case study examples substance abuse

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

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Jo-Hanna Ivers 1* and Kevin Ducray 2

In October 2012, 83 front-line Irish service providers working in the addiction treatment field received accreditation as trained practitioners in the delivery of a number of evidence-based positive reinforcement approaches that address substance use: 52 received accreditation in the Community Reinforcement Approach (CRA), 19 in the Adolescent Community Reinforcement Approach (ACRA) and 12 in Community Reinforcement and Family Training (CRAFT). This case study presents the treatment of a 17-year-old white male engaging in high-risk substance use. He presented for treatment as part of a court order. Treatment of the substance use involved 20 treatment sessions and was conducted per Adolescent Community Reinforcement Approach (A-CRA). This was a pilot of A-CRA a promising treatment approach adapted from the United States that had never been tried in an Irish context. A post-treatment assessment at 12-week follow-up revealed significant improvements. At both assessment and following treatment, clinician severity ratings on the Maudsley Addiction Profile (MAP) and the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) found decreased score for substance use was the most clinically relevant and suggests that he had made significant changes. Also his MAP scores for parental conflict and drug dealing suggest that he had made significant changes in the relevant domains of personal and social functioning as well as in diminished engagement in criminal behaviour. Results from this case study were quite promising and suggested that A-CRA was culturally sensitive and applicable in an Irish context.

1. Theoretical and Research Basis for Treatment

Substance use disorders (SUDs) are distinct conditions characterized by recurrent maladaptive use of psychoactive substances associated with significant distress. These disorders are highly common with lifetime rates of substance use or dependence estimated at over 30% for alcohol and over 10% for other substances [1 , 2] . Changing substance use patterns and evolving psychosocial and pharmacologic treatments modalities have necessitated the need to substantiate both the efficacy and cost effectiveness of these interventions.

Evidence for the clinical application of cognitive behavioural therapy (CBT) for substance use disorders has grown significantly [3 - 8] . Moreover, CBT for substance use disorders has demonstrated efficacy both as a monotherapy and as part of combination treatment [7] . CBT is a time-limited, problem-focused, intervention that seeks to reduce emotional distress through the modification of maladaptive beliefs, assumptions, attitudes, and behaviours [9] . The underlying assumption of CBT is that learning processes play an imperative function in the development and maintenance of substance misuse. These same learning processes can be used to help patients modify and reduce their drug use [3] .

Drug misuse is viewed by CBT practitioners as learned behaviours acquired through experience [10] . If an individual uses alcohol or a substance to elicit (positively or negatively reinforced) desired states (e.g. euphorigenic, soothing, calming, tension reducing) on a recurrent basis, it may become the preferred way of achieving those effects, particularly in the absence of alternative ways of attaining those desired results. A primary task of treatment for problem substance users is to (1) identify the specific needs that alcohol and substances are being used to meet and (2) develop and reinforce skills that provide alternative ways of meeting those needs [10 , 11] .

CRA is a broad-spectrum cognitive behavioural programme for treating substance use and related problems by identifying the specific needs that alcohol and or other substances are satisfying or meeting. The goal is then to develop and reinforce skills that provide alternative ways of meeting those needs. Consistent with traditional CBT, CRA through exploration, allows the patient to identify negative thoughts, behaviours and beliefs that maintain addiction. By getting the patient to identify, positive non-drug using behaviours, interests, and activities, CRA attempts to provide alternatives to drug use. As therapy progresses the objective is to prevent relapse, increase wellness, and develop skills to promote and sustain well-being. The ultimate aim of CRA, as with CBT is to assist the patient to master a specific set of skills necessary to achieve their goals. Treatment is not complete until those skills are mastered and a reasonable degree of progress has been made toward attaining identified therapy goals. CRA sessions are highly collaborative, requiring the patient to engage in ‘between session tasks’ or homework designed reinforce learning, improve coping skills and enhance self efficacy in relevant domains.

The use of the Community Reinforcement Approach is empirically supported with inpatients [12 , 13] , outpatients [14 - 16] and homeless populations (Smith et al., 1998). In addition, three recent metaanalytic reviews cited CRA as one of the most cost-effective treatment programmes currently available [17 , 18] .

A-CRA is a evidenced based behavioural intervention that is an adapted version of the adult CRA programme [19] . Garner et al [19] modified several of the CRA procedures and accompanying treatment resources to make them more developmentally appropriate for adolescents. The main distinguishing aspect of A-CRA is that it involves caregivers—namely parents or guardians who are ultimately responsible for the adolescent and with whom the adolescent is living.

A-CRA has been tested and found effective in the context of outpatient continuing care following residential treatment [20 - 22] and without the caregiver components as an intervention for drug using, homeless adolescents [23] . More recently, Garner et al [19] collected data from 399 adolescents who participated in one of four randomly controlled trials of the A-CRA intervention, the purpose of which was to examine the extent to which exposure to A-CRA procedures mediated the relationship between treatment retention and outcomes. The authors found adolescents who were exposed to 12 or more A-CRA procedures were significantly more likely to be in recovery at follow-up.

Combining A-CRA with relapse prevention strategies receives strong support as an evidence based, best practice model and is widely employed in addiction treatment programmes. Providing a CBT-ACRA therapeutic approach is imperative as it develops alternative ways of meeting needs and thus altering dependence.

2. Case Introduction

Alan is a 17 year-old male currently living in County Dublin. Alan presented to the agency involuntarily and as a requisite of his Juvenile Liaison Officer who was seeing him on foot of prior drugs arrest for ‘possession with intent to supply’; a more serious charge than a simple ‘drugs possession’ charge. As Alan had no previous charges he was placed on probation for one year. This was Alan’s first contact with the treatment services. A diagnostic assessment was completed upon entry to treatment and included completion of a battery of instruments comprising the Maudsley Addiction Profile (MAP), The World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the Beck Youth Inventory (BYI) (see appendices for full description of outcome measures) (Table 1).

3. Diagnostic Criteria

The apparent symptoms of substance dependency were: (1) Loss of Control - Alan had made several attempts at controlling the amounts of cannabis he consumed, but those times when he was able to abstain from cannabis use were when he substituted alcohol and/or other drugs. (2) Family History of Alcohol/Drug Usage - Alan’s eldest sister who is now 23 years old is in recovery from opiate abuse. She was a chronic heroin user during her early adult years [17 - 21] . During this period, which corresponds to Alan’s early adolescent years [12 - 15] she lived in the family home (3) Changes in Tolerance - Alan began per day. At presentation he was smoking six to eight cannabis joints daily through the week, and eight to twelve joints daily on weekends.

4. Psychosocial, Medical and Family History

At time of intake Alan was living with both of his parents and a sister, two years his senior, in the family home. Alan was the youngest and the only boy in his family. He had two other older sisters, 5 and 7 years his senior. He was enrolled in his 5th year of secondary school but at the time of assessment was expelled from all classes. Alan had superior sporting abilities. He played for the junior team of a first division football team and had the prospect of a professional career in football. He reported a family history positive for substance use disorders. An older sister was in recovery for opiate dependence. Apart from his substance use Alan reported no significant psychological difficulties or medical problems. His motives for substance use were cited as boredom, curiosity, peer pressure, and pleasure seeking. His triggers for use were relationship difficulties at home, boredom and peer pressure. Pre-morbid personality traits included thrill seeking and impulsivity (Table 2).

5. Case Conceptualisation

A CBT case formulation is based on the cognitive model, which hypothesizes that "a person’s feelings and emotions are influenced by their perception of events" . It is not the actual event that determines how the person feels, but rather how they construe the event (Beck, 1995 p14). Moreover, cognitive theory posits that the “child learns to construe reality through his or her early experiences with the environment, especially with significant others” and that “sometimes these early experiences lead children to accept attitudes and beliefs that will later prove maladaptive” [24] . A CBT formulation (or case conceptualisation) is one of the key underpinnings of Cognitive Behavioural Therapy (CBT). It is the ‘blueprint’ which aids the therapist to understand and explain the patient’s’ problems.

Formulation driven CBT enables the therapist to develop an individualised understanding of the patient and can help to predict the difficulties that a patient may encounter during therapy. In Alan’s case, exploring his existing negative automatic thoughts about regarding school and his academic competences highlighted the difficulties he could experience with CBT homework completion. Whilst Alan was good at between session therapy assignments, an exploration of what is meant by ‘homework’ in a CBT context was crucial.

A collaborative CBT formulation was done diagrammatically together with Alan (Figure 1). This formulation aimed to describe his presenting problems and using CBT theory, to explore explanatory inferences about the initiating and maintaining factors of his drug use which could practically inform meaningful interventions.

Simmons and Griffiths et al. make the insightful observation that particular group differences need to be specifically considered and suggest that the therapist should be cognizant of the role of both society and culture when developing a formulation. They firstly suggest that the impact played by gender, sexuality and socio-cultural roles in the genesis of a psychological disorder, namely the contribution that being a member of a group may have on predisposing and precipitating factors, be carefully considered. An example they offer is the role of poverty on the development of psychological problems, such as the link evidenced between socio economic group and onset of schizophrenia. This was clearly evident in the case of Alan, who being a member of a deprived socioeconomic group, growing up and living in an area with a high level of economic deprivation, perceived that his choices for success were limited. His thinking, as an adolescent boy, was dichotomous in that he saw himself as having only two fixed and limited choices (a) being good at sport he either pursue a career as a professional sportsman or alternatively (b) he engage in crime and work his way up through the ranks as a ‘career criminal’. Simmons & Griffiths secondly suggest that being a member of a particular group can heavily influence a person’s understanding of the causality of their psychological disorder. A third consideration when developing a formulation is the degree to which being a member of a particular group may influence the acceptance or rejection of a member experiencing a psychological illness. Again this is pertinent in Alan’s case as he was part of a sub-group, a gang engaged in crime. For this cohort, crime and drug use were synonymous. Using drugs was viewed as a rite of passage for Alan.

Drug use, according to CBT models, are socially learned behaviours initiated, maintained and altered through the dynamic interaction of triggers, cues, reinforcers, cognitions and environmental factors. The application of a such a formulation, sensitive to Simmons and Griffiths (2009) aforementioned observations, proved useful in affording insights into the contextual and maintaining factors of Alan’s drug use which was heavily influenced by the availability of drugs ,his peer group (with whom he spent long periods of time) and their petty drug dealing and criminality. Similarly, engaging with his football team mates during the lead up to an important match significantly reduced his drug use and at certain times of the year even lead to abstinence. Sharing this formulation allowed him to note how his drug use patterns were driven, as per the CBT paradigm, by modifiable external, transient, and specific factors (e.g. cues, reinforcements, social networks and related expectations and social pressures).

Employing the A-CRA model allowed for this tailored fit as A-CRA specifically encourages the patient to identify their own need and desire for change. Alan identified the specific needs that were met by using substances and he developed and reinforced skills that provided him with alternative ways of meeting those needs. This model worked extremely well for Alan as he had identified and had ready access to a pro- social ‘alternative group’ or community. As he had had access to an alternative positive peer group and another activity (sport) which he was ‘really good at’, he simply needed to see the evidence of how his context could radically affect his substance use; more specifically how his beliefs, thinking and actions in certain circumstances produced very different drug use consequences and outcomes.

6. Course of Treatment and Assessment of Progress

One focus of CBT treatment is on teaching and practising specific helpful behaviours, whilst trying to limit cognitive demands on clients. Repetition is central to the learning process in order to develop proficiency and to ensure that newly acquired behaviours will be available when needed. Therefore, behavioural using rehearsal will emphasize varied, realistic case examples to enhance generalization to real life settings. During practice periods and exercises, patients are asked to identify signals that indicate high-risk situations, demonstrating their understanding of when to use newly acquired coping skills. CBT is designed to remedy possible deficits in coping skills by better managing those identified antecedents to substance use. Individuals who rely primarily on substances to cope have little choice but to resort to substance use when the need to cope arises. Understanding, anticipating and avoiding high risk drug use scenarios or the “early warning signals” of imminent drug use is a key CBT clinical activity.

A major goal of a CBT/A-CRA therapeutic approach is to provide a range of basic alternative skills to cope with situations that might otherwise lead to substance use. As ‘skill deficits’ are viewed as fundamental to the drug use trajectory or relapse process, an emphasis is placed on the development and practice of coping skills. A-CRA was manualised in 2001 as part of the Cannabis Youth Treatment Series (CYT) and was tested in that study [21] and more recently with homeless youth [23] . It was also adapted for use in a manual for Assertive Continuing Care following residential treatment [20] .

