Addiction Counselor Practice Test Book

*34.* Circumstances, Motivation, Readiness, and Suitability (CMRS) Scales are used for what purpose? a. Assessing client readiness for treatment b. Assessing various financial and family support domains c. Assessing client suitability for research participation d. Assessing clients for treatment level of care

*A: Assessing client readiness for treatment* CMRS scales, by G. De Leon, were developed to aid in determining client readiness for substance abuse treatment. The scales measure client perceptions in four interrelated domains: circumstances (the external pressures influencing substance abuse change), motivation (internal pressures driving change), readiness (perception and acceptance of the need for treatment), and suitability (the client's perception of the appropriateness of the treatment modality or setting) for community or residential treatment. CMRS scales consist of eighteen Likert-type (five-point, strongly disagree to strongly agree) response items. The scores are summed to derive a total score. Research on validity and reliability has offered strong support for the CMRS scales.

*41.* All of the following are true of depression and substance abuse EXCEPT that a. drugs of abuse can successfully treat depression. b. depression can lead to self-medication with drugs of abuse. c. drugs of abuse can induce symptoms of depression. d. drugs of abuse can worsen symptoms of depression.

*A: Drugs of Abuse can successfully treat depression* Drugs of abuse are not able to successfully treat depression. While transient relief can be experienced, the subsequent withdrawal depression invariably serves to worsen the original symptoms. Among the most common assessment tools for depression is the twenty-one-item Beck Depression Inventory, now in its second revision (BDI-II). The BDI is designed for use with individuals between the ages of thirteen and eighty. It can be utilized as a self-report instrument, or administration may be provided by a verbally trained administrator. The new format is inclusive of a prior two-week period, and other items were revised to assess both increases and decreases in sleep and appetite, better allowing formulation of a DSM diagnosis.

*33.* The Stage Model of Change addresses how many client stages? a. Five stages b. Six stages c. Seven stages d. Eight stages

*B: Six stages* The first stage in the stages of change is precontemplation. This stage is characterized by: (1) giving no thought to change, (2) feeling resigned to substance abuse, (3) a sense of loss of control, (4) denial (there is no personal problem), and (5) minimization of consequences experienced. The second stage is contemplation. This stage is characterized by evaluation of the costs, benefits, and burdens associated with the substance abuse behavior as well as those involved in any proposed change. The third stage is preparation. This stage involves early experimentation with minor changes in use patterns to better evaluate the idea of change proposal. The fourth stage is action. This stage involves taking direct action in pursuit of change. The fifth stage is maintenance. This stage is characterized by efforts to maintain the change achieved. Finally, the sixth stage is relapse. This stage is initially demoralizing, though it is a normal part of change. Ideally, it culminates in a return to the contemplation or action stages.

*100.* What does the term culture-bound syndrome refer to? a. An illness (mental or physical) unique to a cultural group b. An illness presenting or interpreted distinctively, due to cultural influence c. Both A and B d. Neither A nor B

*C: Both A and B* The term culture-bound syndrome has been used in different ways. First, it can refer to an illness truly bound to a specific culture. For example, the mottled discoloration on the thighs caused by the heat of a laptop resting on the legs of an excessive techie computer user or the fatal brain disorder (kuru) caused by now-banned cannibalism among the South Foré people of the eastern New Guinea Highlands. Second, it can refer to otherwise common mental or physical illnesses that are subsequently construed as unusual because of the pathoplastic influence of culture. For example, interpreting the hallucinatory symptoms of schizophrenia as evidence of demonic possession or considering the apparently other worldly experience of grand mal seizures to be a sacred disease—as described by Hippocrates—and more recently by the animistic Hmong, who may then revere and elevate such persons to the station of shaman.

*6.* What is the MOST common symptom of Wernicke's encephalopathy? a. New memory formation b. Loss of older memories c. Psychosis d. Confusion

*D: Confusion* Other symptoms of Wernicke's encephalopathy include poor muscle coordination and oculomotor impairment (problems moving the eyes in a controlled fashion). Wernicke's syndrome is a short-term condition resulting from vitamin B1 (thiamine) deficiency, typically developing after years of drinking and poor nutrition. Of those with Wernicke's syndrome, 80 to 90 percent will develop long-term psychosis and memory problems known as Korsakoff syndrome. While poor coordination is a symptom, retrograde amnesia (loss of old memories) and learning impairments are among the more classic hallmarks of the condition. Because they are so often found together, the two syndromes are often referred to concurrently as Wernicke-Korsakoff syndrome.

*3.* How is drug tolerance BEST described? a. The inability to get intoxicated b. The need for more of a drug to get intoxicated c. Increased sensitivity to a drug over time d. Decreased sensitivity to a drug over time

*D: Decreased sensitivity to a drug over time* When a drug is used regularly, the body is gradually able to adapt to the effects of the drug. Evidence of tolerance is twofold: (1) greater doses of the drug are required to achieve previous effects, and (2) doses that would have produced profound physiological compromise or even death are now readily tolerated without untoward effects. In some cases, it has been noted that up to ten times a lethal dosage, or even more, may be taken without any signs of significant physiological compromise. Tolerance develops as the body seeks homeostasis, or a functional state of equilibrium, in spite of the presence of the drug.

*35.* When is a client fully prepared to enter treatment? a. Treatment is court ordered. b. Family pressures a client to enter treatment. c. Job-based drug testing creates a clear need. d. A client accepts the need for treatment.

*35. D: A client accepts the need for treatment* External events and pressures may persuade or even compel a client to enter treatment, and treatment admission may follow. However, true readiness is when a client perceives and then accepts the need for treatment. This typically requires the client to possess at least some insight into his or her condition, the associated costs and consequences, and a recognition that self-induced efforts have been unsuccessful. Finally, readiness involves a meaningful desire to effect change. The use of assessment instruments, such as the use of circumstances, motivation, readiness, and suitability scales can be particularly helpful in judging readiness for change.

*36.* Guiding principles in treatment planning are identified by which acronym? a. MTSRA b. MATRS c. MSRTA d. MRAST

*36. B: MATRS* This acronym represents the following guiding treatment planning principles: *M = measurable.* Goals and objectives must be clearly measurable so that progress and other changes can be identified readily and documented. *A = attainable.* Goals and objectives, and interventions as well, must be achievable (attainable) during the active treatment phase. *T = time limited*. The active focus of treatment should be on short-term or time-limited goals and objectives. *R = realistic.* It must be realistic for a client to complete the identified objectives of each goal within the specified time period. *S = specific*. Objectives, and associated interventions, must be sufficiently specific and goal focused to ensure progress toward attainment. A key element is involving the client directly in the planning process to ensure that the goals, objectives, and action steps are mutually derived to ensure client buy-in and commitment.

*43.* What of the following is NOT a key component in a treatment plan? a. Problem statements from the intake assessment b. Goal statements derived from problem statements c. Objectives, which are what the client will do to meet treatment goals d. The theoretical approach to be operationalized via treatment.

*43. D: The theoretical approach to be operationalized via treatment* The key components of a treatment plan include: (1) problem statements, which are based on information obtained during the assessment; (2) goal statements, which are derived from the problem statements; (3) objectives, which consist of what the client will do to meet treatment goals; and (4) interventions, which are defined as what the staff will do to assist the client. Relevant client strengths are often a required component. It is often useful to draw problems from a master problem list. The list should include all identified problems, regardless of available program services, and whether they should be immediately addressed or deferred. Identification of problems is a shared client-counselor endeavor. Problem statements should be nonjudgmental, jargon-free, and written in complete sentences. Couch problem statements in behavioral specifics to ease writing goals, objectives, and interventions.

*57.* How many sequential stages must outpatient clients work through, regardless of the level of care at which they enter treatment? a. Two stages b. Four stages c. Six stages d. Eight stages

*57. B: Four stages* Independent of the levels of care defined by the American Society of Addiction Medicine *(ASAM)*, outpatient clients must work through four sequential stages of treatment, regardless of the entry treatment level of care. The stages consist of: Stage 1—treatment engagement (establish a treatment contract including goals and client responsibilities; resolve acute crises; develop a therapeutic alliance; and prepare a treatment plan); Stage 2—early recovery (continue abstinence; sustain behavioral changes; terminate a drug-using lifestyle and develop drug-free alternatives; learn relapse triggers and prevention strategies; identify and resolve contributing personal problems; and begin a twelve-step or mutual-help program); Stage 3—maintenance (solidify abstinence; deepen relapse prevention skills; enhance emotional functioning; increase sober social networks; and address other problem areas); Stage 4—community support (sustain abstinence and a healthy lifestyle; establish treatment independence; extend social network and support group connections; pursue healthy community activities; and solidify important outlet activities and pursue new interests).

*58.* What is the usual recommended minimum duration of days for the intensive outpatient treatment (IOT) phase? a. Thirty days b. Sixty days c. Ninety days d. One hundred twenty days

*58. C: Ninety days* The most common recommended minimum duration of days in an intensive outpatient treatment (IOT) phase is ninety days. However, research reveals that longer duration of care is related to better treatment outcomes—specifically, less substance use and better social functioning in clients over time. Consequently, it may be both advantageous and cost-effective to plan lower-intensity outpatient treatment over a longer time period to enhance treatment outcomes. The ultimate duration should be adjusted to meet the client's rate of progress, psychiatric status, support system, clinical needs, and so on. IOT programming is commonly provided for nine or more hours over three to five days per week. The consensus panel recommends six to thirty hours, depending upon client needs. For some clients, more frequent, shorter visits may be of greater benefit than fewer, longer sessions. For other clients, more or longer sessions, approaching the intensity of partial hospitalization, may be needed.

*78.* Two clients in a treatment group begin dating. What would a proper response be? a. Address program policy preventing dating among group members. b. Initiate a group activity to acknowledge their new relationship. c. Terminate treatment for both of the members. d. Terminate treatment for one of the members.

*78. A: Address program policy preventing dating among group members.* Most treatment programs have policies that prevent clients from engaging in intimate relationships that might undermine treatment. This typically includes prohibiting clients and counselors from socializing outside the confines of the program. Some programs also discourage any contact between clients outside the program's structured activities. Virtually all programs discourage dating, sexual relationships, moving in together, and other forms of significant involvement. However, many programs do encourage clients to collaborate in mutual-help group attendance, and some even encourage mutual support in other meaningful aspects of their lives. Where boundary issues occur, options include assigning one of the clients to another group or providing individual counseling to one while waiting for the other to complete the program. Should mutual substance abuse occur, recommitment contracts and renewed abstinence contracts may be needed. Regardless, it is important for counselors to fully understand the boundaries within the treatment program and to consistently apply these guidelines.

*95.* When behaviorally assessing for a co-occurring disorder, what is the MOST important variable to consider? a. Alcohol or drug toxicity or withdrawal symptoms b. The client's denial of any psychiatric problem c. The client's family history of psychiatric disorders d. The client's immediate behavior

*A: Alcohol or drug toxicity or withdrawal symptoms* Client information, immediate behaviors, current medications, family history, and so on may well be indicative of a co-occurring disorder. However, they are not definitive criteria. The diagnosis must be proven or validated by the client's ongoing clinical presentation. Symptoms of withdrawal, as well as those of acute or chronic alcohol and drug toxicity, can readily present as a psychiatric disorder. They can also mask underlying psychiatric symptoms. True psychiatric symptoms often become apparent during the early stages of abstinence. Program staff should recognize that co-occurring disorders are common. Beyond the client's clinical presentation, additional attention should be given to: (1) the psychiatric history of the client and his or her family, especially documented diagnoses, prior treatment, and any psychiatric hospitalizations; (2) medications and medication compliance; and (3) ongoing symptoms and mental status changes over time. As the assessment proceeds, caution must be taken to ensure the client is properly treated for any serious medical withdrawal problems. Other safety issues, such as suicidality or homicidality and any inability to function, communicate, or care for oneself also should be responded to aggressively.

*114.* Sensitive interviewing and engagement techniques are important to optimize client responsiveness and investment. What does the ask-tell-ask technique refer to? a. Asking permission of the client to talk with them, telling them of any concerns you have, and then asking for their thoughts on what you shared b. Asking clients what they understand, telling them where they are wrong, and asking again if they understand c. Asking clients for their opinions, telling them where their opinions are valid and workable, and then asking them if they concur d. Asking clients to listen, telling them what they need to know, and asking if they will acquiesce to what is being asked of them

*A: Asking permission of the client to talk with them, telling them of any concerns you have, and then asking for their thoughts on what you shared* When making referrals, it is important to carefully inform clients of your concerns and reasons and then to engage them in ways that do not induce obstruction. The ask-tell-ask technique can assist in this. Further, providing ample information, background, and personal insights into referrals can also assist. To this end, it is important for case managers to be intimately familiar with their referrals, having completed site visits, meeting with provider staff, and in other ways becoming well prepared to put clients' concerns to rest. Finally, all substance abuse communications should be conducted away from clients' families and other staff, and any further sharing should take place only after receiving clients' express permission to that end.

*148.* Clients with a history of abuse have a tendency to place themselves in situations in which further abuse is likely, particularly an unsafe relationship. If this occurs, what is the counselor's BEST response? a. Coach them to explore the situation, issues of risk, and self-endangerment. b. Point out to them the issues that are obvious to the counselor. c. Provide a lecture on issues of abuse recovery and important safety concerns. d. Contact the unsafe individual, and intervene on the client's behalf.

