective. ERIC Digest.
Substance abuse is a critical problem in the United States across
allsegments of the population and impacts in some way all members ofour society.
It is the most prevalent mind disorder, the number onecontinuing health problem,
and the number one prison problem in theUnited States (Inaba, Cohen, and
Holstein, 1997). The significantnumber of the United States population having
substance abuseproblems is indicated by approximately 6% abusing illegal drugs,
12%having problems with drinking, 25% being addicted to nicotine
and,conservatively, 10% addicted to prescription medications.
counselors no matter what their specialty or setting willencounter clients with
presenting or related problems of substanceabuse. However, counselor education
programs and their accreditingbodies do not require knowledge or skill
development in this area.Thus, it is critical that we implement strategies to
insure that allcounselors in practice and in counselor preparation
programsunderstand the process of substa
abuse is defined as the categories classified in the Diagnostic and Statistical
Manual IV (DSM-IV) (American Psychiatric Association, 1994) as Substance-Related
Disorders and Substance-Induced Disorders. These disorders include the active
use and/or dependency on any mood-altering substance. Substances include
alcohol, sedatives, amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opiods, caffeine, nicotine, and prescription drugs, as well as legal drugs.
Similar addiction processes to those of substance abuse include experiences such
as eating, gambling, sex, and work addiction. Addictive behavior is
characterized by preoccupation with the substance or the experience, withdrawal
symptoms after not engaging in the substance or experience, increased tolerance
for the substance or activity in order to achieve the same effect, and continued
use despite negative consequences. While similarities of behavior exist across
all types of substance abuse, individuals cannot be categorized, defined, and
treated in relation only to their substance abuse problem. An individual with a
substance abuse problem is unique in his/her history, pattern of use and abuse,
and counseling and related treatment needs.
many models of causation of substance abuse have been proposed, no clear
etiology has been identified. Models emphasize morality or individual conscious
choice, biological or disease vulnerability, behavioral learning patterns,
cultural-environmental concerns, or biopsychosocial impact. The biopsychosocial
model views substance abuse as a complex interaction of all of the other models
and endorses multiple strategies for counseling from these models as
appropriate. Counselors need to review these models to develop a conceptual
position regarding causation upon which he/she can make consistent therapeutic
assumptions and decisions to guide counseling practice.
regarding effective counseling strategies for counseling individuals with
substance abuse are limited in that this counseling specialty area has been
driven more by experience and clinical intuition than by research. As a result,
most traditional substance abuse treatment programs (e.g., Alcoholics Anonymous,
alcoholism education, half-way houses and therapeutic communities utilizing
confrontation, group therapy, individual counseling, and use of medication) have
not demonstrated their efficacy. Some successful treatment outcomes have been
linked to short-term interventions, aversion therapy, stress management,
solution-focused brief therapy, and social skills training, yet seldom are these
methods utilized in traditional substance abuse treatment programs in the United
States. Given this, conclusions regarding counseling and substance abuse have to
come from general counseling research data.
regardless of their settings, impact as change agents within the context of
therapeutic relationships with individuals. Successful relationships are
facilitated by a skilled counselor who helps the client become more invested in
the process and who utilizes therapeutic techniques appropriate to the client. A
thorough review of counseling outcome research (Sexton, Whiston, Bleuer, and
Walz, 1997 pp. 58-62, pp. 87-93) concludes the following:
Counseling is a process beneficial to most clients of skilled counselors.
However, it is not always so. A significant number of clients get worse.
Counseling models (e.g., cognitive, experiential, behavioral, dynamic) are
effective and, when compared, seem equivalent in their effect on counseling
Successful counseling has process factors which are common across the various
counseling models. These factors include the counselor's establishing an open,
trusting, collaborative relationship, facilitating client cognitive learning
through reframing, feedback, and insight, and assisting the client in behavior
changes through behavioral regulation, reality testing, and successful
Successful counseling outcome is dependent on counselor therapeutic skills such
as focusing conversations on life problems, addressing presenting problems
directly, and providing structure for counselor-client intervention.