There are twelve standard and three optional procedures proposed in the A-CRA model. The delivery of the intervention is flexible and based on individual adolescent needs, though the manual provides some general guidelines regarding the general order of procedures. Optional procedures are ‘Dealing with Failure to Attend’, ‘Job-Seeking Skills’, and ‘Anger Management’. Standard procedures are included in table 3 below. For a more detailed description of sessions and procedures please see appendices.

Smith and Myers describe the theoretical underpinnings of CRA as a comprehensive behavioural program for treating substance-abuse problems. It is based on the belief that environmental contingencies can play a powerful role in encouraging or discouraging drinking or drug use. Consequently, it utilizes social, recreational, familial, and vocational reinforcers to assist consumers in the recovery process. Its goal is to essentially make a sober lifestyle more rewarding than the use of substances. Interestingly the authors note: ‘Oddly enough, however, while virtually every review of alcohol and drug treatment outcome research lists CRA among approaches with the strongest scientific evidence of efficacy, very few clinicians who treat consumers with addictions are familiar with it’. ‘The overall philosophy is to promote community based rewarding of non drug-using behaviour so that the patient makes healthy lifestyle changes’ p.3 [25] .

A-CRA procedures use ‘operant techniques and skills training activities’ to educate patients and present alternative ways of dealing with challenges without substances. Traditionally, CRA is provided in an individual, context-specific approach that focuses on the interaction between individuals and those in their environments. A-CRA therapists teach adolescents when and where to use the techniques, given the reality of each individual’s social environment. This tailored approach is facilitated by conducting a ‘functional analysis’ of the adolescent’s behaviour at the beginning of therapy so they can better understand and interrupt the links in the behavioural chain typically leading to episodes of drug use. A-CRA therapists then teach individuals how to improve communication and other skills, build on their reinforcers for abstinence and use existing community resources that will support positive change and constructive support systems.

A-CRA emphasises lapse and relapse prevention. Relapseprevention cognitive behavioural therapy (RP-CBT) is derived from a cognitive model of drug misuse. The emphasis is on identifying and modifying irrational thoughts, managing negative mood and intervening after a lapse to prevent a full-blown relapse [26] . The emphasis is on development of skills to (a) recognize High Risk Situations (HRS) or states where clients are most vulnerable to drug use, (b) avoidance of HRS, and (C) to use a variety of cognitive and behavioural strategies to cope effectively with these situations. RPCBT differs from typical CBT in that the accent is on training people who misuse drugs to develop skills to identify and anticipate situations or states where they are most vulnerable to drug use and to use a range of cognitive and behavioural strategies to cope effectively with these situations [26] .

7. Access and Barriers to Care

Alan engaged with the service for eight months. During this time he received twenty sessions, three of which were assessment focused, the remaining seventeen sessions were A-CRA focused; two of the seventeen involved his mother, the remaining fifteen were individual. As Alan was referred by the probation services, he was initially somewhat ambivalent about drug use focussed interventions. His early motivation for engagement was primarily to avoid the possibility of a custodial sentence.

8. Treatment

My sessions with Alan were guided by the principles of A-CRA [27] which focuses on coping skills training and relapse prevention approaches to the treatment of addictive disorders. Prior to engaging with Alan, I had completed the training course and commenced the A-CRA accreditation process, both under the stewardship of Dr Bob Meyers, whose training and publication offers detailed guidelines on skills training and relapse prevention with young people in a similar context [27] .

During the early part of each session I focused on getting a clear understanding of Alan’s current concerns, his general level of functioning, his substance abuse and pattern of craving during the past week. His experiences with therapy homework, the primary focus being on what insight he gained by completing such exercises was also explored. I spent considerable time engaged in a detailed review of Alan’s experience with the implementation of homework tasks during which the following themes were reviewed:

-Gauging whether drug use cessation was easier or harder than he anticipated? -Which, if any, of the coping strategies worked best? -Which strategies did not work as well as expected. Did he develop any new strategies? -Conveying the importance of skills practice, emphasising how we both gained greater insights into how cognitions influenced his behaviour. After developing a clear sense of Alan’s general functioning, current concerns and progress with homework implementation, I initiated the session topic for that week. I linked the relevance of the session topic to Alan’s current cannabis-related concerns and introduced the topic by using concrete examples from Alan’s recent experience. While reviewing the material, I repeatedly ensured that Alan understood the topic by asking for concrete examples, while also eliciting Alan’s views on how he might use these particular skills in the future.

Godley & Meyers [21] propose a homework exercise to accompany each session. An advantage of using these homework sheets is that they also summarise key points about each topic and therefore serve as a useful reminder to the patient of the material discussed each week. Meyers, et al. (2011) suggests that rather than being bound by the suggested exercises in the manualised approach, they may be used as a starting point for discussing the best way to implement the required skill and to develop individualised variations for new assignments [27] . The final part of each session focused on Alan’s plan for the week ahead and any anticipated high-risk situations. I endeavoured to model the idea that patients can literally ‘plan themselves out of using’ cannabis or other drugs. For each anticipated high-risk situation, we identified appropriate and viable coping skills. Better understanding, anticipating and planning for high-risk situations was difficult in the beginning of treatment as Alan was not particularly used to planning or thinking through his activities. For a patient like Alan, whose home life is often chaotic, this helped promote a growing sense of self efficacy. Similarly, as Alan had been heavily involved with drug use for a long time, he discovered through this process that he had few meaningful activities to fill his time or serve as alternatives to drug use. This provided me with an opportunity to discuss strategies to rebuild an activity schedule and a social network.

During our sessions, several skill topics were covered. I carefully selected skills to match Alan’s needs. I selected coping skills that he has used in the past and introduced one or two more that were consistent with his cognitive style. Alan’s cognitive score indicated a cognitive approach reflecting poor problem solving or planning. Sessions focused on generic skills including interpersonal skills, goal setting, coping with criticism or anger, problem solving and planning. The goal was to teach Alan how to build on his pro- social reinforcers, how to use existing community resources supportive of positive change and how to develop a positive support system.

The sequence in which these topics were presented was based on (a) patient needs and (b) clinician judgment (a full description of individual sessions may be found in appendices).

A-CRA procedures use ‘operant techniques and skills training activities’ to educate patients and present alternative ways of dealing with challenges without substances. Traditionally, CRA is provided in an individual, context-specific approach that focuses on the interaction between individuals and those in their environments. A-CRA therapists teach adolescents when and where to use the techniques, given the reality of each individual’s social environment.

9. Assessment of Treatment Outcome

A baseline diagnostic assessment of outcomes was completed upon treatment entry. This assessment consisted of a battery of psychological instruments including (see appendices for full a description of assessment measures):

-The Maudsley Addiction Profile (MAP). -The Beck Youth Inventories. -The World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

In addition to the above, objective feedback on Alan’s clinical and drug use status through urine toxicology screens was an important part of his drug treatment. Urine specimens were collected before each session and available for the following session. The use of toxicology reports throughout treatment are considered a valuable clinical tool. This part of the session presents a good opportunity to review the results of the most recent urine toxicology screen and promote meaningful therapeutic activities in the context of the patient’s treatment goals [28] .

In reporting on substance use since the last session, patients are likely to reveal a great deal about their general level of functioning and the types of issues and problems of most current concern. This allows the clinician to gauge if the patient has made progress in reducing drug use, his current level of motivation, whether there is a reasonable level of support available in efforts to remain abstinent and what is currently bothering him. Functional analyses are opportunistically used throughout treatment as needed. For example, if cannabis use occurs, patients are encouraged to analyse antecedent events so as to determine how to avoid using in similar situations in the future. The purpose is to help the patient understand the trajectory and modifiable contextual factors associated with drug use, challenge unhelpful positive drug use expectancies, identify possible skills deficiencies as well as seeking functionally equivalent non- drug using behaviours so as to reduce the probability of future drug use. The approach I used is based on the work of [28] .

The Functional Analysis was used to identify a number of factors occurring within a relatively brief time frame that influenced the occurrence of problem behaviours. It was used as an initial screening tool as part of a comprehensive functional assessment or analysis of problem behaviour. The results of the functional analysis then served as a basis for conducting direct observations in a number of different contexts to attest to likely behavioural functions, clarify ambiguous functions, and identify other relevant factors that are maintaining the behaviour.

The Happiness Scale rates the adolescent’s feelings about several critical areas of life. It helps therapists and adolescents identify areas of life that adolescents feel happy about and alternatively areas in which they have problems or challenges. Most importantly it identifies potential treatment goals subjectively meaningful to the patient, facilitates positive behaviour change in a range of life domains as well as help clients track their progress during treatment.

Alan’s BYI score (Table 4) indicates that at the time of assessment he was within the average scoring range on ‘self-concept’, and moderately elevated in the areas of ‘depression’, ‘anxiety’, and ‘disruptive behaviour’. His score for ‘anger’ suggested that his anger fell within the extremely elevated range. When this was discussed with Alan he agreed that this was quite accurate. Anger, and in particular controlling his anger, was subjectively identified as a treatment goal.

10. Follow-up

Given that follow-up occurred by telephone it was not feasible to administer the full battery of tests. With Alan’s treatment goals in mind it was decided to administer the MAP and ASSIST. Table 5 below illustrates Alan’s score at baseline and follow-up for the MAP and ASSIST. For summary purposes I have taken areas for concern at baseline for both instruments.

Alan’s score for cannabis was the most clinically relevant as it placed him in the 'high risk’ domain while his alcohol score indicated that he had engaged in binge drinking (6+ drinks) at T1. However, at T2 Alan’s score suggests that he had made considerable reductions in the use of both substances. Also his MAP scores for parental conflict and drug dealing suggest that he had also made major positive changes in the relevant domains of personal and social functioning as well as ceasing criminal behaviour.

At 3 months post-discharge I contacted Alan by phone. He had maintained and continued to further his progress. His drug use was at a minimal level (1 or 2 shared joints per month). He was no longer engaged in crime and his probationary period with the judicial system had passed. He had received a caution for his earlier drugs charge. At the time of follow-up he was enjoying participating in a Sports Coaching course and was excelling with his study assignments. Relationships had improved considerably with his mother and sister and he had re-engaged with a previous, positive, peer group linked to his involvement with the GAA . Overall he felt he was doing extremely well.

11. Complicating Factors with A-CRA Model

There are many challenges that may arise in the treatment of substance use disorders that can serve as barriers to successful treatment. These include acute or chronic cognitive deficits, health problems, social stressors and a lack of social resources [7] . Among individuals presenting with substance use there are often other significant life challenges including early school leaving, family conflicts, legal issues, poor or deviant social networks, etc. A particular challenge with Alan’s case was the social and environmental milieu which he shared with his drug using peers. For Alan, who initially had few skills and resources, engaging in treatment meant not only being asked to change his overall way of life but also to renounce some of those components in which he enjoyed a sense of belonging, particularly as he had invested significantly in these friendships. A sense of ‘belonging to the substance use culture’ can increase ambivalence for change [7] . Alan’s mother strongly disapproved of his drug using peer group and failed to acknowledge Alan’s perceived loss. This resulted in mother- son conflict. The use of the caregiver session allowed an exploration of perceived ‘losses’ relative to the ‘gains’ associated with Alan’s abstinence. It was moreover seen to be critical to establish alternatives for achieving a sense of belonging, including both his social connection and his social effectiveness. Alan’s sports ability allowed for this to be fostered. He is a talented sportsman which often meant his acceptance within a team or group is a given.

Despite the positive effects of A-CRA it is not without its shortcomings. The approach is at times quite American- oriented, particularly around identifying local resources and its focus on culturally specific outlets in promoting social engagement as alternatives to substance use. While this is supported in the literature, it may not necessarily be transferable to certain Irish adolescent contexts or subcultures.

12. Treatment Implications of the Case

A-CRA captures a broad range of behavioural treatments including those targeting operant learning processes, motivational barriers to improvement and other more traditional elements of cognitivebehavioural interventions. Overall, this intervention has demonstrated efficacy. Despite this heterogeneity, core elements emerge based in a conceptual model of SUDs as disorders characterized by learning processes and driven by the strongly reinforcing effects of the substances of abuse. There is rich evidence in the substance use disorders literature that improvement achieved by CBT (7) and indeed A-CRA (Godley et al. and Garner et al. [22 , 20] ) generalizes to all areas of functioning, including social, work, family and marital adjustment domains. The present study’s finding that a reduction in substance-related symptoms was accompanied by improved levels of functioning, social adjustment and enhanced quality of life, provides further support for this point.