*A: Coach them to explore the situation, issues of risk, and self-endangerment.* Many survivors of significant abuse tend to put themselves in further high-risk situations. Their counter-transference issues with the counselor may draw the counselor into the role of rescuer as they seek the safety, nurturance, and security they deeply desire. If the counselor is not fully self-aware, he or she can be pulled into this dynamic in seeking to defend and support the client. In doing so, however, the client moves into dependency and fails to learn how to identify and set appropriate boundaries in his or her own life. Over time, the concerned counselor may over treat, lend funds, arrange child care, and otherwise inappropriately respond. The counselor may also attempt to intervene with others on the client's behalf and find him- or herself polarized from a client that is now angry with the counselor for intruding into important family or other relationships. While rescuing may temporarily relieve the counselor's concerns and frustrations, it will never provide long-term resolution of the problems.

*118.* In a client's efforts to maintain emotional and psychological balance, what does the term bookend refer to? a. Discussing a trigger event with someone trusted before and after it occurs b. Fully reading and applying reference literature provided in the program c. Remaining steadfast even in the face of temptation to abuse a substance d. Keeping a difficult issue on the shelf until it can be better dealt with

*A: Discussing a trigger event with someone trusted before and after it occurs* Trigger events are often crisis stressors or situations (e.g., notice of divorce, job loss, an impending holiday or anniversary, or visiting someone in an old neighborhood where past friends may again invite and encourage using, etc.). Clients are encouraged to anticipate such events and then bookend them—talking about them with a trusted friend (e.g., a twelve-step sponsor, close confidant, trusted friend, etc.) both before and after they occur. In this way, the client can prepare to remain strong and then debrief and decompress emotionally in order to continue strong in his or her abstinence commitments. A counselor can be of further assistance, addressing the client's specific strengths and weaknesses in order to shore up the client's resolve. In this way, the client can be assisted in avoiding a return to past familiar dysfunctional responses. Mometrix Test Preparation. Addiction Counselor Exam Practice Questions (First Set): Addiction Counselor Practice Tests & Review for the Addiction Counseling Exam (Kindle Locations 1410-1416). Mometrix Test Preparation. Kindle Edition.

*138.* Accurate documentation and reports are necessary if effective treatment and recovery plans are to be developed and implemented. Which of the following is NOT fundamental assessment information at intake? a. Documentation regarding referrals and referral outcomes b. Psychoactive substance abuse history and patterns of use c. Psychological health and psychiatric treatment history d. Current physiological health and medical history

*A: Documentation regarding referrals and referral outcomes* It is very important to document all referrals made along with related outcomes. In this way, the full range of services a client is receiving and has received is known, and the effectiveness of any referral services can also be followed and measured over time. However, referrals are not part of the intake and evaluation process. Essential intake assessment information includes: (1) psychoactive substance abuse history and patterns of use; (2) psychological health and psychiatric treatment history; (3) current physiological health, nutrition, and medical history; (4) medications history and current medications; (5) basic demographic and social information; (6) legal history (arrests, sentences, probation or parole status, etc.); (7) educational history; (8) recreational activity history; (9) religious or spiritual history and current beliefs; (10) sexual orientation; (11) high-risk sexual and substance use practices, if any; and (12) family history and current support network.

*16.* At an initial meeting with a new client, what is the FIRST requirement? a. Establish rapport. b. Evaluate readiness for change. c. Review rules and expectations. d. Discuss confidentiality regulations.

*A: Establish rapport* Exploring readiness for change, rules and expectations, or issues of confidentiality may otherwise serve only to induce client anxiety, defensiveness, or rejection of potential treatment outright. The counselor must generate an authentic and safe environment that is conducive to trust and disclosure. This can be achieved, from a motivational perspective, by assuring the client that he or she will not be told what to do, but rather, help will be given in deciding what he or she is seeking to accomplish. A direct request about what has brought the client in can be helpful if they are ready to talk openly. Otherwise, asking about health, work, or family challenges may provide an oblique entry to asking about substance issues (e.g., "How is this affected by your substance abuse?"). As rapport grows, issues of confidentiality, program requirements (e.g., whether or not sessions can be held in spite of intoxication, etc.), session length, evaluation of change readiness, and so on, can then more naturally unfold.

*21.* What does the acronym GATE stand for? a. Gather information; Access supervision; Take responsible action; Extend the action b. Gather resources; Access procedures; Take clinical notes; Extend the intervention c. Gather documentation; Access contacts; Take counsel; Extend positive outcomes d. Gather the team; Access records; Take consultation; Extend documentation

*A: Gather information; Access supervision; Take responsible action; Extend the action* GATE was established by a consensus panel addressing the evaluation of suicidal ideation and behaviors by substance abuse counselors working with at-risk clients. It consists of activities that are well within the practice scope of a substance abuse counselor. Gathering information involves (1) screening for suicidality and (2) observing for warning signs. Screening involves direct questions regarding current thoughts (plans, means, or preparations) and any past history of attempts. Accessing supervision or consultation (even if the counselor already has specialized training) ensures issues of risk are fully evaluated. Taking responsible action protects client well-being and safety. Extending the action involves securing follow-up and ongoing monitoring as needed. In this way, GATE fully assesses and addresses suicidality. The final step is thorough documentation to secure a medical and legal record of the care provided.

*54.* Which of the following is NOT a primary learning style? a. Gustatory b. Kinesthetic c. Auditory d. Visual

*A: Gustatory* Gustatory refers to the sense of taste and is not a learning style. To learn, we utilize our senses to process information around us. When learning, most people use one of their senses more than the others. There are actually seven learning styles: (1) aural (auditory-musical): learning through sound; (2) visual (spatial): learning via images; (3) verbal (linguistic): learning through words; (4) physical (kinesthetic): learning via touch; (5) logical (mathematical): learning through logic; (6) social (interpersonal): learning best with others; (7) solitary (intrapersonal): learning through self-study. The three most common learning styles are visual, auditory, and kinesthetic. Consequently, programs should explore the use of videotapes, behavioral rehearsals or role plays, written materials, lectures, discussions, workbook assignments, and daily logs or journals. In this way, all primary learning modes can be met.

*134.* The number of older adults is rapidly increasing in the United States and worldwide. As a group, when receiving appropriate treatment for substance abuse, how are older adults likely to act? a. Less likely to continue to use alcohol or drugs b. About as likely to continue to use alcohol or drugs c. More likely to continue to use alcohol or drugs d. Insufficient data to make these comparisons

*A: Less likely to continue to use alcohol or drugs* Older adults are particularly receptive to treatment for drug and alcohol abuse. However, they are less likely to be identified as having a problem compared with the general population. The reasons for this include: (1) they are more likely to feel shame over the problem; (2) they are more likely to be covert about any substance abuse problems; (3) they are less likely to recognize they have a problem as much of the abuse may involve prescription medications, which they tend to justify; (4) they are unaware of interaction problems between alcohol and prescription drugs; (5) they often have physical conditions that may obscure their substance abuse, making it difficult to diagnose. Because of these factors, abuse among the elderly may more likely be spotted via screenings at wellness centers than by drug abuse outreach programs. Finally, this population has special needs, and age-appropriate treatment is essential for optimal outcomes.

*141.* Accurate records are the basis for the treatment plan and measuring client progress. If something is entered in a client record in error, what is the proper response? a. Line through the error, writing error and initialing and dating the change b. White-out or otherwise obscure the error to fully eliminate it from the chart c. Remove the erroneous page and recopy all correct information onto a new page d. Black out the error using a felt pen to ensure the error cannot be read

*A: Line through the error, writing error and initialing and dating the change* No information should be obliterated in a client record. It is only appropriate to line it out with a single line and indicate that the information was entered in error, when, and by whom. Generally, black ink should be used, every page should have a header with the client's name, and all notes should be concluded with the author's signature and any relevant acronym indicating a relevant degree, certification, or licensure. All notes should address interventions and client responses along with references to any related goals or objectives. No other clients should be named in another client's record, limiting references to others by the first name or initials only, if necessary, or by relationship status if adequately clear. Blank areas on a page should be avoided. If a blank space is left, it should be lined through with one or more diagonal lines. Charts should never leave a facility except for purposes of audit.

*133.* Although most individuals with cognitive and physical disabilities desire to work, many are unable to do so. In consequence, as related to substance abuse and the general population, how is this population likely to act? a. More likely to use alcohol or drugs b. About as likely to use alcohol or drugs c. Less likely to use alcohol or drugs d. Insufficient data to make these comparisons

*A: More likely to use alcohol or drugs* Given their disabilities, those who are cognitive or physically disabled are unable to find work and yet also spend a larger share of their income to meet the needs of their disabilities. Consequently, poverty, depression, unmedicated pain, functional limits, and vocational difficulties leave this group particularly vulnerable to drug and alcohol abuse. Further, because of these same cognitive or functional disabilities, coupled with limitations in networks and resources, members of this group are not only more likely to develop a substance abuse problem but less likely to receive treatment for the problems they do develop. In particular, learning disabilities are common among this population, and these learning obstacles also make what treatment they do receive less effective. In consequence, programs more carefully tailored to the needs of this population are very much needed.

*107. When older adults enter treatment, how do their rates of attendance and incidence of relapse, compare to their younger cohorts? a. Much higher attendance and much lower relapse rates b. Somewhat higher attendance and modestly lower relapse rates c. No real difference in attendance or relapse rates d. Much lower attendance and much higher relapse rates

*A: Much higher attendance and much lower relapse rates* When the many barriers to entering treatment are overcome, older adults tend to have substantially better attendance and a significantly lower rate of relapse that are found among younger adults in treatment. Research also indicates that these positive performance measures continue, even if older adults are brought into mixed-age treatment settings. However, the optimum outcomes are dependent upon seniors receiving age-appropriate, individualized treatment services. Seniors often do not envision themselves as abusers—particularly when over-the-counter or prescription drugs are at issue—and they often misunderstand problems arising from alcohol and drug interactions. Consequently, many will need to be reached through health promotion, wellness, social services, and other resources that work with older adults. To this end, program providers need to be involved actively with local aging networks, including home- and community-based short- and long-term care providers. These same external resources can often also assist with specialized cultural, ethnic, and language resources as needed.

*22.* To which of the following do assessment processes and instruments NOT need be sensitive? a. Political orientation b. Age and gender c. Race and ethnicity d. Disabilities

*A: Political Orientation* Political orientation is not typically a sensitive issue in the assessment process. Comprehensive assessment domains include: (1) complete substance abuse history (all substances past and recently used, modes of use, frequency and amounts, etc.); (2) full addiction treatment history (when, where, how long, etc.); (3) significant physical and mental health history (including medications and ongoing care needs, suicidality, etc.); (4) familial history and current issues (marital status, family supports, etc.); (5) educational history; (6) employment history (and current issues); (7) legal or criminal history (including any ongoing matters such as pending court, probation, parole, etc.); (8) emotional, psychological, and perceptual concerns (worldview issues); (9) spiritual or religious issues; (10) lifestyle concerns (sexual orientation, housing transience, etc.); (11) socioeconomic factors (finances, work benefits, insurance, etc.); (12) prior community resource use; (13) cognitive capacity and behavioral functioning; (14) readiness for treatment.

*13.* Regarding substance abuse, what does Convergence Theory propose? a. Rates of substance abuse among women are converging with those of men. b. All individuals eventually narrow drug use to a drug of choice preference. c. Age is a key factor in eventual substance abuse abstinence. d. As individuals age, gender disparities in rates of abuse tend to converge.

*A: Rates of substance abuse among women are converging with those of men* Convergence theory postulates that substance abuse rates are becoming more equal during the twenty-first century—currently, 1.6 men have substance abuse issues for every 1 woman with such issues. Others, however, suggest the data is flawed, as women are more likely to hide their substance abuse behavior and less likely to see help. Other gender differences include the following: (1) men externalize accountability, women internalize (self-blame); (2) issues of self-esteem are more common for women; (3) treatment barriers are higher, as women tend to have pregnancy issues and children needing their care; (4) women tend to increase substance abuse when depressed, while men are more likely to decrease use. Women prostitute to support a habit; men turn to selling drugs or other criminal behavior. Marriage is a deterrent to drug use for men but a risk factor for women. Women drinkers are four times more likely to live with a drinker than is a man.

*38.* How many problem domains are addressed in the Addiction Severity Index (ASI)? a. Six b. Eight c. Ten d. Twelve

*A: Six* The Addiction Severity Index (ASI) addresses six problem domains: (1) medical status, (2) employment and supports, (3) alcohol and drug use, (4) legal status, (5) family and social status, and (6) psychiatric status. At times, alcohol and drug abuse are separated, resulting in a total of seven domains. It is important, however, to emphasize that the ASI is not a comprehensive instrument. For example, it does not ask questions regarding pregnancy or homelessness, for example, even though either of these issues may be of crucial importance to the client. The ASI was designed to primarily explore issues of addiction and other common, closely related issues. The goal of the ASI is to produce a standardized baseline, ensuring that all counselors consistently ask the basic questions (an important construct of research reliability in data gathering). Additional questions may need to be asked to ensure that the client's needs are fully understood and incorporated into any forthcoming treatment plan.