Successful counseling progresses through various process stages, wherein
different types of counselor-client interactions are reflected by different
The above research conclusions support the
following perspective regarding counseling clients with substance abuse
problems. Counselors, to be effective, first must have the ability to develop an
open, collaborative relationship with clients wherein clients perceive trust and
commitment. Carl Rogers identifies, and research supports, this ability as
related to the counselor's skill in conveying, in interaction with clients,
unconditional positive regard and empathic understanding (Austin, 1999). Within
this relationship, the counselor must provide focus for the process by
addressing the client's presenting problems directly and identifying client need
for change. Counselors of clients with substance abuse problems often find this
process difficult because of the chronic nature of interrelated destructive
attitudes and coexisting disorders these clients often bring to counseling. Once
problem identification and client need for change are identified, the counselor
must be able to articulate and implement counseling intervention strategies
perceived by both the counselor and the client as appropriate to the client's
need to change.
process considerations in counseling clients with substance abuse problems hold
to be true for specialists in this area and for counselors working in school,
rehabilitation, mental health, and social work settings. The counselor emphasis
is on the person not the substance abuse problem. Additional knowledge and skill
on the part of the counselor relates to being able to assess the extent and
impact of a client's substance abuse problem and the client's need to change.
Familiarity with and ability to utilize standardized assessment instruments
specific to substance abuse will help the counselor in this assessment process.
Familial and social environment assessment also is required to identify the
extent of and to utilize the client's support systems. The counselor's ability
to identify the needs of the client and the quality of counseling and related
treatment intervention strategies obviously linked to his/her assessment and
should be thoroughly familiar with the facilities and services in his/her
community to insure proper referral for clients with substance abuse problems.
Referral options are determined by client need and are collaboratively agreed
upon as appropriate by the counselor and client. These include short-term,
inpatient care lasting three to seven days for withdrawal from substance abuse,
or intensive, outpatient programs lasting eight to twelve weeks wherein clients
maintain vocational and family responsibilities while participating in
treatment. Another option, the half-way house, provides moderately structured
and supportive residential treatment lasting for three to six months, wherein
successful living within the environment becomes part of the treatment plan.
Other options include therapeutic communities, structured, highly intensive,
residential treatment program such as Synanon, where clients may remain up to
two years, and out-patient alcoholism treatment programs of two kinds, drug-free
clinics with services lasting four to six months, and methadone or opiate
clinics that a client may attend by medical referral for two to five years.
Within these settings, group treatment is the predominant mode of therapy with
individual counseling viewed as an adjunct.
Substance abuse is a major social problem and
concern for counselors. It is the most prevalent mind disorder, encompassing
some 40 percent of the diagnoses in the DSM-IV (American Psychiatric Association
[APA], 1994), the number one continuing health problem, and the number one
prison problem in the United States (Inaba, Cohen, & Holstein, 1997). Yet,
school, rehabilitation, and mental health counselor education programs do not
require expertise in this area as a prerequisite to receiving a degree. Given
this, a need exists to implement strategies to insure that all counselors have
expertise in this area.
digest focuses on identification of counseling outcome research implications for
counseling individuals with substance abuse problems. The following conclusions
regarding counseling individuals with substance abuse problems have been
All counselors, no matter what work setting or clientele, will counsel
individuals with presenting or related problems of substance abuse.
Counselors counsel and empower individuals with substance abuse problems versus
treat the substance abuse problem.
Counselors must be able to establish the same open, collaborative, therapeutic
relationship in counseling individuals with substance abuse problems as they do
with other client populations. This ability is viewed as a prerequisite to
successful outcome in any counseling setting.
Counselors must focus the counseling relationship on addressing the client's
presenting problems directly and identifying client need for change.
Counselors must be able to articulate and implement counseling intervention
strategies perceived as appropriate by both the counselor and the client.
Counselors must know community resources and procedures for referral to be able
to insure access to effective and appropriate support services for clients.
American Psychiatric Association (1994).
Diagnostic and statistical manual (4th ed.), Washington, D.C.: Author.
Austin, L. (1999). The counseling primer. Philadelphia, PA: Accelerated
Inaba, D. S., Cohen, W. E., and Holstein, M. E. (1997). Uppers, downers, and
all-arounders: physical and mental effects of drugs of abuse. Ashland: CNS
Sexton, T. L., Whiston, S. C., Bleuer, J. C., and Walz, G. (1997).
Integrating outcome research into practice. Alexandria, VA: American Counseling