In conclusion, there is some preliminary evidence that A-CRA is a promising treatment in the rehabilitation of adolescent substance users in Ireland and culturally similar societies. Clearly, results from a case study have limited generalisability and there is need for larger controlled studies providing robust outcomes to confirm the efficacy of A-CRA in an Irish context. A more systematic study of this issue is in the interest of adolescent substance users and the health services providers faced with the challenge of providing affordable, evidencebased mental health and addiction care to young people.

13. Recommendations to Clinicians and Students

The ACRA model is a structured assemblage of a range of cognitive and behavioural activities (e.g. a rationale and overview of the paradigm, sobriety sampling, functional analyses, communication skills, problem solving skills, refusal skills, jobs counselling, anger management and relapse prevention) which are shared in varying degrees with other CBT approaches. The ACRA model has the advantage of established effectiveness. A foundation in empirical research together with its manual- supported approach results in it being an appropriate “off the shelf ” intervention, highly applicable to many adolescent substance misusers. Such a focussed approach also has the advantage of limiting therapist “drift”. Notwithstanding the accessible manual and other resources available on- line, clinicians and students are strongly encouraged to undergo accredited ACRA training and supervision.

Unfortunately such a structured model, despite its many advantages, does have limitations. This model may not meet the sum of all drug misusing adolescent service user treatment needs, nor is it applicable to all adolescent drug users, particularly highly chaotic individuals with high levels of co- morbidities or multi-morbidities as often found in this population [29 , 30] . Whilst focussing on specifically on drug use, ACRA does not directly address co-existing problem behaviours or challenges such as depression, anxiety, personality disorder, or post traumatic stress disorder (PTSD) synergistically linked to drug use. It is possible that given the high levels of dual diagnoses encountered in this population as well as the compounding effect that drug use exerts on multiple systems, clinicians and practitioners may find a strict application of the ACRA model limiting, necessitating the application of an additional range or layer of psychotherapeutic competencies? Additionally the ACRA model does not focus explicitly on other psychological activities useful in the treatment of drug misuse such as the control and management of unhelpful cognitive styles or habits; breathing or progressive relaxation skills; anger management; imagery, visualisation and mindfulness. That is, as a manual based approach comprising a number of fixed components, a major potential challenge facing clinicians and students is the tension they may experience between maintaining strict fidelity to a pure ACRA approach, versus the flexibility l approved by more formulation driven CBT approaches?

The advantages of a skilled application of a formulation driven approach which are cited and summarised in are multiple and include the collaborative nature of goal setting, the facilitation of problem prioritisation in a meaningful and useful manner; a more immediate direction and structuring of the course of treatment; the provision of a rationale for the most fitting intervention point or spotlight for the treatment; an integration of seemingly unrelated or dissimilar difficulties in a meaningful yet parsimonious fashion; an influence on the choice of procedures and “homework” exercises; theory based mechanisms to understand the dynamics of the therapeutic relationship and a sense of targeted and ‘extra-therapeutic’ issues and how they could be best explained and managed, especially in terms of precipitators or triggers, core beliefs, assumptions and automatic thoughts.

Thus given the above observations and together with the importance placed on engagement and retention, the high variability in the cognitive, emotional, social and developmental domains [4] differences in roles (e.g. teenagers who are also parents) and levels of autonomy as well as high degrees of dual diagnosis or co- morbidities found in this group [29 , 30] practitioners are encouraged to also develop competencies in allied psychological treatment models such as Motivational Interviewing [31] ; familiarity with the core principles of CBT, disorder specific and problem-specific CBT competences, the generic and meta- competences of CBT as well as an advanced knowledge and understanding of mental health problems that will provide practitioners with the confidence and capacity to implement treatment models in a more flexible yet coherent manner,. In addition to seeking supervision and mentorship students and practitioners are directed, as a starting point, to University College London’s excellent resources outlining the competencies required to provide a more comprehensive interventions [11] .

Both authors reported no conflict of interest in the content of this paper.

Author Contributions

Conceived and designed the experiments: JI. Recruitment & assessment and on going treatment t of patient JI. On going supervision of case KD. Contributed reagents/materials/analysis tools: JI, & KD. Wrote the paper: JI. Contributed to final draft paper KD.

Acknowledgments

We thank Adolescent Addiction Services, Health Service Executive.

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SUBSTANCE ABUSE DISORDER: A CASE STUDY

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Case Formulation and Intervention: Application of the Five Ps Framework in Substance Use Counseling

Volume 10 - Issue 3

Scott W. Peters

Substance use and misuse is exceedingly common and has numerous implications, both individual and societal, impacting millions of Americans directly and indirectly every year. Currently, there are a variety of empirically based interventions for treating clients who engage in substance use and misuse. The Five Ps is an idiographically based framework providing clinicians with a systematic and flexible means of addressing substance use and misuse that can be used in conjunction with standard substance use and misuse interventions. Additionally, its holistic and creative style provides opportunities to address concerns at various points with a variety of strategies and interventions that will best suit clients’ unique situations. It can assist both novice and experienced clinicians working with clients who present for counseling with substance use and misuse. Following a discussion of the Five Ps, a brief case illustration will demonstrate the framework.

Keywords : substance use and misuse, Five Ps, idiographic, systematic, flexible

Substance use and misuse in the United States is extremely common. For the year 2016, the Centers for Disease Control and Prevention (CDC) found that 18% of the U.S. population aged 12 and older had used illicit substances or misused prescription medications (CDC, 2018). The National Survey on Drug Use and Health asserted that close to 30% of respondents aged 12 and older reported use of illicit substances in the past month (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017). Although these statistics are significant, it should be noted that “Most people who use abusable drugs, even most people who use them nonmedically, do so in a reasonably controlled fashion and without much harm to themselves or anyone else” (Kleiman et al., 2011, p. 2). In the context of this article, the word abusable indicates substances that when taken are pleasurable enough to result in excessive dosing or increased frequency of intake (Linden, 2011).

However, there are others who use substances to such an extent that it causes significant distress and impairment in their lives, a phenomenon clinically referred to as a substance use disorder (SUD). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) bases an SUD on a “pathological pattern related to the use of a substance” (American Psychiatric Association, 2013, p. 483). In his report on alcohol, drugs, and health, the U.S. Surgeon General Vivek Murthy reported that more than 20 million Americans have an SUD (U.S. Department of Health and Human Services, 2016). Clients who engage in substance use and misuse can present with a variety of issues beyond use (Bahorik et al., 2017; Compton et al., 2014; Poorolajal et al., 2016). Thus, there exists a need to concurrently examine and address the potentially complex nature of client substance use and misuse.

Implications of Substance Use and Misuse

Substance use and misuse carries numerous potential repercussions. Societally, substance use and misuse consequences exceed “$400 billion in crime, health, and lost productivity” (U.S. Department of Health and Human Services, 2016, p. 2). Published data on those incarcerated appears to be several years old. However, it does suggest that more than 60% had a substance use disorder and 20% were under the influence at the time of their offense (National Center on Addiction and Substance Abuse at Columbia University, 2010). Regrettably, most do not receive treatment while incarcerated (Belenko et al., 2013). Additionally, many individuals who engage in substance use and misuse have co-occurring major medical conditions, such as cancers, cardiovascular accidents (strokes), and respiratory and cardiac illnesses (Bahorik et al., 2017). This population often experiences stigma and suboptimal health care results (McNeely et al., 2018; van Boekel et al., 2013). Substance use and misuse has significant impact on the occupational sector as well. Substance use and misuse has been correlated with both higher rates of absenteeism and workplace injuries (Bush & Lipari 2015). Those who engage in substance use and misuse often have higher rates of unemployment (Compton et al., 2014; Dieter, 2011). This can result in lack of access to treatment services, contributing to increased stress.

Substance use and misuse also has a negative impact on intimate partners, such as assuming increased responsibility and navigating unpredictability (Hussaarts et al., 2012). More ominously, substance use and misuse has been correlated with intimate partner violence (Murphy & Ting, 2010). Further, substance use and misuse is a significant risk factor for suicidality (Poorolajal et al., 2016). Finally, the number of U.S. adults with a comorbid SUD and mental illness has been shown to be almost 8 million, with only about 5% receiving treatment for both (SAMHSA, 2017). Concurrently treating both is very complex, challenging, and expensive. This can be even more problematic given the lack of health care access for large numbers of Americans (Schoen, 2013).

A Holistic Alternative

Addressing client substance use and misuse can be quite complicated, and as mentioned previously, substance use and misuse impacts users and society in a variety of ways beyond substance intake. There are several approaches to managing client substance use and misuse that have demonstrated effectiveness. Among those are 12-step programs (Humphreys et al., 2004), mindfulness-based interventions (Chiesa & Serretti, 2014), evidence-based approaches such as cognitive behavioral therapy (McHugh et al., 2010), and family counseling (O’Farrell & Clements, 2012). These approaches can be accomplished via outpatient counseling, partial hospitalization programs, inpatient and medically managed substance treatment programs, as well as residential and therapeutic communities. However, each has some shortcomings. Twelve-step attendance is most beneficial with inpatient substance use and misuse treatment (Karriker-Jaffe et al., 2018). Evidence-based approaches, such as cognitive behavioral therapy, tend to be nomothetic, assuming homogeneity and generally geared toward symptom amelioration (Robinson, 2011). Mindfulness-based strategies are not as effective when used alone as when used with other approaches (Sancho et al., 2018). Research on the success of family-based interventions has methodological challenges, such as small sample sizes and the difficulty of examining long-term outcomes (Rowe, 2012).

In addition, using these approaches may result in omitting the uniqueness of clients as a consideration in treatment. SAMHSA (2020) pointed out the significance of addressing clients individually based on their distinctive needs in order to provide the best chance for recovery from substance use and misuse. SAMHSA’s recommendations fit well with a more holistic framework in that such a structure allows clinicians to develop a multidimensional picture of clients. By examining and exploring clients’ use or misuse within the context of a multidimensional framework, interventions can be personalized, and areas of concern can be targeted. Such a framework may enhance the effectiveness of the aforementioned interventions (Wormer & Davis, 2018). Some of these evidence-based approaches will be demonstrated later in a case illustration.

As shown above, there are numerous ways to examine and treat client substance use and misuse. For example, some interventions use an individual lens, such as cognitive behavioral therapy, which examines connections between thoughts, feelings, and behaviors (Morin et al., 2017). Other approaches observe substance use and misuse from a family or systems perspective, looking at familial patterns such as communication and normalization of substance use (Bacon, 2019). Delivery of mindfulness-based interventions may help to address stressful events that previously triggered substance use (Garland et al., 2014). In addition, there are frameworks that use a formulation model examining various aspects of clients (Johnstone & Dallos, 2013) such as causal, contributing, environmental, and personal features, providing a much more expansive view of clients’ concerns.

Client substance use and misuse can be quite challenging for counselors, both novice and experienced. Case formulation, also referred to as conceptualization, is a skill new counselors often lack (Liese & Esterline, 2015). Using a framework to assist in case formulation may prove useful to beginning counselors. Experienced counselors, even with competence in a variety of approaches, can also benefit from using a framework to help address anticipated challenges (Macneil et al., 2012). Case formulations have been used in a number of areas such as those with psychosis, anxiety, and trauma (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). One such framework is the Five Ps (Macneil et al., 2012). Macneil and his colleagues (2012) posited that diagnosing was insufficient and it was critical to include other factors such as causal, lifestyle, and personal factors in conceptualizing the case and formulating a plan. Applying this approach with clients who engage in substance use and misuse would allow more individual and flexible ways to intervene with client substance use and misuse. In addition, the collaborative nature of the Five Ps reinforces the concept of an idiographic formulation. This is in keeping with the inherent uniqueness of clients, their concerns, and a variety of factors.

The Five Ps is a type of framework utilizing five factors developed by Macneil et al. (2012). They conceptualized a way to look at clients and their problems, systematically and holistically taking into consideration the (1) Presenting problem, (2) Predisposing factors, (3) Precipitating factors, (4) Perpetuating factors, and (5) Protective factors. Presenting problems are concerns that clients find difficult to manage. Predisposing factors include biological, environmental, or personality considerations that may put clients at risk of further substance use and misuse. Precipitating factors are those that proximally bring about substance use and misuse and its resulting difficulties. Perpetuating factors are those that sustain and possibly reinforce clients’ current substance use and misuse challenges. Protective factors are those that help to moderate actual or potential substance use and misuse impact. The Five Ps framework promotes a very clear and systematic approach to case formulation or assessment that potentially provides a wealth of data. It also provides opportunities for a variety of interventions and strategies targeted to clients and their substance use and misuse or contributing factors.