*90.* What is the Matrix Model designed to treat? a. Stimulant abuse b. Alcohol abuse c. Barbiturate abuse d. Inhalant abuse

*A: Stimulant Abuse* The Matrix Model (also referred to as neurobehavioral treatment) was formulated during the 1980s' spike in cocaine and methamphetamine abuse. The model utilizes a complementary set of evidence-based practices coordinated and delivered as a program. Drawing upon cognitive-behavioral therapy, motivational interviewing, and findings from relapse prevention literature, combined with educational support and twelve-step program involvement, the model seeks to coordinate and optimize evidence-based treatments and support resources. Guiding principles include: (1) developing a positive therapeutic relationship; (2) applying a scheduled structure and expectations; (3) educating participants and families regarding brain chemistry, cravings, recovery, and relapse prevention; (4) incorporating cognitive-behavioral concepts for change; (5) reinforcing positive behavioral changes; (6) outlining the expected course of treatment and recovery; (7) promoting self-help (twelve-step) participation; and (8) using regular drug testing (urinalyses) to track progress.

*125.* Treatment for longer periods of time is closely associated with enhanced outcomes. What is the baseline duration for improved outcomes? a. Three months b. Six months c. Twelve months d. Eighteen months

*A: Three months* While longer is generally better, the positive effects of treatment duration typically begin to emerge at around three months. In planning treatment, the Institute of Medicine adds: (1) there is no one best treatment approach; (2) inpatient (residential) has not been proven superior to outpatient approaches; (3) outcomes improve if other related life problems are also treated; (4) outcomes are influenced by the treatment process, client-therapist characteristics, aftercare adjustment, and interactions among these variables; (5) many life areas improve with significant reductions in use or total abstinence. Finally, when comparing the management success of chronic ongoing-maintenance medical conditions (asthma, diabetes, and hypertension) with relapse rates for cocaine, nicotine, and opiates, the overall treatment response rates were similar, highlighting the similar compliance and behavioral change requirements involved and human nature in meeting these requirements.

*126.* There are numerous classification systems describing various stages of recovery. However, how many stages does the most common stage classification provide for? a. Three stages b. Four stages c. Six stages d. Eight stages

*A: Three stages* The three most common recovery stages are described as: early recovery, middle recovery, and late recovery or maintenance. Key features of early recovery include entering treatment, embarking on abstinence, and staying sober. Early recovery, however, is very fragile, and relapse vulnerability remains high. This stage of recovery typically lasts from one month to one year. Key features of middle recovery include: greater confidence in abstinence grows; cravings persist but are recognized and deflected successfully; lifestyle and personality trait changes are progressing; and although relapse vulnerability persists, it is becoming less significant. Middle recovery lasts at least a year but may continue indefinitely (failing to progress or serial relapsing). Key features of late recovery or the maintenance stage are: maintaining abstinence while also improving life in other related areas; addressing psychological or relationship issues that became apparent through abstinence; and continuing all relapse prevention behaviors and skills previously learned.

*72.* What is the primary purpose of the Texas Christian University Drug Screen (TCUDS)? a. To identify those with versus those without issues of drug dependency b. To establish a roster of the kinds and severity of drugs used in the past c. To evaluate dangerousness and risk taking in drug use patterns d. To correlate drug use patterns with emerging health concerns

*A: To identify those with versus those without issues of drug dependency* The Texas Christian University Drug Screen *(TCUDS)* scale is able to distinguish between individuals with drug use disorders as opposed to those who misuse drugs but are not physically and psychologically dependent. The TCUDS instrument consists of twenty-five questions administered in less than five minutes. The TCUDS is frequently used in adult criminal justice settings. However, it is also appropriate for use in the general population. The TCU Drug Screen II (TCUDS II) is a standardized fifteen-item screening tool also designed to identify any current history of heavy drug use or dependency. Items on the TCUDS II are designed to meet the criteria found in the Diagnostic and Statistical Manual (DSM) and the NIMH Diagnostic Interview Schedule (NIMH DISC). The scale is divided into two parts, with the first assessing drug and alcohol use problems and the second addressing frequency of use and the individual's readiness for treatment. The TCUDS II can be used in an interview setting, or it can be self-administered.

*96.* How are substance abuse treatment programs for adolescents described? a. Very different from treatment programs for adults b. Somewhat different from treatment programs for adults c. Minimally different from treatment programs for adults d. Not at all different from treatment programs for adults

*A: Very different from treatment programs for adults* The physical, emotional, and cognitive changes of this developmental period make treatment more complex. Physical changes are marked by rapid growth, hormonal fluctuations, and the development of secondary sex characteristics. Cognitively, attention spans are shorter, projected awareness of the future is poor, abstract thinking skills are inconsistent, and impulsivity is high. Ideals, morals, and values are still developing, and intellectual interests are expanding. Not until late adolescence do youth become substantially aware of the consequences of their actions, thus allowing meaningful goal setting. The onset of substance abuse in this population is frequently associated with family dysfunction, parental substance use, peer influence, and troubled personal choices. Genetic background and cognitive dysfunction may also play a role. Other risk factors include: (1) a history of personality problems, poor parental or guardian relationships, academic failure, family disruption, and past victimization. An adolescent treatment provider must successfully cope with developmental, behavioral, psychiatric, family, and other treatment challenges. Most will only superficially resemble the challenges of adult clients.

*122.* Group work is utilized extensively in substance abuse treatment. How do group therapy and 12-step groups compare? a. Very different types of groups with very different purposes b. Somewhat different group types with modestly different purposes c. Inherently similar groups, though with some different purposes d. Different names for the same groups with the same purposes

*A: Very different types of groups with very different purposes* Just as individual therapy is a far more private, personal, and in-depth therapeutic modality, so is group therapy very different from twelve-step programming. Although both groups are complementary and important, a therapy group focuses on helping individuals to examine, understand, and interpret the intrapsychic and interpersonal influences and conflicts that motivate and perpetuate substance abuse. In contrast to this, twelve-step program practices are centered on drawing upon focuses such as affiliation, peer confrontation and support, and creating a culture of abstinence and the mutual accountability to sustain it. While both modalities can, for example, address denial, the twelve-step process confronts and breaks it down, while group therapy explores what produced it in the first place. Thus, group therapy is far more complex and requires highly specialized skills and experiences to effectively carry it out. Borrowing from twelve-step programming dilutes the group therapy venture and can lead to partial or complete failure of the group therapy process as the profound potential for psychological growth, emotional healing, and self-understanding remain neglected.

*66.* Adjunctive therapies refer to all EXCEPT which of the following? a. Vocational training b. Stress management c. Meditation d. Acupuncture

*A: Vocational Training* Education, vocational training, and employment issues are core support concerns but do not constitute adjunctive therapies. Adjunctive therapies are used to enhance the emotional and psychological functioning of clients laboring to overcome an addiction. Given the pressures of foregoing their substance of choice, individuals in recovery need alternative outlets for stress as well as better self-care skills. To this end, creative media groups (e.g., dance, drama, music, crafts, and arts) can be very therapeutic and helpful in the recovery process. Other alternative therapies include acupuncture and biofeedback therapy. Both of these can aid in reducing stress and in learning relaxation skills. Similarly, a variety of meditation techniques can be particularly helpful. Mediation techniques include approaches such as mindfulness (learning to appreciate the present), visualization (positive imagery), breath meditation (learning to focus and control thinking and the body), and transcendental meditation (deep awareness and consciousness). As an adjunct to substance abuse treatment, meditation is in harmony with the intent and philosophy of twelve-step and other mutual self-help groups.

*84.* Staff familiarity with twelve-step program facilitation is important because of all of the following EXCEPT that a. clients feel more pressure to attend twelve-step programs by these staff. b. clients are more easily motivated into twelve-step programs by these staff. c. clients' concerns are more meaningfully resolved by these staff. d. clients generally remain abstinent longer with twelve-step involvement. involvement.

*A: clients feel more pressure to attend twelve-step programs by these staff.* Clients are less likely to feel pressure to attend twelve-step groups by staff very familiar with the twelve-step approach. Rather, they are more likely to feel they receive useful encouragement and support from these staff persons. To ensure adequate familiarity, staff (particularly those with no past experience receiving substance abuse treatment) are encouraged to: (1) read Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), and other twelve-step program literature; (2) frequently attend open twelve-step meetings; (3) attend a diversity of twelve-step groups to better identify the unique milieu of those programs available (especially groups that are open to clients with co-occurring psychiatric disorders); and (4) study thoughtfully to ensure that they deeply understand the beliefs, values, and mores that undergird the twelve-step fellowships. In this way, staff can be particularly supportive and directive as clients explore the twelve-step approach to recovery and ongoing abstinence.

*63.* Topics addressed in psychoeducational groups are typically a. sequenced by concept for maximal effectiveness. b. presented as requested or needed by group participants. c. selected randomly by the group educator or presenter. d. determined by the group's prevailing drug of choice.

*A: sequenced by concept for maximal effectiveness.* Substance abuse and recovery topics addressed in psychoeducational groups are presented in a sequential, building order of concepts to ensure optimum learning. Core topics include: (1) understanding the relapse process; (2) relapse prevention tools; (3) creating a personal relapse plan; (4) managing euphoria and desires to test control; (5) stress management and coping skills; (6) anger management and relaxation techniques; (7) self-efficacy in relapse-risk situations; (8) managing slips and avoiding escalation; (9) recovery resources; (10) structuring leisure and recreation; (11) essentials of personal health; (12) regular personal inventory; inventory; (13) managing emotional triggers (shame, guilt, depression, and anxiety); (14) problem family dynamics (enabling and sabotaging); (15) restoring personal relationships; (16) healthy sexuality; (17) essential educational and vocational skills; (18) essential living skills (financial management, housing, and legal assistance); (19) finding meaning in life (spirituality); (20) grief and loss and substance use; (21) parenting essentials (children's needs, developmental stages, and tasks); (22) maintaining balance in life.

*108.* Confidentiality requirements exist to protect client's and their personal lives and information. Without a client signed information release, what is information that can be disclosed? a. A client's enrollment in a treatment program only b. A report of child abuse suspected to be caused by the client c. A client's name, age, gender, and race or ethnicity d. A report of progress to an employer paying for treatment

*B: A report of child abuse suspected to be caused by the client* Only mandated reporting information, such as child abuse, can be disclosed without a client's written consent. This includes any information about whether or not a client is receiving treatment or what he or she may be receiving treatment for, even to an employer paying for the treatment. Further, non-court-ordered information cannot be released even to a law enforcement agency or to any other interested party without the client's written consent. A properly informed client is one who is aware of: (1) to whom or what entity the information is being released; (2) the full purpose for the release; (3) the specific information to be released; and (4) when the information release expires. Client confidentiality regarding substance abuse treatment is protected by the Substance Abuse Confidentiality Regulations 42 CFR (Code of Federal Regulations) Part 2 (codified as 42 U.S.C. [United States Code] §290dd-2 and 42 CFR Part 2 (Part 2) and the Health Insurance Portability and Accountability Act (HIPAA, codified as 42 U.S.C. §1320d et seq., 45 CFR Parts 160 and 164).

*112.* The term authentically connected referral network is used in conjunction with case management. How is it BEST defined? a. A resource directory of available community services to call as needed b. A set of defined relationships able to adapt and flexibly meet client needs c. A rolodex with key names and contacts for needed services d. An informal consortium of providers sharing information among each other

*B: A set of defined relationships able to adapt and flexibly meet client needs* The term authentically connected referral network refers to a carefully established set of service providers prepared to meet client needs as they evolve. Key elements to the network are: (1) established communication linkages to facilitate timely sharing of information with client consent; (2) a focus on community-wide outcomes, ensuring that best interests are being met and that community education ensures understandings about substance abuse; (3) a primary focus on meeting client needs through collaboration as opposed to exclusionary rules; (4) consistency and credibility in conduct to ensure both interagency and client confidence and trust. The goal is for all network agencies and providers to recognize their valued and essential roles in the addiction treatment process and for clients to recognize this and respond with similar trust and confidence.

*69.* What is the sandwich technique? a. A method to increase health food intake b. An intake interviewing technique c. Client pairing for optimal treatment support d. Staff pairing for optimal treatment support

*B: An intake interviewing technique* Optimizing the intake process enhances the likelihood that the client will both disclose crucial intake information and accept treatment. Overly formal intake questioning is likely to be off-putting and may well inhibit self-disclosure and engagement. Both research and anecdotal evidence suggest that less-formal approaches can better build and support rapport between the counselor and client. One less formal approach is the sandwich technique. It involves sandwiching the standard screening and assessment questions between two less-formal discussions. For fifteen to thirty minutes, the counselor: (1) addresses perceptions of the problems that motivated the client to explore treatment; (2) elicits the client's expectations of treatment; (3) supports the commitment to change; (4) offers encouragement that change can be achieved; and (5) explores readiness to change. Next, the formal screening and assessment are conducted, followed by: (1) a less-formal summarizing of findings; (2) initial treatment planning appropriate to the client's change stage; and (3) addressing the individual's expectations for treatment.