Given the variations of substances, the level of use, the functional impairment, co-occurrence with other mental disorders, and inherent client differences, an idiographically based framework seems particularly appropriate with this population. The Five Ps permits counselors to both assess and intervene essentially simultaneously. It allows for client individualization, use of a variety of strategies, ongoing assessment, and modifications as needed. Furthermore, the Five Ps helps clients and counselors explore relationships between each factor and the presenting problem. This framework is idiographic in nature, as it looks at clients individually and holistically (Marquis & Holden, 2008). Idiographic case formulation can be useful for complicated cases, such as those encountered with clients engaged in substance use and misuse (Haynes et al., 1997). It is systematic, while allowing for flexibility and creativity. It can be used in outpatient, inpatient, and residential settings and possibly as part of an aftercare program.

Following is a case illustration demonstrating how the Five Ps may be helpful in formulating and engaging in a clinical application. It should be noted that several evidence-based substance use and misuse approaches were integrated in an eclectic approach throughout the case example to demonstrate the idiographic nature of the Five Ps. Many formulation models are administered within a cognitive behavioral grounding (Chadwick et al., 2003; Easden & Kazantzis, 2018; Persons et al., 2013). The Five Ps does not adhere to any particular theoretical orientation, thus allowing for a greater repertoire of strategies to draw from to help clients with substance use and misuse.

Implementing the Five Ps: The Case of Dax

A brief description of Dax, a hypothetical client, and the events that prompted him to seek services is followed by a detailed application of the Five Ps in addressing Dax’s substance use and misuse. It should be noted that the strategies and interventions applied here are used as illustrations and are specific to Dax and his concerns. In addition, the interventions demonstrated are not to be assumed the only ones that can be applied to Dax. They are examples that the author chose to illustrate the Five Ps in practice.

Dax is a 33-year-old married father of two children: a 9-year-old son, Cam, and a 7-year-old daughter, Zoe. He was recently driving home from work in the evening and law enforcement stopped him because of erratic driving. The officers evaluated him, detained him, and subsequently arrested him for driving while intoxicated. As part of his adjudication, Dax was required to attend five counseling sessions and have a clinician’s report provided to the court. Dax presents as extremely frustrated and embarrassed at being mandated to attend counseling sessions. He is confident that he does not have a problem and that counseling should be reserved for those who cannot stop drinking. Dax drinks two to three times a week, usually having one or two shots of whiskey and two to three draft beers. The night he was pulled over, he had had two additional beers and one additional shot of whiskey on top of his usual consumption after a telephone argument with his wife, Sara. Additionally, he reports significant stress and conflict in his marriage as well as concerns over some upcoming diagnostic tests for their daughter related to a heart murmur. Dax denies any other negative consequences from his alcohol use. He denies any significant increase in alcohol use or any other substance use. Presenting Problem While being mandated to attend counseling, Dax shares concerns that he is afraid of what his daughter’s test results will show. He fears that she will need open-heart surgery and that she may die. The clinician can intervene here by simply normalizing and validating his fears about the test results. A logical analysis using gentle Socratic dialogue may help to challenge his emotional reactions to his daughter’s heart murmur (Etoom & Ratnapalan, 2014). In addition, mindfulness strategies can assist in helping Dax to cognitively diffuse from present to future events (Harris, 2019). He is also adamant that he does not have a problem with alcohol. Here, a conversation about what counseling entails as well as psychoeducation related to the effects of alcohol on executive functioning may prove beneficial (Day et al., 2015). Acknowledging that his reticence is due to being obligated to attend counseling may assist in relationship building (Tahan & Sminkey, 2012). The clinician may also seek more information on the cause of the reported stress between him and his wife.

Predisposing Factors Dax reports a strong paternal history of substance use and misuse. His father started out drinking occasionally and over the years slowly developed a dependency on alcohol. Dax further reports his paternal grandfather died from liver failure. Addressing the potential genetic link to substance use and misuse may prove beneficial in raising Dax’s awareness (Dick & Agrawal, 2008). For example, the clinician may ask Dax if they can share how genes are passed on and expressed, like genes for eye color or hypertension. This may open the door to a conversation regarding how his substance use and misuse may progress to alcohol use disorder and its definition as a pattern of alcohol use leading to clinically significant problems, including increase in use, failed attempts to stop, and use leading to an impaired ability to meet role obligations (American Psychiatric Association, 2013). There could be a discussion of alcohol use disorder being a disease, not that different from any other passed-on trait or disease. Additionally, Dax often struggles with strong and painful emotions, and alcohol helps to address them. Here the clinician may utilize strategies drawn from acceptance and commitment therapy related to his control strategy of using alcohol to avoid his emotions (Harris, 2019). The ball in the pool metaphor (i.e., holding a beach ball under the water works temporarily, but eventually it pops back up) can be compared to alcohol temporarily holding those painful emotions down, eventually to resurface. The clinician may also discuss strategies to help Dax regulate his reactions using emotion-focused interventions such as positive reframing to ameliorate the stress of his daughter’s cardiac condition (Plate & Aldao, 2017).

Precipitating Factors This area explores significant occurrences that preceded or triggered the presenting problem and its consequences. Dax shares that he and his wife are conflicted about how to proceed with their daughter’s medical care. Sara is unequivocal in her confidence in Zoe’s cardiologist and his competence. Dax, however, is hyper-focused on surgery and seems to dismiss Sara’s position. At the end of his workday, he and his wife got into an argument over the phone about an upcoming diagnostic test and the possible results. Dax was quite upset, cursed at her, and then hung up the phone. He then stopped at a local pub and had several drinks.

Here, the clinician may use reality-based strategies that address choice and consequences (Wubbolding & Brickell, 2017). This may include a direct conversation about Dax’s decision to drink, resulting in his becoming impaired, with the consequence of being detained, charged, and adjudicated. Dax can then share his and his wife’s perspectives on their daughter’s care. This conversation can lead to investigating strategies for how each can be heard, including short role-plays with opportunities to practice (Worrell, 2015). The clinician can provide a variety of potential spousal responses, allowing for more adaptability and flexibility in Dax’s responses. The goal here is to build Dax’s competence in communicating, both in listening and expressing. Additionally, there may be a discussion using aspects of existentialism to process inherent anxiety and its connection to unknowable future events (May, 1950; Wu et al., 2015).

Perpetuating Factors The emphasis here is on features that continue the presenting problem. For Dax, he shares that when he and his wife argue, it follows a very predictable pattern. They disagree, interrupt one another, yell, and he calms down by having several beers. He then withdraws and becomes sullen for a few days. Nothing gets resolved, and this cycle appears once again when they have conflict.

The clinician may discuss the concept of circularity and assist in moving from “vicious cycles” to “virtuous cycles and problem resolution” (Walsh, 2014, p. 162). This involves explaining that interactions can act as a kind of back-and-forth loop of action–reaction–action without any resolution, leaving both parties feeling unheard, misunderstood, and frustrated. The goals here are to both break the pattern and to facilitate healthy conversations. Here the clinician may incorporate a solution-focused strategy exploring a time with Dax when he and his wife have disagreed, but he did not interrupt and the outcome was positive (de Shazer, 1985). If he cannot identify a time, simple role-plays in which Dax does not interrupt or yell and instead experiences different outcomes may provide optimism to Dax. The counselor may also assist Dax in emotional regulation, which may prevent the initiation of arguments (Aldao & Nolen-Hoeksema, 2013). In addition, aspects of narrative therapy may provide an opportunity for Dax to re-author a unique outcome that gives meaning and provides a functional identity to him as a father and husband, thus building a sense of optimism (White & Epston, 1990).

Protective Factors Here the focus is on investigating resources and/or supports that may help prevent client substance use and misuse from further becoming problematic. This factor has generally been underutilized despite being shown as beneficial to clients (Kuyken et al., 2009). This is often the opportunity for the client to share what may help them move forward, what their assets are, who can support them, and any other self-identified skills (de Shazer, 1985). These can be in the form of personal characteristics such as tenacity, intellect, or insight. They may also present in the form of family, friends, or hobbies. Oftentimes, when the topic of protective factors is used in substance use and misuse, it is related to deterrence of substance use, notably with adolescents (Liao et al., 2018). In the Five Ps context, protective factors are used to potentially prevent substance use and misuse from having more negative impact as well as to increase client resilience. This factor differs markedly from the first four. Protective factors move away from the problem areas that need interventions to hope and optimism and look to future success and competence (Macneil et al., 2012). Once the protective factors are identified, the ensuing conversation provides opportunities to imagine future outcomes in which protective factors may come into play should situations occur that the client finds problematic. Second, it also tends to shift the conversation toward what is present and going well in their lives and away from those areas that cause distress and suffering (de Shazer, 1985).

In implementing the Five Ps framework with Dax, the clinician chose to use psychoeducation and strategies borrowed from acceptance and commitment, reality, Bowenian family systems, and solution-focused brief therapies to assist Dax with his substance use and misuse. The choice of the above approaches is only meant as an illustration and not as definitive ways to address this particular client. It is likely that other clinicians presented with Dax would use a different combination of approaches. The Five Ps is a systematic way to look at clients and their presentation, and its idiographic construction takes clients’ uniqueness into account. It also allows clinicians to target specific areas of concern (Macneil et al., 2012) and may be used in a variety of clinical settings. Moreover, the Five Ps align with SAMHSA’s recommendation that clinicians tailor treatment to each client because no single treatment is particularly superior (SAMHSA, 2020).

Limitations and Future Research

There are limitations to the Five Ps framework as a way to formulate and intervene with clients’ substance use and misuse. First and foremost, it should be emphasized that this particular framework has not been empirically tested with client substance use and misuse. However, as mentioned previously, case formulations have been used across a variety of client concerns (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). Another potential limitation is that the Five Ps may not be particularly beneficial for substance use and misuse in which there is clinical evidence of an SUD that includes significant withdrawal symptoms. Client substance use and misuse at that level may need medical stabilization and detoxification prior to utilization of the Five Ps. In addition, there may be clients who are simply not ready or able to address some or most of the dimensions of the Five Ps. Furthermore, clients like Dax who are mandated to attend substance-related counseling may have service plans that are not congruent with the Five Ps framework. In spite of these limitations, there may be several potential areas of inquiry.

Previous studies using frameworks to formulate have often used cognitive behavioral therapy as the primary intervention (Chadwick et al., 2003; Persons et al., 2013). Given that client substance use and misuse can be quite complicated, using various approaches within the Five Ps framework may yield positive results. As Chadwick et al. (2003) noted, examining positive client experiences may be one way to discover how to increase client participation in substance use and misuse treatment. Another potential area of study might involve comparing novice counselors to more experienced counselors. As mentioned previously, novice counselors often lack sufficient case formulation skills (Liese & Esterline, 2015). Examining the two groups’ experiences using the Five Ps may provide insight to assist counselor training programs related to substance use and misuse skill development. The implementation of the Five Ps with clients with mild substance use and misuse and those with more significant substance use and misuse, possibly using the DSM-5 diagnosis for SUD, may be another area to explore. This research could point to populations for whom the Five Ps is more and less effective. Studies utilizing the Five Ps with mandated clients may demonstrate its efficacy, notably with agencies that require substance-related counseling.

Client substance use and misuse is a significant problem in the United States, and it continues to cause difficulty for individuals, families, and society. There are numerous methods and combinations of methods to address substance use and misuse, such as family therapy, cognitive behavioral therapy, and self-help groups. Their effectiveness has been well researched, and this paper does not propose a superior way to address substance use and misuse. However, the Five Ps presents a framework in which counselors can examine and intervene with client substance use and misuse using a variety of approaches and strategies. The Five Ps can be used in a variety of settings such as a community mental health agency, primary care clinic, and inpatient or residential treatment centers. The systematic but flexible nature of this framework affords clinicians numerous ways to address substance use and misuse. For some, receiving substance use and misuse services can be stigmatizing. In fact, this stigmatization can come from those who are treating them (Luoma et al., 2007). In addition, the vast majority of those with an SUD never receive treatment (Han et al., 2015). Incorporating the Five Ps, with its holistic framework, may prove attractive to clients and counselors, thus potentially increasing the numbers of clients engaged in substance use and misuse treatment. As mentioned previously, the Five Ps is not meant to replace any other substance use and misuse intervention. It is another way to address the multifaceted and complicated nature of client substance use and misuse. Novice clinicians, who often have a more limited repertoire of strategies, may find the Five Ps valuable because of its systematic framework to clients. Experienced clinicians understandably have a larger catalogue of strategies to choose from. However, they may find this framework valuable as it provides one more way to address the often-encountered complex challenges of substance use and misuse.

Conflict of Interest and Funding Disclosure The authors reported no conflict of interest or funding contributions for the development of this manuscript.

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Scott W. Peters, PhD, LPC-S, is an associate professor at Texas A&M University – San Antonio. Correspondence may be addressed to Scott Peters, One University Way, San Antonio, TX 78224, [email protected].

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Introduction to Social Work: An Advocacy-Based Profession

Student resources, case studies.

Case Study for Chapter 10: Substance Use and Addiction

Jennifer’s brother Emmett resorted to drugs and alcohol to drown his sorrow after their dad left their mother. The local inner city high school had its share of dealers and Emmett’s will power was nil. While weed (cannabis, marijuana, pot) was Emmett’s initial drug of choice, his substance use later led him to having a heroin addiction. Now out of the closet as a gay man, Emmett also was introduced to the club/party drugs of ecstasy and crystal meth. It breaks Jennifer’s and her mom’s heart to watch Emmett maintain his addiction despite some brief stints in drug rehab and attendance at local AA meetings. Emmett’s sponsor uses tough love—a mix of encouragement and challenge—to help Emmett stay on his path to and through recovery.

1) What local, state, and national policy and practice resources exist for social workers who work with people who abuse substances?

2) With the help of a social worker, how might family members intervene to help Emmett recover and maintain his sobriety? How might they benefit personally from social work services as well?

3) How much stigma encircles people who succumb to substance abuse or addiction?  

4) What specific challenges might need to be addressed in treatment in order for Emmett to truly achieve a high functioning level?

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Addressing substance misuse in the workplace: A real-world case study

The reality of substance misuse in the workforce

Substance use disorders affect a substantial portion of American society and its workforce. The Substance Abuse and Mental Health Services Administration (SAMHSA) 2021 national survey results report 46 million Americans living with a clinically diagnosable substance use disorder (SUD). 

A staggering 75% of individuals struggling with a substance use disorder are currently employed and open to treatment. Unfortunately, due to limited access and high costs, fewer than 10% of these individuals receive the help they need. Industries such as manufacturing, retail and logistics, where safety is paramount, are particularly susceptible to the negative consequences of SUDs. 

As revealed in the Pelago 2023 Annual Substance Use Management Survey , 1 in 6 U.S. workers report missing work because of a personal substance or alcohol use problem. When factoring in workers impacted by a family member’s substance use problem, we find that nearly half of all workers are affected by a substance use disorder (SUD). 

Add in the growing direct and indirect costs of substance use disorders highlighted in new CDC data   –  which puts the annual minimum cost of substance use disorders at $15,640 per affected employee totaling more than $35 billion – and the scope and cost of the substance use management challenge becomes clear. 

Understanding the unique role and responsibility employers have in managing substance use issues, a major U.S. health technology company approached Pelago to help address the impact that SUDs were having on both employee well-being and healthcare costs. The company successfully partnered with Pelago to decrease alcohol use, improve mental health and generate a powerful return on investment among its more than 20,000 employees. 

The multifaceted impact of substance misuse

Substance misuse is closely associated with co-morbidities and other chronic conditions. Often hidden in heart and liver disease, osteoporosis, MSK, diabetes, cancer, chronic kidney disease and mental health conditions, SUDs lead to annually compounding healthcare costs. And, as the CDC study pointed out, the hard medical costs do not include business impacts related to absenteeism, presenteeism and turnover.  

It’s also estimated that about 80 million Americans engage in risky substance use behaviors . These individuals often maintain a high level of functionality, making it difficult to identify the problem. For example, 50% of individuals with severe mental health illnesses also have co-occurring substance use disorders . 

The Pelago substance use management program aimed to improve access to care, reduce stigma, improve health and happiness and decrease healthcare claims. With an emphasis on alcohol use, the company’s members engaged with Pelago’s physician-led care team, consisting of nationwide physicians and nurse practitioners as well as dedicated drug and alcohol counselors. Members were able to take advantage of telehealth consultations and psychological support, along with discreet prescription fulfillment and remote monitoring devices.

Program results and outcomes

Since its launch of the Pelago program, the company has seen an impressive 85% utilization rate among registered members. These members have benefited from an average of 46 care team interactions, surpassing industry benchmarks. Furthermore, the program's content engagement has demonstrated positive results, with members completing an average of 10 steps tailored to their individual triggers.

After just 60 days of Pelago care, the company was able to report impressive outcomes, including a 76% reduction in heavy drinking days and a 50% reduction in risk factors for problem drinking compared to industry benchmarks. 

The positive trajectory continued after three months, with participants reporting:

• An average 18 days of alcohol abstinence in the past 30 days compared to just over 11 days prior to treatment entry
• That confidence in achieving complete abstinence increased by 60%, and alcohol craving decreased by 36% during the same period
• The number of heavy drinking days decreased by 54%, accompanied by a 47% decrease in psychological problems and a 53% decrease in troubled sleep patterns

The value of substance use management

This top 10 health technology company’s partnership with Pelago for substance use management demonstrates the value of addressing substance misuse in the workplace. By implementing a comprehensive care program, the company achieved significant improvements in alcohol use, mental health and overall well-being among its employees. 

Effective substance use management that engages the workforce leads to an understanding of the impacts of substance use on one's body and managing that use to a healthy state. This case study demonstrates the power of efforts to combat substance misuse in the workplace and underscores the importance of providing accessible, quality treatment for substance use disorders – not only for the individuals affected but also for the financial health of organizations.

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Teen Cocaine Addiction Case Study: Chloe's Story

This case study of drug addiction can affect anyone – it doesn’t discriminate on the basis of age, gender or background. At Serenity Addiction Centres, our drug detox clinic is open to everyone, and our friendly and welcoming approach is changing the way rehab clinics are helping clients recover from addiction.

We’ve asked former Serenity client, Chloe, to share her experience of drug rehab with Serenity Addiction Centre’s assistance.

Chloe’s Addiction

If you met Chloe today, you would never know about her past. This born and bred London girl is 20 years old, and a flourishing law student with a bright future in the City.

A few years ago though, it seemed as if this straight A student was about to throw away her life, thanks to a  class A drug addiction .

Chloe had a great childhood. By her own admission, school was a breeze for her, with strong academic achievement and social skills making her as successful on the playground as she was in the classroom.

Age 7, Chloe started at a boarding school, and loved having friends around her all the time. With no parents about, Chloe and her friends found themselves invited to house parties. As soon as I could convince people they we 18, they moved on to London’s nightclubs.

It was here where Chloe first came across drugs, and it was a slippery slope to cocaine addiction. She explains: “At 15, I was taking poppers, graduated to MDMA at 16, and then I tried cocaine at our year 13 parties. I got separated from my friends, and found them taking cocaine in a back room. I didn’t want to be left out, so I tried it.” 

Chloe scored straight As in her A levels, and accepted a place at Kings College London to study law. She was introduced to new people, and it seemed that cocaine was available at every place they went. Parties, clubs, and even her new friends were all good sources of a line of cocaine. As a self confessed wild child by this point, Chloe didn’t want to miss out.

The demands of a law degree were high, but so was Chloe’s desire for more cocaine.

Going out almost every night to snort coke, she started to wonder if she was becoming an addict. She spent every penny of the generous allowance from her parents. Chloe spent every penny available on credit cards, and even took on a £2000 bank loan to support her habit.

Chloe estimated that at one point, her addiction had saddled her with more than £13,000 of debt.

Coming out of Addiction Denial

Chloe’s light bulb moment finally came when her best friend, who she shared a flat with, sat her down and asked why they were drifting apart.

Chloe realised that cocaine had become more important to her than her friends, family, and studies. It had to stop. Chloe found the details for Serenity Addiction Centres, and called the same day to ask for help with her addiction.

One thing Chloe particularly appreciated about Serenity Addiction Centres was the flexible approach of the counsellors . They got to know Chloe, listening to her worries, and working out a non-residential rehab plan for her. This allowed her to continue with her studies.

Chloe’s treatment was organised at a clinic not far from her university, allowing her to keep her studies on track, and keeping her life as normal as possible.

Chloe says: “Talking about how I was using cocaine, along with contributing problems from earlier in my life, were a massive help. I didn’t want to be known just as a party girl”.

“If I’d not found Serenity Addiction Centres, there would probably have been a long wait for NHS treatment. Serenity Addiction Centres got the right treatment. Everything was organised with privacy and discretion. I only shared what was happening with my flatmate.”

This level of discretion was really helpful, and the rapid results of her treatment meant that after just three months Chloe felt able to tell her parents what had been happening. 

Life after rehab

It’s amazing that Chloe has now had nearly a year where not taken cocaine, and faced her debts by working part time to repay what she owes. Even better, thanks to Serenity’s fast intervention. Chloe is on course for a 2:1 in her law degree.

If you’re ready to detox? Serenity Addiction Centre’s addiction support team are here to help you find the rehab programme which works for you. Serenity can help you beat your addiction. Gaining control over drugs, allowing you to move on and take back control of your life.

This Drug Addiction Case Study is here so others may identify. Contact us today , and begin your detox journey with Serenity Addiction Centres.

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Using Motivational Interviewing to Treat Adolescents and Young Adults with Substance Use Disorders

A case study of hazelden betty ford in plymouth.

Young people receiving treatment for substance use disorders (SUDs) present a unique clinical challenge. Though premature dropout from treatment happens with adults, as many as 50% of teens and young adults with substance use disorders do not complete treatment. In addition, many who do complete treatment do not fully engage with the treatment process (Gogel et al., 2011). Treatment engagement involves more than just being physically present; it involves actively taking part in all aspects of the treatment process and becoming emotionally invested in those processes as well as in peers attending the same services (Szapocznik et al., 2003; Wise et al., 2001). Another factor that may complicate treatment engagement is the fact that many adolescents enter treatment because of external pressures (such as parental insistence) and, as a result, may have low motivation to engage (Battjes et al., 2003). Because both retention and active engagement in treatment are associated with positive outcomes and recovery from substance use disorders (Williams and Chang, 2000; Moos & Moos, 2003; McWhirter, 2008), organizations offering treatment services to youth should focus on approaches that promote engagement and enhance the patient's intrinsic motivation and commitment to change.

The Hazelden Betty Ford Foundation has a facility in Plymouth, Minnesota , that focuses on providing substance abuse treatment to adolescents and young adults. In a recent interview with me, Dr. Joseph Lee, medical director of the Youth Continuum, stressed the importance of empathy in working with adolescent and young adult patients. A key piece of that work involves recognizing that empathy differs from identification. Empathy is the ability to imagine and accurately understand the feelings of another person and respond in a helpful way, and people with strong empathy can do this while maintaining a sense of being separate from that person (Buckman et al., 2011; Amsel, 2015). Identification, on the other hand, can be expressed as either relating to someone else so much that you lose a sense of yourself, or as identifying someone as so similar to yourself that you feel they must do and experience their situation as you do or did.

"We needed to take an honest look at how we were viewing and working with our patients," said Dr. Lee.

"This clinical introspection was especially critical as we began to treat more patients awash in the opioid epidemic . These kids are even more likely to drop out than other kids, and for them, the risk of going back out and using drugs can be fatal." The realization that empathic rapport is critical to helping the patient get better, combined with too many patients leaving treatment prematurely, particularly those with a high degree of clinical severity, prompted Lee and other clinical leaders to improve clinical practice at the therapist level.

"These kids are even more likely to drop out than other kids, and for them, the risk of going back out and using drugs can be fatal."

The Hazelden Betty Ford Foundation had therefore identified an opportunity to strengthen their empathy in working with patients, along with addressing the urgent needs to keep young patients in treatment, increase their engagement in the treatment process and increase their motivation to change. The next step in the process was to decide on a therapeutic approach to meet these objectives. As applied to patients with substance use disorders, motivational interviewing (MI) is a brief psychotherapy aimed at increasing the patient's motivation and ability to change his/her addictive behaviors (Miller, Zweben, DiClemente, & Rychtarik, 1992). It focuses heavily on therapists bringing empathy to the therapeutic process with clients. Figure 1 lists the five elements of the approach, as outlined by Miller et al. (1992). The first element is expressing empathy for the client, which can be done in a number of ways. Empathic communication signals dignity and respect for the client and helps prevent the development of a superior/inferior relationship where the therapist is telling the client what he or she should be feeling. Empathic communication involves reflective listening, communicating an acceptance of where the client is and supporting them in the process of change (Miller & Rollnick, 1991). In addition to its strong focus on empathy, MI was chosen by Plymouth staff because it is an evidence-based practice in treating substance use disorders, with several studies indicating its effectiveness for adolescent and young adult populations (Barnett et al., 2012; Brown et al., 2015).

"Once we identified that we needed to start doing MI in a more formalized, consistent way across our clinicians, we needed to map out and implement a plan for doing it," Dr. Lee observed.