*147.* Many substance-abusing clients suffer from high impulsivity. If a client begins to act out inappropriately, what is an IDEAL grounding technique? a. Verbal confrontation b. Anchoring exercises c. Walking out of the session d. Pointing out program rules

*B: Anchoring exercises* Many substance-abusing clients suffer from low self-esteem, poor self-control, deficient boundaries, and high impulsivity. Where this behavior is the result of poor emotional control, various interventions may help. Where the problem arises from underlying pathology (e.g., posttraumatic stress disorder [PTSD], bipolar disorder, psychosis, intoxication, etc.), rapid de-escalation and backup support may be immediately necessary. Where the behavior is simply developmental immaturity, grounding techniques are often beneficial. In anchoring, the counselor leads the client to relax, close his or her eyes, and focus on breathing and the immediate environment (the chair, the room, the quiet, etc.). Then, the counselor has the client recognize that, in spite of worries about the past or future, the immediate present is safe. The counselor must support this by avoiding sudden movements, pressured speech, and so on, so as to avoid any hypervigilant response from the client. In mirroring, the counselor has the client synchronize his or her breathing with the counselor's, leading to a calm rate (counselors avoid this technique if transference intimacy has been an issue). In timeout, the counselor allows the client to take a break from the topic, leaving the room if necessary, to relax before continuing..

*127.* Beyond the five basic therapeutic group models (psychoeducational, cognitive-behavioral, interpersonal, and support), other unique group models include: culture specific, expressive, and relapse prevention. What does an expressive group therapy model involve? a. Communication skill-building education b. Art, dance, and psychodrama therapies c. Addressing distorted thinking and self-talk d. Confrontational dialectic therapy

*B: Art, dance, and psychodrama therapies* Other expressive therapies include writing (stories, poetry, etc.) and music. Expressive group therapy allows clients various ways of expressing themselves via alternative methods and allows greater exploration of their thoughts, bodies, and feelings. Through creative expression, clients can tap into their imaginations to better and more safely examine their bodies, feelings, emotions, and thought processes. Culturally specific groups provide opportunities to explore the role of culture in substance abuse and the strengths and handicaps it may produce during the change process. Relapse prevention groups offer clients the opportunity to focus intensely on developing the skills they need to identify, understand, and manage the situations, people, and thoughts that may trigger a return to substance abuse. Each of these groups can be used concurrently with client participation in other groups, augmenting and enhancing the learning and change processes.

*137.* Proper program and progress documentation is necessary for a great variety of reasons. Which of the following is NOT a particularly important reason? a. Ensuring treatment plan accuracy and continuity b. Avoiding client challenges of records and documentation c. Ensuring compliance and continued agency funding d. Avoiding loss or even retroactive return of funds

*B: Avoiding client challenges of records and documentation* Clients are not a party to documentation in records except in the rarest of circumstances. Rather, the need for accurate documentation is essential in determining a proper treatment plan and ensuring that the plan evolves appropriately as the client makes continued progress. Further, funding agencies require documentation to ensure that funds entrusted to the program are being utilized as agreed upon in the funding process. Overall, essential documentation competencies include: (1) recording of intake and screening; (2) client assessment; treatment plan formulation and goals; (3) clinical reports; (4) clinician progress notes; (5) a comprehensive discharge summary; and (6) any other client-related information or data necessary to ensure appropriate compliance, understanding, and treatment selection (e.g., consent forms, etc.). Client records should be safely maintained and stored in accordance with existing city, county, state, and federal regulations.

*10.* Which of the following is NOT a basic chemical class of amphetamines? a. Amphetamine sulphate b. Benzedrine c. Dextroamphetamine d. Methamphetamine

*B: Benzedrine* Amphetamines consist of a group of synthetic stimulants chemically similar to the body's natural adrenaline—the hormone released when the body reacts in high-threat fight-fright-flight circumstances. The three main types are: amphetamine sulphate (commonly known as speed or by its trade name, Benzedrine), dextroamphetamine (trade name Dexedrine or colloquially as Dexy's midnight runners), and methamphetamine (Methedrine or meth, crank, speed, poor man's cocaine, etc.). Among the three classes, methamphetamine has the greatest abuse risk due to its extremely intense rush. While some drugs such as heroin may be unpleasant at first use, amphetamines are immediately pleasurable to most users. Consequently, meth is second only to marijuana as the nonalcoholic drug most abused worldwide.

*24*. Which one of the following alcohol abuse screening tests is designed specifically for use with adolescents? a. CAGE b. CRAFFT c. MAST d. AUDIT

*B: CRAFFT* This instrument was designed specifically for use with adolescents, drawing upon situations that are common to this age group. The instrument derives its name from the key word in each of the screening questions: driving a car while intoxicated; using alcohol or drugs to relax, feel better, or fit in; using alcohol or drug when alone; forgetting events that occurred while using alcohol or drugs; requests by family or friends to limit use; and, getting into trouble while using alcohol or drugs. The other instruments are: AUDIT (Alcohol Use Disorders Identification Test); the CAGE (also an acronym: needing to cut down drinking, feeling annoyed at drinking criticism, feeling guilty at drinking, and needing a morning eye-opener drink); and, the MAST (Michigan Alcoholism Screening Test).

*123.* There are five primary group models used in substance abuse treatment. Which is the model that views dependency as a learned behavior that can be modified? a. Psychoeducational group type b. Cognitive-behavioral group type c. Interpersonal process group type d. Support group type

*B: Cognitive-behavioral group type* The cognitive-behavioral group model views substance abuse as an issue of dependency and dependency as a learned behavior that can be modified. Modification is accomplished through a variety of interventions such as: (1) identifying the conditioned stimuli that trigger specific addictive behaviors; (2) producing ways to avoid conditioned stimuli; (3) creating contingency management strategies (relapse prevention strategies); and (4) desensitizing stimuli-response patterns. The cognitive-behavioral approach recognizes dependency as arising from the interplay of numerous contributing factors, including: (1) neurobehavioral, (2) biopsychosocial, and (3) genetic and physiological (i.e., the disease model). Cognitive-behavioral therapy groups change perceptions, beliefs, and thinking patterns to alter relapse behaviors and develop social networks to offer support for change.

*28.* Who should create a treatment plan? a. A multidisciplinary team of professionals b. Collaborative team with the client c. The primary treatment provider d. A professional boilerplate to ensure completeness

*B: Collaborative team with the client* Client collaboration in treatment planning is essential as client buy-in is essential to ultimate success. While various generic treatment plans may be useful in ensuring that all essential elements of planning have been addressed, boilerplate boilerplate plans should not be used to short-cut the planning process. The inclusion of the client's most important personal goals may well be crucial to the buy-in required. The outcome should be a written document that includes: (1) treatment goals, (2) action steps that are both measurable and time sensitive, (3) clearly defined expected outcomes, and (4) explicit verbal or even written agreement between the counselor and client.

*130.* Substance abuse affects not only the user but the family as well. What are intergenerational affects MOST commonly caused by? a. The legal system, with incarceration, unemployment, and family separation b. Compensating issues needed to cope with addictive dysfunction c. The counseling system, pushing families to encounter an addict's issues d. Society, rejecting the addict and all those associated with him or her

*B: Compensating issues needed to cope with addictive dysfunction* Families alter normal behaviors in many ways to cope with substance abuse and addiction. Children are likely to assume roles and responsibilities beyond those of their normal maturational development. They may miss out on their childhood, having to cope with insecurities and anxieties that are distorting and deforming of the normal developmental processes. Spouses and intimate others develop compensating behaviors such as denial and cover-up strategies to try and cope socially. Aging parents have to skip the normal launching phase that most young adults prepare for and achieve. Friends, neighbors, and coworkers have to adjust to their unreliability. Moreover, abusers often abandon or estrange themselves from their families, choosing reinforcing associations with other users in order to cope with their increasing antisocial and isolating needs. Children, in particular, are likely to telescope these issues intergenerationally as they grow up to become overprotective, overly controlling, dependent, or otherwise unbalanced in their own marriages (which may then fail) and in their parenting practices (which distort the experiences of the next generation, etc.).

*48.* How does the Center for Substance Abuse Treatment *(CSAT)* indicate that treatment or interventions provided following discharge from a formal inpatient or outpatient program be referred to? a. After care b. Continuing care c. Follow-up care d. Post-discharge care

*B: Continuing care* In keeping with the chronicity model of treatment (suggesting that substance abuse treatment requires a long-term treatment model, much like a chronic illness) as opposed to the acute treatment model, the Center for Substance Abuse Treatment (CSAT) recommends that treatments or other care provided following program discharge be referred to as continuing care. Thus, the terms aftercare and follow-up care are to be discouraged. In this way, care provider models can better perceive the need to realign themselves from an acute care model to a chronic care model. The result is expected to be better and more enduring care and support for those working to overcome issues of addiction and compulsion. Examples of continuing care include mutual-help groups (including twelve-step and other support groups) available in the community community and follow-up client appointments for episodic checkups, similar to typical medical checkups for other chronic diseases).

*29.* How must assessment information be handled to be the MOST effective? a. Carefully documented b. Converted into goals and objectives c. Available to all treatment providers d. Summarized with the client for feedback

*B: Converted into goals and objectives* Careful assessment documentation, information sharing, and summarizing with the client for feedback can help ensure that the assessment information is accurate and readily available. However, to be most effective, assessment information must be converted into clear goals, objectives, and action steps. Beyond this, the assessment must be recorded in a clinically useful, reliable, and valid manner. In this way, the information and data can be readily understood and replicated and applied in a uniform manner most relevant to treatment. Simplistic labels, unidimensional scores, and checklists will not alone achieve these ends. The record must include adequately organized narration and summation to be fully effective.

*94.* How many categories does SAMHSA's Service Coordination Framework for Co-Occurring Disorders have? a. Two categories b. Four categories c. Six categories d. Eight categories

*B: Four categories* The Substance Abuse and Mental Health Services Administration (SAMHSA) has offered a Service Coordination Framework for Co-Occurring Disorders, which offers four categories by which to indicate the level of care a given client needs: Category I—mental disorders, less severe + substance use disorders, less severe; locus of care is a primary health care setting; Category II—mental disorders, more severe + substance use disorders, less severe; locus of care is a mental health system; category III—mental disorders, less severe + substance use disorders, more severe; locus of care is a substance use treatment system; and Category IV—mental disorders, more severe + substance use disorders, more severe; locus of care is state hospitals, jails or prisons, emergency rooms, and so on. In the first category (low severity mental health and substance use), the bias is for basic primary care. The middle two categories involve a bias for treatment in concert with the severity level of the primary diagnosis. The last category recognizes that, when both psychiatric disturbances and drug use are severe, clients tend to need highly integrated, even locked, care settings.

*31.* How many levels of treatment placement are recognized by the American Society of Addiction Medicine (ASAM)? a. Two levels of treatment placement b. Four levels of treatment placement c. Six levels of treatment placement d. Eight levels of treatment placement

*B: Four levels of treatment placement* The American Society of Addiction Medicine *(ASAM)* recognizes four levels of treatment placement and five specific levels of care. The lowest level (referred to as Level 0.5) is designated as early intervention, which refers to education and other services for individuals with at-risk behaviors but for whom a substance abuse diagnosis cannot be confirmed. Level I consists of basic nonresidential outpatient services, primarily education, counseling, and behavioral change. Level II offers Intensive outpatient or partial hospitalization (inpatient evenings or weekends, etc.). The focus is on comprehensive biopsychosocial assessments and individualized treatment plans. Level III consists of residential or inpatient treatment and offers a planned regimen of care in a twenty-four-hour live-in setting. Level IV is medically managed intensive inpatient treatment. Level IV provides twenty-four-hour medically directed evaluation and treatment of substance-related and mental disorders in an acute care setting.

*120.* In working with substance abuse clients, counselors must be aware specific guidelines found in the HIPAA statutes. What do these guidelines address? a. HIV counseling and practice guidelines b. Health privacy and confidentiality standards c. Health, addiction, and abuse practice guidelines d. Facility intake and admission policy standards

*B: Health privacy and confidentiality standards* The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows workers and families to retain their health insurance coverage when changing or between jobs. HIPAA also governs the management and release of Protected Health Information (PHI). The act ensures the right to privacy for all adults and minors ages twelve to eighteen. The act requires a signed disclosure before any health care information can be disclosed to any entity, agency, or individual, including parents of minors over the age of twelve. The more stringent guidelines, however, arise from the Code of Federal Regulations (CFR Title 42 Part 2). In 2000, the Department of Health and Human Services (DHHS) issued the Standards for Privacy of Individually Identifiable Health Information. The DHHS Privacy Rule imposed three additional privacy protection steps: (1) consent for information release must comply with 45 CFR §164.508; (2) clients must be given a copy of the signed form; and (3) a copy of each signed form must be kept for six years from its expiration date.

*7.* Which of the following conditions does alcohol NOT induce? a. Steatosis b. Nephrosis c. Hepatitis d. Cirrhosis

*B: Hepatitis* Hepatitis refers to inflammation of the liver. Alcohol is toxic to all body tissues. Because alcohol must be metabolized by the liver, it is particularly susceptible to the toxic effects. Consequently, many heavy drinkers suffer from alcoholic hepatitis, characterized by abdominal pain, nausea, vomiting, and a swollen liver. In more extreme cases, jaundice and bleeding can result. Jaundice (a yellowing of the skin and whites of the eyes) is from bilirubin, a by-product of aging red blood cells broken down in the liver, that should have been fully metabolized by the liver. Spontaneous bleeding occurs because key clotting factors are made in the liver, but production is inhibited by hepatitis. Steatosis consists of fatty deposits in the liver that, if severe, can prove fatal. Cirrhosis refers to scarring of the liver from alcohol damage, preventing its normal functioning. High blood toxins can also cause hepatic encephalopathy—a reversible dementia—if the toxins are reduced.