As one might imagine, this plan was fairly complex. Though all staff in patient-facing roles received training, the implementation of Motivational Interviewing was heavily concentrated on two roles: alcohol/drug addiction counselors and addiction technicians. Addiction counselors are a core part of the residential program. They administer assessments, participate in treatment planning and engage in therapy with the patient around his or her unique needs and challenges. The addiction technicians help support the patient, including easing their transition between the medical services unit and the residential treatment unit, helping them get to appointments on time and filling in for other non-clinical aspects of treatment, such as conducting meditation exercises.

Systematic training of staff in these two roles was a vital first step in implementing Motivational Interviewing with patients. Several tactics were used as part of training, including the use of an Motivational Interviewing text, required attendance at several two-day workshops and in-person training by both external MINT-certified specialists and several Plymouth staff well-versed in Motivational Interviewing methods, including Dr. Lee; Travis Vanderbilt, an LADC counselor; and David Wells, a PhD-level psychologist in the mental health clinic. Once counselors and technicians were trained, Lee and other Plymouth Motivational Interviewing experts set up a process to measure how counselors conducted therapy sessions with patients. The process involves periodically taping therapy sessions and auditing them for elements of Motivational Interviewing. The conclusions of these audits are then shared with each counselor in regular supervision meetings with his/ her manager. "The results of the audits and feedback on the clinician's use of Motivational Interviewing are a vital part of the process and happens on an ongoing basis," says Dr. Lee. "But we focus on making these conversations collegial and constructive as opposed to punitive…the idea is to model Motivational Interviewing even in the practitioner/supervisor discussions."

Successful implementation of Motivational Interviewing with Plymouth staff took several months, as is typically the case with clinical programs addressing behavioral health issues. By the middle of 2016, Motivational Interviewing was fully implemented and used consistently with all residential patients. Figure 2 shows atypical discharge rates for patients as a function of when they were discharged from the Plymouth residential program. These rates represent the percentage of patients who left treatment prematurely for various reasons (against staff advice, against medical advice, or occasionally at staff request). Over the last several quarters, the percentage of atypical discharges has been trending downward in a pattern consistent with the timeframe of motivational interviewing implementation. Only 9.9% of patients discharged in Q1 of 2017 left treatment prematurely, as opposed to 13.28% of patients in Q3 of 2015 (a 25% decrease). Though several other factors may have impacted these rates for example, an increase over time in the use of Suboxone for patients with opioid use issues the results are encouraging.

Qualitative feedback from staff members at Plymouth also suggests a positive impact of Motivational Interviewing on both staff and patients. Staff members described it as a "very person centered" approach, in part because it allows the clinician to effectively build rapport through empowerment rather than directives. Young patients are very receptive to the approach because they feel they are being worked with in a collaborative way, not talked down to or ordered to do certain things. Several staff members reported being able to help emotionally distressed patients change their mind about leaving treatment. In a couple of cases, the patient had left the facility, but the counselor was able to convince them to come back. Plymouth staff members directly attributed these outcomes to their use of Motivational Interviewing. "Motivational Interviewing is helping our patients because it reduces many of the impulsive decisions and encourages them to think through their actions before doing them," said one staff member. "It also helps them process through emotions they are not used to experiencing before making important decisions." Several counselors also reported that the therapeutic alliance formed with their patients has been strengthened through the use of Motivational Interviewing, which is quite important given the role of the alliance in predicting positive outcomes after treatment (Connors et al., 1997; Cook et al., 2015).

Behavioral health provider organizations wanting to implement evidence-based clinical practices in a highly accurate, reliable way can do so through an implementation science approach. At its core, implementation science involves the use of research and measurement to ensure that practices are implemented correctly within clinical settings (Proctor et al., 2009). The first step of the approach is to identify a practice that has a strong evidence base, meaning that it has been studied in a scientific manner and found to produce positive outcomes across studies. The second step involves mapping out how to deliver the clinical practice based on the organization's current structure, staffing models, clinical workflows and other processes related to care delivery. A key part of the second step is the training of staff directly administering the program or practice. Hazelden Betty Ford in Plymouth has completed these steps with regard to implementing motivational interviewing with residential patients. Clinical leaders and other staff will focus on subsequent steps over the coming months. This work will focus on evolving and standardizing the processes for measuring how effective each counselor is at implementing Motivational Interviewing with patients. Most importantly, counselors and supervisors will make sure that these assessments are used to continuously improve Motivational Interviewing practice.

"Motivational Interviewing is helping our patients because it reduces many of the impulsive decisions and encourages them to think through their actions before doing them."

This final step, though critical, is often overlooked by organizations implementing new clinical practices. It is one thing to implement something and occasionally measure how things are going. It is another thing to use what is learned and apply it back to care delivery on a continuous, long-term basis. As more behavioral health service providers use this model to bring evidence-based practices to patients, we can expect patient engagement and outcomes to improve.

Case Study October 2017.  Download the  Adolescent Motivational Interviewing case study .

Acknowledgements

Dr. joseph lee, medical director of the youth continuum.

Joseph Lee, MD, has extensive experience in addiction treatment for youth and families from across the country and abroad, providing him an unparalleled perspective on emerging drug trends, co-occurring mental health conditions and the ever-changing culture of addiction. A triple board certified physician, Lee completed his medical degree at the University of Oklahoma, his adult psychiatry residency at Duke University Hospital and his fellowship in child and adolescent psychiatry at John Hopkins Hospital. He is a diplomat of the American Board of Addiction Medicine and is a member of the American Academy of Child and Adolescent Psychiatry's Substance Abuse Committee. He is also the author of  Recovering My Kid: Parenting Young Adults in Treatment and Beyond , which provides a candid, helpful guide for parents in times of crisis.

• Amsel, B. (2015). Losing myself in your feelings: Empathy and identification. www.goodtherapy.org/blog/losing-my-self-inyour- feelings-empathy-and-identification-0925154 Barnett, E., Sussman, S., Smith, C., Rohrbach, L. A., & Spruijt-Metz, D. (2012). Motivational interviewing for adolescent substance use: A review of the literature. Addictive Behaviors, 37, 1325-1334.
• Battjes, R. J., Gordon, M.S., O'Grady, K. E., Kinlock, T. W., & Carsell, M. A. (2003). Factors that predict adolescent motivation for substance abuse treatment. Journal of Substance Abuse Treatment, 24, 221-32.
• Brown, R. A., Abrantes, A. M., Minami, H., Prince, M. A., Bloom, E. L., Apodaca, T. R. et al. (2015). Motivational interviewing to reduce substance use in adolescents with psychiatric comorbidity. Journal of Substance Abuse Treatment, 59, 20-29.
• Buckman, R., Tulsky, J. A., & Rodin, G. (2011). Empathic responses in clinical practice: Intuition or tuition? Canadian Medical Association Journal, 183, 569-571. doi:10.1503/ cmaj.090113
• Connors, G. J., Carroll, K. M., DiClemente, C. C., Longabaugh, R., & Donovan, D. M. (1997). The therapeutic alliance and its relationship to treatment participation and outcome. Journal of Consulting Clinical Psychology, 65, 588-598.
• Cook, S., Heather, N., & McCambridge, J. (2015). The role of the working alliance in treatment for alcohol problems. Psychology of Addictive Behaviors, 29, 371-381.
• Gogel, L. P., Cavaleri, M. A., Gardin, J. G. II & Wisdom, J. P. (2011). Retention and ongoing participation in residential substance abuse treatment: Perspectives from adolescents, parents and staff on the treatment process. Journal of Behavioral Health Services & Research, 38, 488-496.
• Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (37-69). New York, NY: Oxford University Press.
• McWhirter, P. T. (2008). Enhancing adolescent substance abuse treatment engagement. Journal of Psychoactive Drugs, 40, 173-182.
• Miller, W. R., and Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
• Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism; Rockville, MD: NIAAA Project MATCH Monograph Series Volume 2, DHHS Publication No. (ADM) 92-1894.
• Moos, R. H., & Moos, B. S. (2003). Long-term influence of duration and intensity of treatment on previously untreated individuals with alcohol use disorders. Addiction, 98, 325-338.
• Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health, 36, 24-34. doi:10.1007/s10488-008-0197-4
• Szapocznik, J., Perez-Vidal, A., & Brickman, A. L., et al. (1988). Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach. Journal of Consulting and Clinical Psychology, 56(4), 552-557.
• Williams, R. J. & Chang, S. Y. (2000). A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clinical Psychology: Science and Practice, 7, 138-166.
• Wise, B. K., Cuffe, S. P., & Fischer, T. (2001). Dual diagnosis and successful participation of adolescents in substance abuse treatment. Journal of Substance Abuse Treatment, 21, 161-165.

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Substance Abuse, Depression, and Social Anxiety: Case Study and Application of Cognitive Psychotherapy

Feda abu al-khair.

Assistant Professor in Clinical Psychology, Al-Ahliyya Amman University, 19328, Amman, Jordan

Associated Data

The data used to support the findings of this study have not been made available because of the privacy issues.

A 20-year-old male was referred by a psychiatrist to the clinic for treatment. He was diagnosed with social anxiety disorder (SAD), depression, and substances abuse. He complained of depressive mood and severe anxiety symptoms. These symptoms are triggered in social situations, as well as when talking to others, being in public areas, and going to malls or any crowded places. Because of his symptoms, he avoided getting into the situation, which affected his daily life. The patient was diagnosed with SAD, major depression, and substance abuse and underwent 20 separate sessions of cognitive behavioral therapy (CBT). The application of CBT led to a decrease in the number of anxiety attacks and angry outbursts that the patient suffers from. It also helped him learn some techniques to use in his interactions within the society, as well as other techniques, such as cognitive reorganization of dysfunctional thoughts, and gradually exposed him to the social situations. He also learned to practice some relaxation techniques, to teach him integration in social situations and confrontation instead of avoidance.

1. Introduction

Social anxiety disorder (SAD), one of the most common anxiety disorders, is rapidly increasing and disproportionately affects young people [ 1 ]. It is the third most common mental disorder after depression and alcohol dependence. According to epidemiological reports, the current prevalence is 5%–10%, and the lifetime prevalence is 8.4%–15% [ 2 ]. However, based on prevalence studies in seven countries, researchers found that the global prevalence of social anxiety is significantly higher than previously reported, and more than one-third of respondents met the threshold for SAD Standard. If left untreated, it can cause many serious problems in people's lives [ 1 , 3 ].

People with SAD experience significant fear and/or anxiety, in one or more types of situations on the social level, where they think others will judge and negatively evaluate them. The danger they feel during these situations is excessive compared to the feelings of a regular person, in form and intensity, when the two are placed in the same sociocultural context [ 4 ].

Comorbidity factors: SAD commonly occurs alongside other anxiety disorders, major depressive disorder, and substance use disorders. Typically, SAD emerges before the onset of these other disorders, except for specific phobia and separation anxiety disorder. Prolonged social isolation resulting from SAD can lead to the development of major depressive disorder. Among older adults, there is a significant comorbidity between SAD and depression. Individuals may turn to substances as a form of self-medication to cope with social fears. However, the symptoms of substance intoxication or withdrawal, such as trembling, can also intensify social anxiety. Body dysmorphic disorder frequently coexists with SAD, and generalized SAD often co-occurs with avoidant personality disorder. In children, there is a high prevalence of comorbidities between SAD and high-functioning autism spectrum disorder, as well as selective mutism [ 4 ].

A review highlighted the significance of the relationship between alcohol use and individuals suffering from SAD who believe that consuming alcoholic beverages will have a positive effect on them. People suffering from disorders, such as SAD and alcohol use disorder (AUD), expect alcohol to have more positive effects in social settings (such as decreased tension and social assertiveness) than those not suffering from AUD and those with lower levels of anxiety [ 5 – 7 ].

Many studies have been conducted on cannabis, nicotine, and other dependencies; however, many others concentrate on alcohol, when investigating the co-occurrence of alcohol and substance use disorder (ASUD) and SAD [ 8 ]. It is widely acknowledged that people with SAD will more likely be the consumers of alcoholic beverages and/or abuse drugs. Comorbid SAD and ASUD are clinically significant because they are linked to higher morbidity, poorer treatment outcomes, and decreased therapy seeking.

People with anxiety conditions are typically advised to begin using drugs (self-medication) to treat their symptoms. However, due to alterations in the biology of the brain, substance use can cause or contribute to a person's susceptibility to suffer from anxiety [ 5 , 6 , 9 ].

The study aims to determine the efficacy of cognitive psychotherapy in cases of SAD, depression, and substance abuse. Cognitive behavioral therapy (CBT) should have a major impact in these cases, by reducing the patient's complaints, such as anxiety from speaking in public and from social situations, low mood, and symptoms of depression. It should also allow patients to return to their studies and social life, without having to depend on different substances.

1.1. Description of Case Study and Methods

1.1.1. case report.

The patient is a 20-year-old single man. He is unemployed and has a history of polysubstance abuse and family problems. For the past 2 years, he has used alcohol, cocaine, and medical substance (Lyrica and other medications). He has a history of social anxiety with biological symptoms, which are unresponsive to medication. He expressed low self esteem and feelings of worthlessness. He was pessimistic about the future, saying, “I don't see anything ahead for me.” He described a passive death wish, but denied having any active suicidal thoughts. He described feeling fast heartbeats, blushing, trembling, sweating, trouble catching his breath, dizziness, and panic complaints, especially when talking to people and women in specific. He also described being unable to carry out a conversation with others, feelings of being watched and laughed at, and believing that he is ugly looking. He described having these complaints since adolescence. The patient has been an addict for the past 2 years. He started with Marijuana and alcohol, and then he tried several medical drugs.

The patient talked about various upsetting memories of instances that took place during his childhood and up to his late teenage years. This included memories, such as not being given a choice or participating in decision making, his father's absence from the house due to travel, followed by the discovery of his marriage to another woman and the presence of children. His family's upbringing style is firm, authoritarian on the part of the mother, and permissive on the part of the father.

1.2. Assessment and Diagnosis

Depending on psychiatrist referral letter, Structured Clinical Interview and Several tools were used to evaluate and diagnose patient's social anxiety and depression symptoms. They varied from self to clinician administered measures, and included the following:

1.2.1. Beck Depression Inventory (BDI)

The BDI [ 10 ] is constituted of 21 items. It is self-administered and represents an assessment of the physiological, affective, and cognitive aspects of depression, and is a measure of its severity. A total score of 10 or less is considered normal. A person is considered clinically depressed, if he or she obtains a score of 20 or more, on the BDI. The BDI is characterized by its high reliability and validity. Treatment outcome research makes use of the characteristics of this scale. The scale was translated by Abdul Khaleq 1996, and it has high reliability and validity in the Arab regions, as stated in [ 11 – 14 ].

1.2.2. Liebowitz Social Anxiety Scale (LSAS)

Twenty-four items constitute the LSAS [ 15 ]. It is administered by a clinician, so that the respondent may rate his or her feelings of fear and avoidance, on a scale of 0 (none) to 4 (extreme). It was translated to Arabic by Ibrahim [ 16 ], and it has high reliability and validity in the Arab regions, as stated in [ 17 , 18 ].

To examine SAD, the LSAS, with its good psychometric properties, is often employed in treatment outcome research [ 19 ]. Cutoff scores determined by Mennin et al. [ 20 ] for social phobia are greater than 30 and greater than 60 for generalized social phobia.

1.3. Formulation

Based on the assessment of the patient's case, which was determined from the psychiatrist's letter and the information he provided during the first meeting, he was diagnosed with social anxiety and depression. The patient showed symptoms of social anxiety, which were concluded to be the signs of his low self-esteem, manifested through avoidance. Depression was also another type of manifestation he exhibited, with an experience of persistent low spirits, ruminations about the past, and feeling guilty for exhibiting angry outbursts during current times. As a result, while patient's symptoms satisfied the diagnosis for social anxiety, they seemed to result from his depression, which started during adolescence. The CBT longitudinal model [ 21 ] was thought to be the best tool to use to understand patient's depression in view of the experiences he had in earlier life. These are the core beliefs, negative in nature, he has derived in life, as well as the rigid life rules, all of which contributed to his low self-esteem and led him to demonstrate signs of depression. Social anxiety has led him to drug addiction, due to his beliefs that the drug's effects will encourage him to talk to and deal with people. It is worth noting that the patient has been undergoing pharmacological treatment with his psychiatrist since the beginning.

1.4. Therapy Program

Fennell's [ 22 ] guidelines were followed for all sessions:

• Establishing the agenda.
• Reviewing events that have taken place since the previous session, feedback on the previous session, and homework.
• Going over the agenda once more.
• Prioritizing and discussing agenda items.
• Collaboratively assigning homework.
• Checking reactions.

1.5. Techniques of Cognitive Behavioral Therapy

1.5.1. self-monitoring.

Self-monitoring refers to observing one's behaviors and experiences systematically during various occasions for a certain time.

It is used in the therapy as a method of intervention, as it helps patients examine thoughts, emotions, and behaviors. It helps them identify the situations they are afraid of and find the best course of action for dealing with them.

Drastic changes occur from self-monitoring, according to Kazdin [ 23 ]. Korotitsch and Nelson-Gray [ 24 ] concluded that an immediate change is among the therapeutic effects of self-monitoring, despite their small scale. The clinician required the patient to track his thoughts, feelings, behaviors, as well as any differences he notices in himself.

1.5.2. Cognitive Reorganization

The four stages of cognitive reorganization, according to Beck et al. [ 25 ] are: (i) identifying dysfunctional thoughts, (ii) cognitive reorganization, (iii) modifying dysfunctional thoughts, and (iv) assimilating the new functional thoughts. On the second stage, patients begin to recognize their automatic or dysfunctional thoughts, as well as the emotions associated with them. For instance, a recurring thought for the patient was that others see him as an ugly, insignificant person. This notion contributed to his feelings of anxiety and fear.

Nevertheless, another adaptive thought that he can adopt instead is: “I may not like everyone, but there are those who love me as I am”.

As a result, the patient was taught during all sessions to use adaptive thoughts instead of negative thoughts. Part of six of his sessions was dedicated to discussing a record he kept of his dysfunctional thoughts.

1.5.3. Relaxation

Relaxation techniques were used to treat a patient's symptoms, particularly those that resulted from his anxiety and depression and were physiological in nature.

According to Jacobson's technique, there are certain breathing and muscle relaxation exercises in use, which can be beneficial in a patient's case. As such, the clinician worked on teaching him these exercises over eight sessions, to help him manage the physical symptoms he suffers from. The patient was taught to use deep breathing and some short muscle relaxation techniques in his day-to-day life, particularly when confronted with an unpleasant situation [ 26 ].

1.5.4. Training in Assertiveness and Motivation

Assertiveness training can be beneficial in cases where the patients suffer from depression, anxiety in social settings, addiction, and issues related to unspoken anger.

Since it is now known that assertiveness is learned rather than an inborn trait, assertiveness training can be employed in enhancing self-esteem and ameliorating interpersonal skills. It is true that some people seem more assertive, nevertheless, assertiveness can be acquired. In the patient's case, he was assisted in determining the situations where he faces more challenges on an interpersonal level, as well as the behaviors he exhibits that he needs to concentrate on in order to improve. Furthermore, the therapist assisted him in identifying the beliefs and attitudes that he may have developed, which caused him to become too passive. As part of this technique, she used role-playing exercises.

1.5.5. Clinical Sessions

The patient had one-on-one sessions for 50 min with his therapist each to complete his therapeutic treatment, over the course of 5 months. The reasons for employing CBT were examined during the first session. Educating the patient on SAD, depression, and addiction were a point of focus during therapy. Automatic thoughts and how they affect cognition were examined, helping him in identifying these types of thoughts and feelings as he experienced them.

As homework, he was given an anxiety self-monitoring diary. The therapist emphasized the issue of establishing and maintaining a good relationship between patient and clinician during the course of therapy. The patient described certain situations, as well as important events in his life where he felt that his symptoms were worse. This took place during the second session, where he also got the diary for dysfunctional thoughts as homework, after going through the explanation about cognitive reorganization and its four stages. On the third session, he learned breathing and muscle relaxation exercises, from a specialist, to acquire tools to help him relax and effectively manage his stress. Eight 20-min sessions were followed with similar exercises. He was also asked to both practice these sessions at home and track his progress on a daily basis.

From session four to session nine, time was devoted to using adaptive responses to challenge dysfunctional thoughts. Initially, there was an attempt to identify automatic negative thoughts in certain situations, during which he was asked to keep track of his moods. After recognizing patient's negative thoughts, emotions, and behaviors, the work was done to verify the evidence that supported them.

To help the patient effectively socialize with others, sessions 10–12 were dedicated to learning assertiveness skills. The therapist talked to the patient about the meaning of assertiveness for him, the reasons that prevented him from becoming assertive, and differences in behaviors, from assertiveness to aggressiveness, passing by submissiveness. This information has proved useful to him. To practice such skills, the exercises incorporating roleplay were used.

During the following sessions (13–20), situations that induce anxiety in the patient were investigated and then ordered according to the level of anxiety he feels during each. Through exposure techniques, the patient was confronted with each level of anxiety in real time, where he got to practice each step, until he signaled his confidence to proceed to the level to follow.

The last session saw the patient discussing how he got over difficult situations, including being introduced to people for the first time, visiting friends, public speaking, and participating in presentations in class. He was able to challenge his cognition in the situations he had previously identified as difficult and then employed the techniques he learned (breathing and muscle relaxation) to manage symptoms of anxiety.

Preventing relapse was discussed during the last session, as well as methods to achieve this purpose, and other methods for surmounting the difficulties and failures of the past. Finally, there was a discussion related to how to apply change to the skills he learned and how to use the new techniques he acquired on a day-to-day basis.

2. Results and Discussion

It was clearly seen that patient's levels of anxiety in daily social situations were effectively improved through CBT, in case of SAD. According to the exposure sessions, which also included a discussion of patient's efforts outside of the clinical setting, The patient had the courage to walk through a pedestrian crossing and look at people, ask a security guard for directions, and communicate with new people in public places.

Findings show that CBT helped the patient reduce his anger, cravings, and stress (see Table 1 ). Furthermore, it improved his sleep quality and assertiveness. These findings are consistent with the previous research results. Cannabis use disorder was effectively treated with CBT, a treatment method which was rendered even more effective with the use of medication. A patient's functions (physiological, psychosocial, and social) are affected by substance use and its related disorders, but CBT significantly aids in the treatment of deficits at these levels [ 27 , 28 ].

Thoughts record.

It was found that when treating alcohol and opioid withdrawal disorders in a rehabilitation facility, CBT was effective. Patients felt more at ease staying in therapeutic sessions, after the detoxification process. A previous study found that best results could be obtained from a combination of pharmacotherapy and CBT, during the treatment of patients suffering from substance use disorder.

During the current study, CBT sessions, organized, structured, and running on an individual basis between patient and therapist were conducted. Each session had a planned objective and a set agenda. The patient's cognitive reorganization, stress management, daily living functions, and lapse relapse prevention were all prioritized. The patient's depression and social anxiety significantly improved, because the results on the scales have been decreased (see Table 2 ).

Outcome measures for social anxiety and depression.

The therapeutic process of the patient investigated in this study, suffering from substance use disorder, included “skills training”, a technique also known as “skills building”. Much focus was placed on any deficits, the patients suffer from related to emotions, cognition, behaviors, organization, problem solving, and interpersonal relations, during skill building.

The treatment made use of any approach targeting individual differences between patients. The connections the patient developed with others were a point of focus because the opposite of addiction is not sobriety, but rather connection with society. The patient's interpersonal skills were also targeted in this study. Such skills aid in the resolution of relationship complications. They help enhance effective communication and allow the patient to make use of it along with social support. Assistance received from all these tools helps individuals abstain from addictive materials and promotes the establishment of healthy relationships [ 29 ].

3. Conclusion

CBT was effective in decreasing the patient's symptoms, including his low moods, avoidance of social interactions, and anger. It also affected the patient in terms of his gradual return to work and positive relationships with his family members.

Acknowledgments

The author acknowledges the support she received in editing this paper from Dahlia Eldeeb.

Data Availability

Additional points.

Study Limitations . The patient had fluctuations in motivation. The family has gone through a lot of stressful life events. The patient's father is busy and does not frequently communicate with him. The study approach was cognitive behavioral therapy (CBT), and the case had multiple problems from childhood. Perhaps it would be more useful to use some analytical or Gestalt techniques to deal with past problems.

The patient has given his consent to having the clinical information relating to his case reported in a medical publication.

Declaration of Generative Artificial Intelligence (AI) and AI-Assisted Technologies in the Writing Process: The author did not use any generative AI or AI-assisted technologies in the writing process.

Conflicts of Interest

The author declares that there is no conflicts of interest.