*143.* If a client leaves a treatment program early or involuntarily, how is the written discharge summary affected? a. It is not needed altogether. b. It is produced as usual. c It is abbreviated or cursory. d. It is comprised only of the terminal facts.

*B: It is produced as usual.* A comprehensive discharge summary is always produced, regardless of how long or short the client's involvement was in the treatment program. Specifically required content includes: (1) whether the program was or was not completed successfully; (2) the reasons or rationale that resulted in client discharge; (3) whether the discharge was voluntary or involuntary; (4) any transfer or referrals involved in the discharge, with specific information about each, including transfer or referral rationale; (5) summary information on treatments offered and recovery level achieved; (6) the client's status in abstinence or continued substance use; (7) educational or vocational accomplishments; (8) legal status at the point of discharge; (9) relevant continuing medical issues, if any; and (10) any involved supports or services that are expected to be continued beyond discharge.

*44.* What does the SOAP progress note acronym stand for? a. Subjective, Overview, Actions, and Plan b. Subjective, Objective, Assessment, and Plan c. Subjective, Observation, Assessment, and Plan d. Subjective, Overview, Attention, and Plan.

*B: Subjective, Objective, Assessment, and Plan* The SOAP note was first generated by Dr. Lawrence Weed, MD, in the 1970s to provide physicians with rigor, structure, and a way for practices to communicate with each other. Subjective provides a narrative summary of the client's current condition, usually including the presenting problem (why they came to be seen). Common elements include: (1) onset (if applicable); (2) chronology (improvements or worsening, variations in the problem, etc.); (3) symptom qualities (the nature of the symptoms, etc.); (4) severity (degrees of distress); (5) modifying factors (what helps or worsens the condition, etc.); (6) additional symptoms (whether related or unrelated to the presenting problem); and (7) treatments (prior treatments, if the client has previously been seen elsewhere). Objective captures key facts that are measurable, quantifiable, and repeatable aspects of the client's situation (physical symptoms, lab results, weight, etc.). Assessment refers to the clinician's early diagnostic impressions. Plan describes the clinician's next steps in response to the information obtained (further assessments, referrals, medications, interventions, etc.).

*99.* Who is primarily responsible for ensuring that treatment is effective for culturally diverse clients? a. The client b. The provider c. The institution d. The family

*B: The provider* It is the provider who is primarily responsible to ensure that treatment is effective for clients of cultural diversity. Ensuring effective treatment requires two separate understandings: (1) how to properly communicate and interact with persons from differing cultures and (2) knowledge of the specific culture from of the person receiving service. In truth, every competent and caring clinician should always look past stereotypes, seek shared understandings, treat clients with respect, maintain an open mind, ask questions when needed (both of clients and other involved providers), and remain willing to learn. Thus, being culturally competent merely makes explicit this ongoing duty and obligation. Beyond this, however, providers should diligently endeavor to acquire a deeper and broader understanding of the major values, mores, standards, and expectations of those cultures he or she routinely serves—while still, however, allowing for idiosyncratic variations within that cultural paradigm. In this way, culturally diverse clients can receive effective, meaningful, and culturally acceptable services in a sensitive and kind way. Doing so ensures even greater treatment efficacy and more enduring positive outcomes.

*61.* What is the MOST common duration of counseling in an intensive outpatient treatment *(IOT)* program? a. Twenty to thirty minutes, one time each week b. Thirty to fifty minutes, one time each week c. Forty to sixty minutes, one time each week d. Thirty to fifty minutes, two times each week

*B: Thirty to fifty minutes, one time each week* Individual counseling is typically scheduled for thirty to fifty minutes at least weekly in the initial treatment stage. Sessions are held with a primary counselor to help facilitate a meaningful, collaborative therapeutic alliance. A common session format involves: (1) asking for reactions to recent group meetings; (2) reviewing outside activities since the last session; (3) asking about current feelings; (4) exploring any interim drug and alcohol use; and (5) inquiring about any urgent issues. Recent group topics, treatment plans, and coping strategies are reviewed. Fears and anxieties about change are explored, and drug testing feedback is provided. Sensitive issues not appropriate for the group are discussed. However, no effort is made to address any underlying conscious and subconscious issues contributing to substance use. Assistance with access to needed services outside the program's scope is given, and planning for transitions between levels of care or for discharge is completed. The session concludes with a review of the client's plans and treatment schedule. Clients with co-occurring disorders may require primarily individual counseling.

*89.* What is the MOST important reason that ordered and routine activities are built into the therapeutic community (TC) treatment process? a. To relieve boredom that may serve as a trigger for substance abuse b. To counter the typically disordered lives of substance-abusing clients c. To reduce the stress through focused programmed activities d. To distract from the negative thinking that may lead to substance abuse

*B: To counter the typically disordered lives of substance-abusing clients* A key feature of therapeutic communities (TCs) is structured programming. This involves scheduled activities and routines that help clients learn to avoid chaotic lifestyles and focus on daily activities that prevent the boredom and negative thinking that so often accompanies relapse behavior. TC treatment protocols consist of phases and stages that allow the tracking of client activities and measurement of progress. Treatment duration is dependent upon successful client progress. Staff and peer networks offer support, and other community-based services are integrated as needed to sustain recovery. The TC treatment approach is ideal for clients with past criminal issues, educational and employment deficits, relationship problems, and a history of failed treatment. Because of the focused, hierarchical, and often confrontational features of this treatment modality, it must be modified for those with co-occurring psychiatric disorders, antisocial personality traits, and various other dysfunctional behaviors. When used in an intensive outpatient program, a drug-free environment must be ensured.

*73.* What is physiological dependence on a drug determined by? a. The addictive properties of the drug b. Tolerance or symptoms of withdrawal c. A psychological need to again use the drug d. Frequency and amount of the drug taken

*B: Tolerance or symptoms of withdrawal* Physiological dependence exists if tolerance or withdrawal is in evidence. Tolerance is in evidence if there is a need for significantly more of the involved substance to achieve a desired effect or intoxication or if the effects of the substance are significantly diminished when the same amount of the substance is used. Withdrawal is in evidence if abstinence induces a withdrawal syndrome as expected for the substance or the same substance (or one closely related chemically) is used to relieve or ward off withdrawal symptoms. The DSM lists a set of eleven symptoms, 2 or more of which must have occurred at any time during the past 12 months for a diagnosis of substance use disorder. 1) Tolerance, defined as either the need for larger and larger amounts of the drug in question over time to achieve the desired result, or a decrease in the effect of the drug with continued use of the same amount; 2) Withdrawal, defined by either the known withdrawal symptoms for a particular drug, or by the fact that the drug, or a similar drug, is taken to avoid withdrawal symptoms; 3) An increase in the amount of the drug taken, or the continued use of the drug past the intended time; 4) An inability to control usage; 5) A large amount of time and effort devoted to obtaining the drug in question, using the drug in question, or recovering from its effects; 6) The giving up of important activities in order to obtain or use the drug in question, or recover from its effects; 7) The continued use of the drug in question regardless of the ill effects it has caused; 8) Craving; 9) Recurrent drug use which leads to inability to fulfill major role; 10) Recurrent drug use though it is physically harmful; 11) Recurrent drug use despite it leading to continued social problems

*81.* In providing counseling treatment, what are counselors encouraged to do? a. Select a single counseling approach, and refine it fully. b. Use multiple counseling approaches to meet clients' needs. c. Avoid relying on any formal counseling technique. d. Recognize that all counseling techniques are equally effective.

*B: Use multiple counseling approaches to meet clients' needs.* Research is unable to confirm any optimal counseling approach as numerous factors, such as the substances used, degrees of dependency, treatment duration, irregular client characteristics, and so on, will inevitably shape research outcomes. Further, clients typically have complex psychosocial needs and unique personal and emotional factors that will require considerable creativity by involved providers. Consequently, counselors increasingly use a variety of approaches that are revised and tailored to meet each client's singular needs. This kind of theoretical accommodation and modification is a hallmark of effective treatment. However, when altering or combining approaches, counselors will need to recognize that theoretical conflicts may arise. In some cases, these conflicts could attenuate or even extinguish the success of the approach. Consequently, counselors must have a competent grasp of the approaches being utilized to ensure that ineffective or untoward outcomes are not unintentionally produced.

*77.* What is an appropriate response to a substantial gift from a client? a. "You shouldn't have!" b. "Thank you so much!" c. "I can't accept that, but thank you!" d. "A gift like that is not appropriate."

*C: "I can't accept that, but thank you!"* A substantial gift may be loosely defined as one exceeding $20 in value. The giving of small gifts is not uncommon, and these gifts are usually acceptable—particularly if they can be shared by all staff or clients. At times, gifts may also be culturally significant, and extra care may be needed to ensure no offense occurs. These are often handmade items or items representative of a culture, ethnicity, or home country. Many will have unique meanings and background stories. Certain cultures view gift giving as a demonstration of respect and gratitude for a valuable service. Failure to accept could result in termination of treatment. Such gifts should be accepted whenever possible. They are not typically given with any ulterior motives. Inappropriate gifts (e.g., those that are too personal, too costly, or offered in exchange for favors, etc.) should be tactfully and politely refused. Citing program rules can help to explain and prevent problems. All gifts should be reported to supervising staff and entered into the case record.

*131.* HIV remains a profound problem in the United States. What approximate percentage of all HIV cases are found among females in this country? a. 5 percent b. 15 percent c. 25 percent d. 35 percent

*C: 25 %* Approximately 25% of all human immunodeficiency virus (HIV) cases are among adolescent and adult females in the United States. Although HIV continues to predominantly affect men who are sexually active with other men (homosexual or bisexual gay males), women are particularly susceptible to contracting the HIV virus. Due to many factors, African American and Hispanic or Latina women account for more than four-fifths of all HIV cases among women. At highest risk of new infection, however, are gay people who abuse substances as this group is also most likely to engage in risky sexual behavior. Other factors that contribute to issues of risk are: substance abuse, homelessness and poverty, psychiatric disorders, living in chaotic and high-crime areas, and so on. The incidence of substance abuse among those with HIV is higher than the national average, in part, no doubt, to issues of stress and depression that accompany the diagnosis. Although newer treatment options improve the overall outcome somewhat, obtaining treatment and maintaining the complex treatment regimen required is far more difficult among those who abuse alcohol and other substances.

*47.* How does the Center for Substance Abuse Treatment (CSAT) recommend that substance abuse be considered and treated? a. A psychological disorder b. An acute disease c. A chronic treatable condition d. A degenerative treatable disorder

*C: A chronic treatable condition* The Center for Substance Abuse Treatment *(CSAT)*—part of the Substance Abuse and Mental Health Services Administration Administration within the U.S. Department of Health and Human Services—notes that substance abuse has been treated as an acute disorder for most of the twentieth century. This shaped treatment, which was typically short term and intensive, much like treating an acute infection. Detoxification occurred, information was shared, and the individual was discharged to manage independently. They now recommend that substance abuse be treated like a chronic condition, such as diabetes or hypertension. To this end, treatment needs to be realigned to allow for a gradual recovery with regular checkups to ensure that the condition remains in control.

*124.* Matching clients with groups requires careful consideration. Where would a first-generation American Hispanic woman be BEST assigned? a. An all-women's group b. An all-Hispanic, Spanish-speaking group c. A group based on immediate needs d. A mixed new-immigrant group

*C: A group based on immediate needs* There is a myriad of factors to consider in assigning a client to any given group. These include: group availability, client stage in recovery, client preference, gender and culture issues, substance of abuse, and so on. Further, changes in group assignments may be needed episodically as clients progress, relapse, gain motivation, develop new insights needing address, and so on. Diversity issues include age, gender, race, ethnicity, education, language, sexual orientation, religion, and culture, among others. Cultural competence requires a counselor to recognize that: (1) a young Asian male may be unable to express himself openly among older Asians due to issues of respect; (2) many Hispanics or Latinos are adverse to rules and the authority figures that sustain them; (3) women may contend with the need to nurture and invest emotional energy in men; and so on. Adaptations, accommodations, and skillful group leadership will be required to optimize all participants' group opportunities.

*8.* What does formication refer to? a. The creation of freebase cocaine b. Sex between two unmarried individuals c. A sensation of bugs crawling under the skin d. Extrapyramidal symptoms of agitation

*C: A sensation of bugs crawling under the skin* Chronic users of cocaine, crack cocaine, methamphetamine, and other such stimulants develop a profoundly unpleasant sensation of bugs crawling under their skin. They may even come to believe the bugs are present and needing to be removed. In less severe cases, users may pick at their skin to the point of causing sores and scabs. In more extreme cases, users may cut themselves in a desperate attempt to release the bugs and find relief. The condition is also known as Magnon's syndrome and may also be referred to colloquially as coke bugs or crank bugs, and so on.

*98.* How is the concept of culture BEST described? a. A shared set of beliefs, norms, and values among a racial group b. A shared set of beliefs, norms, and values among an ethnic group c. A shared set of beliefs, norms, and values among any given group d. A shared set of beliefs, norms, and values among a given nationality

*C: A shared set of beliefs, norms, and values among any given group* Culture is best understood broadly, referring to a shared set of values, norms, and beliefs common to any group of people, whether it is based on race, ethnicity, nationality, or any other shared identity or affiliation. According to 2010 Census Bureau figures cited by the Brookings Institute, approximately 12.9 percent of the current U.S. population is foreign born (of note, the figure exceeded 13 percent during every decade from 1860-1920). Beyond country of birth, however, there are many other variables that can shape a client's culture and worldview. Diverse client populations include: non-white Hispanics and Latinos; African Americans; Native Americans; Asian Americans and Pacific Islanders; persons with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS); lesbian, gay, bisexual, and transsexual (LGBT) populations; those with disabilities; rural populations; homeless populations; and older adults. Counselors must navigate between the prevailing culture, treatment culture, and the client's culture as coping styles, social supports, stigma, and a myriad of other factors can be profoundly influenced by a client's culture.

*135.* The likelihood of developing a substance abuse disorder fluctuates throughout the life course. What is the most likely period in life for a substance abuse problem to begin? a. Middle age b. Young adulthood c. Adolescence d. Childhood

*C: Adolescence* Substance abuse issues may develop at any time throughout the life course, especially during times of stress, divorce, family discord, unemployment, pain-inducing injury, depression, and other particularly vulnerable periods. Overall, however, the period of greatest risk is adolescence. This group is particularly vulnerable for numerous reasons, including: (1) the developing brain (during childhood and adolescence) is more susceptible to the changes induced by addiction; (2) the likelihood of exposure to substances of abuse increases at this time; (3) immaturity makes it more difficult to cope with peer pressure; (4) underdeveloped judgment (typically generating a sense of invulnerability) makes the desire for risk taking greater; (5) transitional stressors moving toward adulthood increase the need for alternative coping options, particularly those with little developmental demands; (6) the social demands of school and relationships become more acute; (7) hormonal and other developmental changes induce further instability. Programs sensitive to these needs are greatly needed in the substance abuse treatment field.

*109.* The CAGE questionnaire is a four-question screening tool. What is this screening instrument designed to screen for? a. Cocaine abuse b. Marijuana abuse c. Alcohol abuse d. Heroin abuse

*C: Alcohol abuse* The CAGE questionnaire effective and quickly screens for alcohol abuse by asking for a yes or no response to four questions: (1) Have you ever felt the need to cut down on your drinking; (2) do you feel annoyed by people complaining about your drinking; (3) do you ever feel guilty about your drinking; and (4) do you ever drink an eye-opener in the morning to relieve the shakes? Extensive studies reveal that two yes responses will accurately identify 75 percent of the alcoholics who honestly respond to it (and correctly rule out 96 percent of nonalcoholics). The CAGE has been modified to screen for drug abuse by simply replacing the word drinking with drug use in the initial three questions and then delivering the fourth question: Do you use one drug to change the effects of another drug, or do you ever use drugs first thing in the morning to take the edge off?

*93.* What would be the MOST typical co-occurring disorder client? a. An alcohol-abusing man b. A drug-abusing man c. An alcohol-abusing woman d. A drug-abusing woman

*C: An alcohol-abusing woman* Individuals admitted for substance abuse treatment who also have a co-occurring psychiatric disorder are more likely to be female alcohol abusers than female drug users or male users of either alcohol or drugs. While most drug abusers are referred for treatment through the criminal justice system, female alcohol users are most typically referred through health care providers. Multiple studies reveal that the rates of co-occurring disorders are roughly that about 39 percent admitted for substance abuse treatment programs will meet Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for antisocial personality disorder; 11.7 percent are suffering with major depression, and 3.7 percent are struggling with a general anxiety disorder. Other challenges common among clients with dual-diagnoses (co-occurring disorders) include: chronic unemployment and homelessness, family conflict and disruption, incarceration and subsequent law enforcement involvement (probation or parole), and violent victimization. Further, complex problems such as suicidal ideation and attempts, medication noncompliance, high self-medication needs, emotional issues, significant medical problems, and a host of other challenges often complicate the treatment process.

*37.* In cases involving the criminal justice system, what is the minimum recommendation for frequency of updating treatment plans? a. Following sentencing b. Upon release to a community setting c. At all transition points d. Both A and B

*C: At all transition points* Treatment may be begun during incarceration, continued at transfer to minimum security, then to a halfway house, and finally out to home on probation or parole. At all transition points, treatment plans should be updated. This need is particularly acute because an offender's level of treatment needs, due to potential problems with motivation and environmental stressors, may significantly change at each of these junctures. Case management is typically required to ensure comprehensive services, and common participants include criminal justice staff, prerelease planners, halfway house staff, vocational or educational staff, health providers, and involved family. Because of the frequency of co-occurring disorders in this population, numerous professionals use the Integrated Screening, Assessment, and Treatment Planning model as it provides for evaluation of both substance abuse and mental health issues.

*79.* At a local dance club, a counselor spots a client drinking at the bar. What is the BEST response to this? a. Confront the client immediately, encouraging him or her to leave the club. b. Quietly find a moment to talk with the client privately at the club. c. Avoid contact with the client, and leave the club immediately. d. Avoid contact with the client, but remain at the club.

*C: Avoid contact with the client, and leave the club immediately.* No effort should be made to engage the client in such a public setting. Remaining at the club would likely precipitate some sort of contact. Therefore, leaving without contact would be best. Then, later, when the client returns to the program, a private conversation should be engaged. During this discussion, the client can be informed of the unexpected contact and what was witnessed. In this way, the client is able to privately disclose his or her issues regarding the lapse (or relapse, as the case may be) with regard to the return to using alcohol. This discussion can then build to include those issues, experiences, and triggers that may have contributed to the occurrence. In this way, the client can use the experience to build upon those skills needed to increase his or her abstinence goals and the steps needed to achieve them.

*55.* What is the influence of family on treatment outcomes? a. Treatment outcomes are improved with family support. b. Treatment outcomes are worse with family involvement. c. Both A and B d. Neither A nor B

*C: Both A and B* It has been noted that substance abuse treatment outcomes can be substantially improved when supportive family members are involved. However, it is also true that problematic family relationships can greatly hamper the treatment process and reduce the likelihood of enduring recovery. This is particularly true where family culture and traditions run counter to treatment and recovery processes. Ideally, family therapy will be available as an adjunct to the treatment process, as necessary. Where program resources lack this component of care, referrals to therapists or organizations that provide family therapy should be considered. Involved family members will also need to be educated regarding the addiction process as well as learning how to optimally support their loved one's recovery. Balance is important as attempts to exert too much control can drive their loved one away or even back into abuse. Conversely, where family involvement is too limited, the client may lack the support necessary to sustain themselves into recovery and beyond.

*52.* Which form of substance abuse is naltrexone used to treat? a. Alcohol dependence b. Opioid dependence c. Both A and B d. Neither A nor B

*C: Both A and B* Naltrexone is effective for some people with alcohol dependency. It has also been noted, however, that naltrexone may not be effective in treating men with chronic, severe alcohol dependence. In certain circumstances, naltrexone has also been effective in treating opioids addiction. Disulfiram (Antabuse) is another adjunctive medication used in the treatment of alcoholism. Naloxone (Narcan), a shorter-acting agent similar to naltrexone, is used primarily in situations of opioid overdose, though it is also used in the treatment of alcoholism to lower cravings. Buprenorphine and buprenorphine combined with naloxone are now also available for the treatment of opioid dependence and can be prescribed in programs that have medical personnel on staff.

*65.* Which of the following substances lack effective treatment medications? a. Cocaine b. Marijuana c. Both of the above d. Neither of the above

*C: Both of the above* There are effective medications for the treatment of alcohol and opioid addictions. The medications reduce cravings, inhibit the intoxicating effects, produce aversion, and lessen the desire to use the target substance. However, in spite of considerable laboratory research and extensive clinical trials, no effective medications for the treatment of dependence on stimulants such as cocaine, marijuana, inhalants, or hallucinogens has been discovered. There are medications to modestly mitigate the difficult withdrawal symptoms caused by these substances. For example, symptoms of stimulant withdrawal include insomnia, agitation, anxiety, and even delirium, psychosis, and hyperthermia in particularly acute cases. Neuroleptic medications can lessen the symptoms of psychosis and delirium, and benzodiazepines can reduce the symptoms of agitation and anxiety. Beyond symptom management, however, there are no target treatment drugs for these substances.

*91.* What are significant drawbacks to community reinforcement (CR) and contingency management (CM) approaches? a. CR and CM are only effective if used together. b. CR and CM are not enduringly effective. c. CR is labor intensive, and CM can be costly. d. CR requires others' support, and CM requires ongoing rewards.

*C: CR is labor intensive, and CM can be costly* Considerable research has demonstrated that *community reinforcement (CR)* and *contingency management (CM)* are both independent-effect treatment interventions. Further research, however, does support that CR and CM are most effective when used in conjunction with each other. Because a return to baseline drug use can follow the termination of CM, in particular, more long-term supports (such as twelve-step program involvement) may be needed for more enduring success. Maximum benefits accrue with larger rewards that increase in value to maintain CM motivation. By contrast, CR typically involves rewards from more-enduring sources (family, job, pleasurable activities, etc.) that can more naturally persist after treatment completion. Even so, education in relationship enhancement, goal setting and attainment, balanced lifestyle, and so on, can more fully ensure long-term treatment benefits. Finally, rewards and other reinforcements must be consistently applied and must only be provided in response to measurable successes (e.g., extended negative-result urine screens, etc.).

*119.* In working with substance-abusing clients, counselors must be aware of the applicable guidelines in CFR Title 42 Part 2. What do the guidelines deal with? a. Substance abuse treatment program accreditation and standards b. Issues involving the illicit manufacture and sale of drugs of abuse c. Confidentiality in areas of alcohol and substance abuse d. Mandated client treatment under a court directive or order

*C: Confidentiality in areas of alcohol and substance abuse* The Code of Federal Regulations (CFR) Title 42 Part 2 deals with issues of confidentiality when working with clients coping with drug or alcohol use and abuse. The confidentiality restrictions apply: (1) to records, which may not be disclosed even in administrative, civil, criminal, or legislative proceedings by any governmental authority; (2) to communications, even if the person seeking information already has it, could otherwise obtain it, is an official or law officer, has a subpoena, or otherwise claims the right of information release not permitted in the CFR; and (3) to acknowledgements, such as regarding the presence of a client (unless he or she is in a facility or facility area not dedicated solely to alcohol or drug abuse treatment, and no mention of drug or alcohol treatment is made), whether past, current, or anticipated in the future without the client's written consent. A subpoena will be valid for information release only if a court of competent jurisdiction also explicitly enters an order authorizing information release specific to these regulations.

*101.* Beyond the culture of the client, what is another key cultural issue? a. Client's number of generations in the United States b. Clients living in cultural enclaves c. Culture of the counselor d. Client's primary language

*C: Culture of the counselor* Not only do clients bring their culture to the treatment experience, but counselors do as well. A group of professionals also has a culture that consists of shared values, norms, and beliefs. Complicating the clinician's culture further is the language (jargon) used, an emphasis on books, the professional mind-set (way of looking at things), and so on. Health institutions and training facilities are grounded in Western medicine, launched in ancient Greece, emphasizing the central role the human body in disease. Further, objectivity and scientific and empirical methods are the only trusted source of knowledge about diseases and treatment. By 1900, Western medicine began to recognize social contributions to disease, widening the view to issues of diet, lifestyle, employment and income, and family structure, which led to the field of public health. These cultural views make it harder for counselors to recognize symptoms couched in non-Western medical language or to understand a client's concerns and needs. Finally, different assumptions about the clinician-client role model, the etiology of illness, and acceptable treatments offer further relational barriers.

*20.* Which of the following functions is NOT what a Certified Alcohol and Drug Abuse Counselor can usually perform? a. Client screening b. Substance abuse assessment c. Diagnose mental disorders d. Formulate a treatment plan

*C: Diagnose mental disorders* Certified Alcohol and Drug Abuse Counselors, absent additional mental health training and licensure, do not have the credentials and training necessary to diagnose mental disorders. They do have the training and certification necessary to diagnose substance abuse disorders and are well within their scope of practice to screen, assess, and otherwise evaluate clients for substance abuse issues and to formulate and carry out substance abuse treatment plans. Because of the frequency with which co-occurring mental illnesses exist within the substance abusing community, Certified Alcohol and Drug Abuse Counselors can become very familiar and proficient with numerous commonly occurring mental disorders. It can therefore seem natural to broaden the scope of practice as experience grows. However, legal scope-of-practice parameters do not provide for Certified Alcohol and Drug Abuse Counselors to diagnose mental illness, and it is essential that they collaborate with other professionals whenever non-substance abuse mental health issues arise.