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Co-occurring Mental Health and Substance Use Disorders: Guiding Principles and Recovery Strategies in Integrated Care (Part 1)

Individuals with co-occurring mental health and substance use disorders (CODs) have complex treatment needs. Historically, these issues were treated separately, as competing discreet needs. Barriers in access to integrated care for substance related and mental health disorders prevented many individuals from finding relief from their COD. The structures in place that prevented integrated care were many. Public and private funding, research, and public policy all created troughs between disciplines of care. Researchers and practitioners have noted how the separation of mental health and substance abuse treatment has created additional barriers and obstacles for clients with CODs: Parallel treatment results in fragmentation of services, non-adherence to interventions, dropout, and service extrusion, because treatment programs remain rigidly focused on single disorders and individuals with dual disorders are unable to negotiate the separate systems and to make sense of disparate messages regarding treatment and recovery (Osher, Drake, 1996; Drake, Mueser, Brunette, and McHugo. 2004).

Mental health services and treatment structures for substance related disorders were on divergent paths and many professionals considered one another with skepticism. Today, some, but not all, of those barriers have been eliminated.

According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 2011 National Survey on Drug Use and Health, Mental Health Findings, more than 8 million adults in the United States have CODs. Only 6.9% of individuals receive treatment for both conditions and 56.6% receive no treatment at all (SAMHSA, 2012).

This is the first of two practice briefs that will explore eight principles of integrated care for CODs (Mueser et al., 2003). This brief will examine the first four of the following principles:

• Principle 1: Integration of mental health and substance use services
• Principle 2: Access to comprehensive assessment of substance use and mental health concerns
• Principle 3: Comprehensive variety of services offered to clients
• Principle 4: An assertive approach to care/service delivery
• Principle 5: Using a harm reduction approach to care
• Principle 6: Motivation-based and stage wise interventions
• Principle 7: Long-term perspective of care
• Principle 8: Providing multiple psychotherapeutic modalities

After a brief review of each principle, an illustrative case study will be provided and suggestions for implementing each of the principles in a client session will be offered (SAMHSA, 2009a; 2009b).

Principle 1: Integration of Mental Health and Substance Use Services

Multidisciplinary teams provide integrated services and relevant care that is client centered and longitudinal in nature. Agency policies and practices recognize the relapse potential with CODs and do not penalize clients for exhibiting symptoms of their mental health or substance related disorders. Team members may include the client and their family members or supportive persons, practitioners who are trained in substance abuse and mental health counseling, and a combination of physicians, nurses, case managers, or providers of ancillary rehabilitation services (therapy, vocational, housing, etc.) such as social workers, psychologists, psychiatrists, marriage and family therapists and peer support specialists. Based on their respective areas of expertise, team members collaborate to deliver integrated services relevant to the client’s specific circumstances, assist in making progress toward goals, and adjust services over time to meet individuals’ evolving needs (Mueser, Drake, & Noordsy, 2013). The team members consistently and regularly communicate with the client to discuss progress towards goals, and they work together to meet the individual treatment needs of each client.

Penny, 43, experienced her first depressive episode in her mid teens. During her first treatment for substance use (marijuana and alcohol) at age 17, Penny was diagnosed with attention deficit hyperactivity disorder (ADHD). However, over the next few years, she became increasingly edgy and irritable with intermittent periods of euphoria, accelerated energy and impulsive behaviors followed by periods of despair. She had repeated hospitalizations and concurrent and sequential contact with both mental health and substance abuse treatment systems over the years. Penny was labeled with a variety of diagnoses, including bipolar disorder, ADHD, major depression, anxiety disorder, borderline personality disorder, and chemical dependence.

Penny’s multi-disciplinary team consisted of her primary practitioner who held LADC/LPCC dual licenses, a primary care physician, a psychiatrist, a family therapist, a peer recovery support specialist, and a vocational specialist. Penny participated in individual therapy as well as recovery skills groups with her primary practitioner. Her primary care physician monitored Penny’s physical concerns including her diabetes and hypothyroid disorder. Penny’s psychiatrist prescribed and monitored Penny’s mood-stabilizing medications and provided case consultation to Penny’s team. The family therapist provided ongoing support to Penny and her boyfriend Don, and helped Penny and her team decide if and when to begin reparations in her relationship with her children. In addition, the family therapist provided feedback to the team about how Penny’s relationships impacted her recovery status and overall stability. The vocational specialist acted as a resource for Penny once she expressed a desire to return to work, helped Penny and her team identify resources for employment, and acted as liaison with Penny’s employer. The peer recovery support specialist helped Penny identify recovery support groups and helped Penny and her team identify barriers and resources to overcome those barriers to recovery success.

Principle 2: Access to Comprehensive Assessment of Substance Use and Mental Health Concerns

Integrated care recognizes that CODs and the resulting consequences of those conditions are commonplace. Therefore, practice protocols that standardize comprehensive biopsychosocial assessments are essential to identifying major mental illnesses and substance use. A comprehensive assessment includes screening, and when needed, further examination of substance use and mental health concerns. Practitioners utilize information collected from the comprehensive assessment to provide recommendations for treatment —such as the role one condition has on the efficacy of particular treatment strategies for the other condition(s). Screening tools for substance related disorders can include the CAGE-AID (Brown & Rounds, 1995), the Michigan Alcohol Screening Test (MAST) (Selzer, 1971), the Drug and Alcohol Screen Test (DAST) or the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al., 1993). For mental health concerns the Global Appraisal of Individual Needs-Short Screener (GAIN-SS) (Dennis, Chan, & Funk, 2006), or Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983) may be used.

When feasible, the practitioner gathers information from the client’s family and other professional resources who might have relevant information regarding symptom severity, substance use, and role functioning. Information gathered during the initial assessment can assist in a collaborative goal setting process. Ongoing assessment is critical in the treatment of co-occurring disorders and involves evaluation of changes in circumstances, substance use, stability and symptom expression, and goal attainment. Conducting a comprehensive integrated assessment helps define areas that can be addressed in treatment and identify specific treatment recommendations (Mueser et al., 2013). The context of the comprehensive assessment should occur within a recovery-oriented perspective. Progress toward recovery is individualized as described in the following definition: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (SAMHSA, CMHS, 2011).

Penny and her primary practitioner completed a comprehensive biopsychosocial assessment that included questions about distressing mental health symptoms as well as substance use patterns and periods of abstinence/remission. During her early 20s Penny entered college to become a nurse. Soon after beginning school, her anxiety increased. She experienced racing thoughts, extreme irritability, interruptions in sleep and a pronounced overconfidence followed by periods of despair and an inability to get out of bed. Penny returned to using alcohol and marijuana and eventually discontinued her education.

In her early 30s, Penny completed substance abuse treatment and was abstinent from alcohol and marijuana. She also participated in individual therapy and was prescribed lithium. She experienced a period of relative stability and returned to school. However, Penny disliked the side effects of her medication and felt she was stable enough to discontinue taking the lithium. She sought care from a physician for her anxiety and was placed on the benzodiazepine Xanax.

Penny currently lives with Don, her boyfriend of 8 years. Due to chronic conflict in their relationship, she is in danger of becoming homeless. Don has a construction business and manages to make a solid living. They both smoke marijuana most evenings as a way to wind down from the day. Don occasionally uses cocaine and in very rare situations Penny has joined him. She has been abstinent from alcohol since receiving a DWI 9 months ago. Penny has been estranged from her two adult children, Linda, 24, and Jeff, 22, for 6 months and 3 years, respectively. Her parents are deceased.

Penny’s practitioner was able to collect information from Penny’s boyfriend, her children, previous therapists, agencies and hospitals with whom she has had contact. During the assessment the practitioner discovered information about periods of increased mental illness symptoms while Penny was abstinent from substances, and a return to substance use in correlation with mental illness symptoms. The comprehensive assessment provided initial information about Penny’s current mental illness symptoms and substance use and was used to determine treatment priorities and programs that align with Penny’s needs.

Principle 3: Comprehensive Variety of Services Offered to Clients

Clients are provided with comprehensive integrated services that are cohesive, relevant and responsive to their identified needs and goals (Bipolar Disorder, n.d.). Practitioners coordinate with one another and collaborate with the client to prioritize treatment needs in a manner that does not overwhelm the client. A multidisciplinary team provides support for a broad range of issues relevant to the client population served by the agency. This includes culturally relevant information about community support systems and an array of mental health or substance related resources available to clients and their support persons.

Comprehensive services that are relevant to persons with CODs often include but are not limited to: medication assisted therapy, cognitive behavioral therapy (CBT), family therapy, life skills/ psychosocial rehabilitation, psychoeducation, and supported employment. Medication assisted therapy helps control distressing symptoms of many health and mental health dis-orders and is helpful for mood stabilization. Medication is also used in the treatment of substance use disorders to inhibit substance use, reduce cravings, reduce withdrawal symptoms, and as replacement therapy. CBT helps people with CODs learn to change harmful or negative thought patterns and behaviors.

Family therapy enhances coping strategies and focuses on improving communication and problem solving amongst family members and significant others. Life skills/rehabilitation provides clients with new information and opportunities to practice skills such as sleep hygiene practices, self-care, stress reduction and management, and medication maintenance. Psychoeducation provides information about the interacting dynamics of CODs and treatment (e.g., recognition of early signs of relapse so they can seek support before a full-blown episode occurs.) Supported employment provides opportunities for the client to contribute meaningfully in a work environment. A vocational specialist is part of the treatment team and works as a liaison with employers, client and the rest of the treatment team to support the client in the work environment. A case manager/navigator assists the client and their support persons in access-ing resources necessary to their recovery. These relationships are longitudinal in nature and supportive rather than therapeutic.

Penny and her treatment team agreed that she would benefit from mood stabilizing medication for her mental health disorder as well as cognitive behavioral therapy to help her develop coping strategies to help regulate and stabilize symptoms such as feelings of despair, racing thoughts, and behavioral dysregulation. Penny and Don recently began family counseling to explore the role and impact of substance use on their relationship, to develop communication skills and to identify strategies to help Don support Penny in her recovery from COD. Penny expressed interest in mending the relationship with her children in the future. If they are reunited, Penny identified a goal of attending family therapy with her children to improve communication and explore the impact of her COD on her relationship with them. Penny also identified a desire to return to work and will be making an appointment to discuss her work goals with the supported employment specialist.

Penny participates in a skills group to assist her in managing the symptoms of her CODs such as emotional and behavioral regulation, self care, sleep hygiene, and to manage triggers related to her substance use.

Principle 4: An Assertive Approach to Care/Service Delivery

Assertive outreach involves reaching out to individuals who are at risk or in crisis and their concerned persons, by providing support and engaging them in the change process. Sometimes this occurs by engaging the individual who seeks care for a substance use issue and providing services that stabilize a COD. An assertive approach is time unlimited and occurs in a variety of situations, including a client’s own community setting (Bond, 1991; Bond, McGrew, & Fekete, 1995). Assertive outreach includes meeting the client in community locations and providing practical assistance in daily living needs. These strategies increase or decrease in intensity depending on the client’s day-to-day living needs such as housing, transportation, money management, or seeking employment. This approach also provides opportunities to explore and address how substance use interferes with goal attainment.

Assertive outreach by Penny’s multidisciplinary team included meeting with a vocational specialist to assist Penny in looking for a job. Penny’s primary practitioner met with Penny weekly in Penny’s home and discussed progress towards her goals. Although Penny had not declared she wanted to stop using or cut down this provided Penny’s practitioner with an opportunity to introduce discrepancy by exploring how substance use interfered with taking steps toward Penny’s goals and practicing or using coping skills. Penny and her primary practitioner examined how Penny’s use impeded her ability to follow through with completing job applications and job interviews as steps toward finding steady, meaningful work.

This brief examined four of the eight principles of COD treatment. The first four principles underscore the importance of the integration of COD services and access to comprehensive assessment and care using assertive outreach and a client centered approach. The next brief will explore the latter four COD principles and implementation strategies. The final COD principles emphasize a long-term care model using a harm-reduction approach, motivation-based stage-wise treatment interventions and multiple treatment modalities (Mueser et al., 2003). The principles in both briefs place the client and their support persons, front and center as active participants, guides, resources and experts in their own recovery. Unpacking the principles of integrated treatment for CODs provides opportunities for practitioners to utilize multiple strategies to engage clients in treatment as discussed in this practice brief.

As you consider the practice of integrated care, examine your agency and your own clinical practice. Consider how you might try new strategies in an effort to implement the principles of COD treatment. We invite practitioners to engage in a dialogue surround-ing the strategies implemented in sessions to engage COD clients. Please consider the following and email us to describe successful COD strategies and challenges utilizing the principles of COD treatment.

• What strategies have you tried using one of the above principles that worked particularly well?
• What challenges have you encountered?
• Please provide suggestions for additional strategies you found helpful.