*71.* What is the SDSS designed to measure? a. Substance-induced depression over time b. Variations in polysubstance use over time c. Drug use disorder severity over time d. Severity and duration of intoxication symptoms

*C: Drug use disorder severity over time* The Substance Dependence Severity Scale (SDSS) is a structured interview that provides current (last thirty days) DSM and ICD-10 substance use disorders and harmful use diagnoses. The instrument measures the quantity and frequency of recent drug use, which directly translates into variations in clients' clinical status. Following the usual two to three days of training (for those with a preexisting clinical assessment and diagnosis background), the SDSS can be administered in thirty to forty-five minutes. Past research indicates that the SDSS dependence scales are reliable and valid measures of DSM diagnostic severity. More recent investigations into test-retest reliabilities for the ICD-10 dependence scales yielded good to excellent results for alcohol, cannabis, cocaine, and heroin. Test-retest reliabilities for the ICD-10 harmful use scales fell in the good range for alcohol, cocaine, and heroin but were poor to fair for cannabis. Concurrent validity, diagnostic concordance, and internal consistency results were similar to the test-retest findings. These findings support the use of the SDSS in assessing DSM and ICD-10 dependence and harmful use diagnoses.

*74.* According the DSM-5 criteria, a client that has previously met the criteria for stimulant use disorder but now has not met the criteria for stimulant use in 10 months (except for craving) would be termed to be in ______ remission. a. Full b. Partial c. Early d. Sustained

*C: Early* Early remission is no stimulant use criteria being met (except for craving) for at least 3 but less than 12 months. Sustained remission is no stimulant use criteria being met (except for cravings) for 12 months or longer. The terms full and partial are no longer used to describe remission.

*64.* What was the original CIWA-Ar scale designed for? a. Evaluation of opioid withdrawal risk b. Evaluation of amphetamine withdrawal risk c. Evaluation of alcohol withdrawal risk d. Evaluation of benzodiazepine withdrawal risk

*C: Evaluation of alcohol withdrawal risk* The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) scale assists in identifying which alcohol-dependent clients can receive ambulatory detoxification versus inpatient care. The CIWA-Ar can be administered in minutes by staff with a minimum of three hours training. There is some disagreement about cutoff points on the scale. Numerous physicians concur that scores of twenty or higher should be treated in a medical inpatient setting. Other specialists suggest that clients with scores into the low twenties can be safely managed in an outpatient setting, providing there is proper monitoring, medications supervision, and so on. Consequently, medical staff must rely on their best judgment or program policy and procedures. The CIWA-Ar also guides the administration of medications at thirty- to sixty-minute intervals. Doses are only given in response to observed withdrawal signs at a specified intensity. The CIWA-Ar has reduced both client numbers receiving medications and the amounts of medications given. Revisions of the instrument have enabled the monitoring of both benzodiazepine and opioid withdrawal symptoms.

*139.* Treatment and recovery plans must remain current and effective for optimal client progress and well-being. Consequently, how often are treatment plans typically updated? a. Every fourteen to twenty-one days or as changes or progress indicate a need b. Every twenty-one to thirty-six days or as changes or progress indicate a need c. Every thirty to ninety days or as changes or progress indicate a need d. Every sixty to one hundred twenty days or as changes or progress indicate a need

*C: Every thirty to ninety days or as changes or progress indicate a need* Relevant changes might arise if a client tests positive for an addictive substance, if mandatory meetings are missed, if an ancillary support program terminates services, or where substantial progress is noted. While formats may vary, the flow of information in a treatment or recovery plan remains consistent: (1) alcohol or drug-related problems are listed, including social, vocational, family, and medical problems; (2) current short- and long-term objectives; (3) action plans that will meet short-term goals; (4) client progress measures toward identified goals; and (5) updates to the discharge summary or continuing care plan as ongoing changes warrant. In this way, the treatment and recovery plan remains actively applicable, and client progress can be carefully monitored and followed.

*53.* Which of the following is NOT a core treatment and recovery skill? a. Stress management b. Substance refusal training c. Exercise and health training d. Relaxation training

*C: Exercise and Health Training* Although exercise can be an important stress reducer, and health improvement is also meaningful, these are not core treatment and recovery skills. Substance refusal training is crucial as development of this skill helps clients to practice and become comfortable with refusing addictive substances. Outside of the program, it is inevitable that clients will at times be offered illicit substances, and they need the skills to reflexively but politely refuse without returning to substance abuse. Stress management and relaxation training are both important as unmanaged stress is a significant trigger for relapse. Assertiveness training teaches individuals how to get their needs met proactively (but not aggressively) and to avoid allowing others to take advantage of them. Unmet needs can be a powerful trigger to relapse, thus this is an important skill.

*97.* What is the MOST effective treatment approach for adolescents, in terms of less drug use at treatment completion? a. Parent education b. Peer group therapy c. Family therapy d. Multifamily interventions

*C: Family Therapy* Family therapy posits that conditions leading to adolescent drug use began in the home, and thus, the family can help with recovery. Family-based therapeutic approaches include multidimensional family therapy and multisystemic therapy. These approaches extend classic family therapy models to promote change in four areas: (1) the adolescent, (2) family members, (3) family interaction patterns, and (4) outside (nonfamily) influences. The family cognitive-behavioral therapy approach combines family systems theory with cognitive-behavioral therapy. The premise is that family cues and contingencies reinforce the conditioned behavior of adolescent substance abuse. Adolescent community reinforcement focuses on altering environmental influences that perpetuate substance use while also teaching enhanced coping skills for better self-management. The family support network develops a support group for parents, augmented with group and home therapy sessions. The family intervention program focuses on the family and other systems that affect the family (e.g., schools and the community). It partners a family therapist with a community resource specialist to address key family issues that arise when an adolescent uses substances.

*56.* How many main levels exist in the substance abuse continuum of care, according to the American Society of Addiction Medicine (ASAM)? a. Three levels of care b. Four levels of care c. Five levels of care d. Six levels of care

*C: Five levels of care* The five main levels in the substance abuse continuum of care, as identified by the American Society of Addiction Medicine *(ASAM)* are: Level 0.5: early intervention services (subclinical or pretreatment, exploring risks and addressing problems or risk factors that appear to be related to substance use); Level I: outpatient services (nonresidential, less than nine hours per week); Level II: intensive outpatient or partial hospitalization services— nonresidential, a minimum of nine hours per week (Level II is subdivided into levels II.1 and II.5); Level III: residential or inpatient services—minimum of twenty-five hours per week (Level III is subdivided into levels III.1, III.3, III.5, and III.7); and Level IV: medically managed intensive inpatient services (subacute, with daily physician supervision). These levels are not discrete but rather points on a treatment continuum.

*128.* In 1965, Bruce Tuckman proposed a model of group development that included five phases. What is the one phase that is NOT part of Tuckman's model? a. Performing b. Storming c. Framing d. Norming

*C: Framing* All groups pass through five phases to accomplish their purposes: forming, storming, norming, performing, and adjourning (last phase added in 1977). Forming involves engaging, exchanging information, and creating bonds. The key characteristics are tentative overtures, polite exchanges, and worries about fitting in. Storming involves dissatisfaction, disagreement, competition, and conflict. Key characteristics are criticizing ideas, interrupting, hostility, and attendance issues. Norming involves forming group structure, establishing roles and relationships, developing cohesion, and creating harmony. Key characteristics are seeking consensus, reaching agreements, creating support, and achieving a sense of we in endeavors. Performing involves task focus, emphasizing productivity, and identifying achievements. Key characteristics are cooperation, problem solving, and decision making. Adjourning involves completing tasks, ending duties, and dropping dependency. Key characteristics are feeling regrets, managing emotions, and disbanding.

*105.* What is the difference between AIDS and HIV? a. HIV can be fatal; AIDS is a nonfatal chronic condition. b. HIV is a common viral illness, while AIDS is a lethal infection. c. HIV is the virus that causes the AIDS syndrome. d. HIV is sexually transmitted, while AIDS is acquired in other ways.

*C: HIV is the virus that causes the AIDS syndrome.* Human immunodeficiency virus HIV is the virus that causes the acquired immunodeficiency syndrome (AIDS) syndrome. HIV is the viral agent that causes AIDS, which is the final stage in the HIV disease process. The Centers for Disease Control and Prevention reports that more than 918,000 people have AIDS at any given time (2004). The disease continues to be most prevalent among men who have sex with men and intravenous drug users, with these groups collectively accounting for almost four-fifths of all cases of HIV/AIDS. The disease disproportionately affects minorities. While13 percent of the U.S. population is African American, they represented 50 percent of all new HIV infections in 2004. HIV is also spreading rapidly among women and adolescents, with nearly half of new HIV cases reported among females age thirteen to twenty-four, and more than 60 percent among females age thirteen to nineteen. Gay substance abusers are at high risk because they more frequently engage in high-risk sexual behaviors when intoxicated. Although new medications have significantly extended life for many with HIV/AIDS, the treatment protocols are burdensome and expensive. HIV also contributes to poverty, homelessness, and other medical problems.

*87.* Why do therapeutic communities (TCs) often focus on habilitation instead of rehabilitation? a. Many clients cannot successfully be rehabilitated. b. Rehabilitation is not as effective as habilitation. c. Habilitation helps clients learn new skills they never had. d. Rehabilitation focuses only narrowly on detoxification.

*C: Habilitation helps clients learn new skills they never had.* Rehabilitation refers to the recovery of skills and abilities that have been lost. Due to extended and severe drug use, criminal behavior, or co-occurring disorders, many therapeutic community (TC) clients need to develop skills and abilities they never previously properly possessed. The TC model views substance abuse as a holistic (whole person) disorder rather than as an isolated disorder. Consequently, TC clients are assessed across an interrelated continuum of psychological and social deficits (e.g., dishonesty, poor impulse control, anger issues, etc.), along with their substance abuse patterns. The key beliefs and values necessary for recovery include: (1) complete honesty; (2) reality orientation to the here and now; (3) personal accountability for all behavior; (4) empathy and concern for others; (5) a strong work ethic and realization that rewards must be earned; (6) proper differentiation between external behavior and the inner self; (7) understanding that change is always occurring; (8) understanding that learning has value; (9) developing economic self-sufficiency; (10) community involvement is important; and (11) quality citizenship matters.

*25.* Which of the following is the MOST important introductory statement or question to ask in a suicidality evaluation? a. Have you ever tried to take your own life? b. Do you have thoughts about killing yourself? c. I need to ask you a few questions about suicide. d. Have you ever attempted suicide?

*C: I need to ask you a few questions about suicide.* It is important to introduce the topic rather than simply launching into questions. In this way, the client can understand for the questions that follow. This introduction should be followed by very clear questions. Screen for thoughts: "Have you had thoughts about deliberately ending your life?" Screen for past attempts: "Have you ever tried to end your life?" A past history of attempts greatly increases the likelihood of future attempts. Any affirmative response to thoughts should lead to questions such as: "Have you had these thoughts for long?" "What have you been thinking of doing?" "Have you made firm plans about this?" "Do you have (the pills, etc.) that you've been thinking of using?" Where a client has begun to formulate clear plans and realistic means, and so on, immediate intervention is essential.

*132.* Members of the lesbian, gay, bisexual, and transgender (LGBT) community face many challenges, including issues of discrimination. Regarding substance abuse as compared with the general population, how is the LGBT community likely to act? a. Less likely to use alcohol or drugs b. About as likely to use alcohol or drugs c. More likely to use alcohol or drugs d. Insufficient data to make these comparisons

*C: More likely to use alcohol or drugs* On all measures of alcohol and drug use and abuse, the incidence of occurrence is higher. The lesbian, gay, bisexual, and transgender (LGBT) community has a greater likelihood of alcohol and drug use generally, are more likely to abuse these substances, are less likely to maintain abstinence, and continue alcohol use longer into their later years. Research reveals that as high as 30 percent of the lesbian community may have a drinking problem. In addition, LGBT substance abusers tend to use more frequently and more kinds of drugs. In particular, judgment-altering drugs are also more common (e.g., amyl nitrite, gamma hydroxybutyrate, ketamine, and ecstasy). The more frequent use of judge-altering drugs such as those at raves and parties appears to be correlated with the higher rates of human immunodeficiency virus (HIV) infection due to a greater frequency of higher-risk sexual behaviors. Unquestionably, this community would benefit from greater education, services, and specially oriented groups and services.

*42.* How does motivation for participating in treatment differ from motivation to change problem behaviors? a. There is no difference between treatment and behavior change motivation. b. Motivation for behavioral change precedes motivation for treatment. c. Motivation for change is internal; treatment may be pushed on a client. d. Motivation for treatment precedes motivation for behavioral change.

*C: Motivation for change is internal; treatment may be pushed on a client* Clients may enter treatment by court order or family pressure. Motivation for behavioral change is a personal and internal matter, with a greater likelihood of ultimate success. Assessing motivation may be pursued via the Stages of Change Readiness and Treatment Eagerness Scale *(SOCRATES)*. It is a nineteen-item self-report instrument comprised of three main scales—recognition, ambivalence, and taking Steps—requiring approximately three minutes to complete. SOCRATES identifies client states on a continuum between not prepared to change and already changing. Those in the pre-contemplation stage typically deny the problem. Clients in the preparation and action stages typically admit that they have a problem. Optimal treatment planning requires an understanding of where a client is in the change readiness process, which also promotes more effective exploration of the current barriers to further change. There are two versions of SOCRATES. One version is used to assess alcohol issues and the other addresses personal drug use.

*50.* According to the American Society of Addiction Medicine *(ASAM)*, what is the minimum of treatment time the intensive outpatient treatment *(IOT)* must provide? a. Three hours of treatment per week b. Six hours of treatment per week c. Nine hours of treatment per week d. Twelve hours of treatment per week

*C: Nine hours of treatment per week* Intensive outpatient treatment (IOT) has traditionally consisted of a minimum of nine hours of weekly treatment provided in three three-hour sessions. However, some programs provide more contact hours and others as few as six contact hours per week. Even so, according to the American Society of Addiction Medicine (ASAM)'s Patient Placement Criteria, IOT programs must provide nine or more structured contact hours each week and treatment at six or more hours per day during a partial hospitalization program. The Center for Substance Abuse Treatment (CSAT) consensus panel agreed that IOT key features include: (1) six to thirty contact hours each week; (2) step-up and step-down care with varying intensity; (3) a minimum of ninety days continuing care following discharge; and (4) various additional core features and services.

*102.* What are the two key mental health treatment paradigms of Western medicine? a. Objectivity and the scientific method b. Theoretical and applied practice c. Pharmacological therapy and psychotherapy d. Biological and environmental perspectives

*C: Pharmacological therapy and psychotherapy* Biological psychiatry is focused on the biological causes and treatments of psychiatric disorders. The first forms of biological psychiatry appeared in the mid-nineteenth century and paved the way for pharmacological therapy for mental illness. The practice of psychotherapy (or talk therapy) emerged near the end of the nineteenth century with the establishment of psychotherapy (originally psychoanalysis) by Sigmund Freud. Although numerous disparate forms of psychotherapy now exist, all emphasize verbal communication as the basis for treatment. Most modern approaches now combine pharmacological therapy and psychotherapy, referred to as multimodal therapy. However, the emphasis on verbal communication retains the potential for miscommunication and more especially so when counselor and client come from different cultures. Misunderstandings can result in misdiagnoses, treatment conflicts, and noncompliance. Thus, the importance of effective cross-cultural communication continues to assume greater significance.

*113.* In providing case management services, beyond providing seamless care and being client focused, what is the primary aim? a. Provide referrals to needed services in as timely a way as possible b. Determine how to integrate needed referrals in a coordinated fashion c. Produce the least-restrictive level of care possible in meeting the client's needs d. Promote client self-determination in identifying and selecting needed services

*C: Produce the least-restrictive level of care possible in meeting the client's needs* Although it is important to provide timely and well-coordinated referrals and to encourage client self-determination in this process, it is most important to secure the least-restrictive level of care. In this way, client self-determination is also ensured. To achieve this, clients and case managers must collaborate in selecting among available options. Self-determination is most fully ensured when clients are allowed to take the lead in identifying their needs and in choosing from among resource options that most fully meet their personal goals and lifestyle. Flexibility is important, as is adaptability, to ensure that referral providers and agencies are adequately responsive. Clients should be assessed for their ability to apply for, access, and follow through with selected referrals, with the case manager providing assistance where needed. Informing, educating, and guiding clients through this process can help to ensure an overall least-restrictive level of care.

*149.* A counselor finds herself treating a perpetrator of incest abuse. A survivor of past abuse herself, the counselor finds this deeply disturbing. What would be her BEST response? a. Ignore her personal feelings, and focus on the client's issues and needs. b. Confront the client about his past, and press for growth in this area. c. Refer the client to a counselor more comfortable with the client. d. Find a therapist to help her better cope with a client such as this.

*C: Refer the client to a counselor more comfortable with the client.* Counselors must recognize that they are also entitled to limits. While working with difficult clients is a part of the job, it does not require working in situations that are personally deeply disturbing or troubling. It can also lead to substandard service for the client, who is entitled to receive counseling from a professional who is not compromised by his or her past history. In situations such as this, it may be helpful to seek supervisory consultation to better determine what is occurring and the degree of the associated problem. The client should be notified in advance of the need (but not the direct reason) for a transfer to avoid generating issues of rejection or abandonment. He or she should be informed that another clinician better suited to meeting his or her needs is available. Any subsequent issues about the transfer should also be addressed in the new therapeutic relationship.

*129.* A productive group therapeutic engages deep issues in many individuals with remedial or neglected issues. This may at times induce regression. How is regression defined? a. Feelings of regret and guilt that accompany past failures b. A sense of emotional closure when painful issues are recalled c. Reverting to a prior developmental level (i.e., juvenile or infantile) d. Strong feelings of anger projected inward toward oneself

*C: Reverting to a prior developmental level (i.e., juvenile or infantile)* Productive groups not infrequently elicit strong responses. The group experience is enhanced by: (1) self-disclosure that is genuine rather than contrived, honestly reflecting feelings, attitudes, and struggles; (2) authentic behavior that reflects the real self as opposed to the socially presented self, or the front used to avoid criticism and rejection; (3) personal risk taking, usually initiated by a leader, leading to the openness and candor that allows for actual growth and progress; (4) personal privacy, secured by group consensus and commitment to such a degree that self-disclosure, authentic behavior, and risk taking are possible. It should be noted that the key contributions already noted are to be exercised in balance and moderation. All expressions should be self-oriented, revealing oneself rather than pushing through into the private space of others. In this way, negative exchanges among group members can be avoided. Group leaders, while modeling, should be careful not to over-disclose to avoid damaging confidence and trust.

*32.* How many Assessment Dimensions are recognized by the American Society of Addiction Medicine (ASAM)? a. Two assessment dimensions b. Four assessment dimensions c. Six assessment dimensions d. Eight assessment dimensions

*C: Six assessment dimensions* In assessing clients, the American Society of Addiction Medicine *(ASAM)* encourages evaluations using six interactive dimensions: (1) acute intoxication or withdrawal potential (the level of intoxication or risk of severe withdrawal symptoms or seizures and exploring inpatient or ambulatory detoxification); (2) biomedical conditions and complications (other illnesses that may create risk or complicate treatment); (3) emotional, behavioral or cognitive conditions and complications (diagnosable mental disorders or mild, undiagnosable mental problems that complicate treatment); (4) readiness to change (open or resisting treatment, acknowledging or denying addiction, high or low motivations, etc.); (5) relapse, continued use or continued problem potential (immediate or low risk of substance use; good or poor coping or relapse prevention skills; severity of collateral problems such as suicidal behavior; etc.); (6) recovery environment (influence or proximity of people, resources, and situations that may help or pose a threat to safety or continued treatment).

*67.* Dealing with smoking cessation during a substance abuse treatment program is a. something too overwhelming for the majority of individuals. b. something that should not be brought up by anyone but the client. c. something to be seriously considered if the client desires it. d. something that should be required during any treatment program.

*C: Something to be seriously considered if the client desires it.* The majority of drug- or alcohol-dependent individuals are also smokers. And, more in this group die from smoking-related conditions than from their substance abuse. Treating staff believe that smoking cessation may complicate drug or alcohol abstinence. However, clients may feel otherwise—believing the best time to quit would be during treatment for their drug or alcohol use. Fewer than 10 percent of clients would object to a clinic's smoking ban if nicotine replacement therapy was available. Smoking cessation success is highest when coupled with behavioral therapy and nicotine replacement therapy. Thus, treatment programs are ideal settings for smoking cessation. Finally, there are strong associations between reduced smoking and reductions in substance abuse. Numerous forms of nicotine replacement are available, and clients are encouraged to try various products before deciding what works best for them. The antidepressant medications bupropion and nortriptyline help to reduce nicotine cravings, probably because they help reduce depression—which is a major cause of relapse.

*23.* What are serious mental health symptoms that resolve with abstinence in thirty days or less MOST likely due to? a. A resolution of transient situational stressors at home, school, or work b. A serious underlying mental disorder that temporarily improved c. Substance abuse-induced disorders that require continued abstinence d. Malingering to manipulate circumstances for underlying goals

*C: Substance abuse-induced disorders that require continued abstinence* Serious mental health issues, such as persistent suicidality, delusions, or hallucinations that precipitously resolve with abstinence are most likely substance abuse-induced disorders that will not reoccur without a return to the former substance abuse. In like manner, serious mental health issues that do not resolve in an abstinence period of thirty days or longer are likely due to an underlying mental disorder that must be evaluated and properly treated. In certain circumstances, an underlying mental disorder becomes exacerbated by substance abuse. In these situations, some measure of improvement will be noted, but it will fall substantially short of total resolution. This reflects the persistence of the underlying disorder; they will still need appropriate treatment for meaningful resolution of the condition.

*39.* The Addiction Severity Index has been formally adopted by which organization? a. The Substance Abuse and Mental Health Services Administration *(SAMHSA)* b. The Center on Drug and Alcohol Research *(CDAR)* c. The National Institute on Drug Abuse *(NIDA)* d. The Institute for Governmental Service and Research *(IGSR)*

*C: The National Institute on Drug Abuse (NIDA)* The Addiction Severity Index (ASI) was first released in 1977 and formally adopted for use by the National Institute on Drug Abuse in 1980. The ASI was developed by the Drug Evaluation Network Systems, which was sponsored in this endeavor by the White House Office of National Drug Control Policy (ONDCP) and the Center for Substance Abuse Treatment (CSAT). Since that time, the ASI has become the most widely used assessment instrument in the field of addictions. It is recommend as a baseline instrument for addiction assessment by a great many governmental and private substance abuse treatment organizations, and due to its standardized questions, it is particularly useful for research. A teen version (T-ASI) and a shortened version (ASI-Lite) are also available. Currently in its fifth iteration, version six is in development.

*70.* Which of the following was NOT identified as being among the three MOST effective screening tools for substance use disorders? a. The *CSAT* Simple Screening Instrument b. The Alcohol Dependence Scale (ADS) and the Addiction Severity Index *(ASI)*-Drug Use Subscale combined c. The Substance Abuse Screening Instrument d. The Texas Christian University Drug Screen

*C: The Substance Abuse Screening Instrument* Researchers have compared eight commonly used screening instruments for efficacy in determining the presence of substance use disorders. Only three possessed optimal accuracy, positive predictive value, diagnostic sensitivity. These three instruments are: (1) the Center for Substance Abuse Treatment (CSAT) Simple Screening Instrument; (2) the combined Alcohol Dependence Scale (ADS) and the Addiction Severity Index (ASI)-Drug Use Subscale; and (3) the Texas Christian University Drug Screen. Other popular brief screening instruments include the Substance Abuse Screening Instrument, the CAGE Questionnaire, and the Offender Profile Index. Each of these instruments is in the public domain and thus may be reproduced and used freely.

*5.* What happens as tolerance for barbiturates develops? a. The margin between intoxication and lethality increases. b. The margin between intoxication and lethality decreases. c. The margin between intoxication and lethality stays the same. d. Tolerance does not develop for barbiturates.

*C: The margin between intoxication and lethality stays the same.* While tolerance for barbiturates does develop, tolerance for an otherwise lethal dose only marginally increases and never exceeds twofold. This means that the likelihood of an unintentional fatal dose increases substantially over time as the need for the intoxicating effect pushes that threshold ever closer to a lethal dose. Given the impairments in memory and judgment that typically accompany CNS depressant intoxication, simple forgetfulness can lead to a fatal overdose. Finally, using barbiturates with any other CNS depressant substance, such as alcohol, can result in an additive CNS depression that can readily be fatal. Death most often occurs via respiratory or cardiac suppression.

*85.* When outcomes from cognitive-behavioral coping skills therapy and motivational enhancement therapy are compared with outcomes from twelve-step facilitation, how do clients fare BEST? a. cognitive-behavioral coping skills therapy b. motivational enhancement therapy c. Twelve-step facilitation d. All the above

*C: Twelve-step facilitation* The three approaches all produced positive outcomes in improving drinking from admission baseline to one year in follow-up. However, twelve-step facilitation showed a measurable advantage when clients were followed for three years post treatment. Other studies have comparatively investigated the outcomes of aftercare by way of structured relapse prevention and twelve-step facilitation. Of importance, the twelve-step facilitation approach has provided more positive overall outcomes for the greater share of people who abuse substances. The findings were particularly positive for: (1) clients who were experiencing high levels of psychological distress; (2) substance users who were women; and (3) clients who reported the use of multiple substances at the outset of treatment. Specifically, these three groups clearly remained abstinent for more extensive periods following treatment with twelve-step facilitation, as compared to structured relapse prevention. In point of fact, both approaches have contributions to make to the recovery process. However, where limitations in resources, time, and other obstacles exist, it is particularly important to ensure that members of these three groups are meaningfully encouraged to participate in available twelve-step programs.

*83.* Which of the following is NOT a strength of twelve-step programs? a. Twelve-step meetings are free, widely available, and offer ongoing support. b. The twelve-step approach easily accommodates client diversity. c. Twelve-step programs offer easy monitoring of assigned step tasks. d. The twelve-step approach offers recovery in cognitive, health, and spiritual areas.

*C: Twelve-step programs offer easy monitoring of assigned step tasks.* Twelve-step programs offer easy monitoring of assigned step tasks. Among the many benefits of twelve-step program participation are: (1) cost—meetings are a free, available virtually worldwide, and they provide a source of continuous support; (2) many larger cities offer specialized meetings for those with unique needs (e.g., youth, women, specific sexual orientations, treatment beginners, foreign language speakers, etc.); (3) the twelve-step approach addresses recovery in varied domains, such as cognitive health, spiritual health, and physical health realms, accommodating a focus of almost any potential participant; (4) the twelve-step approach easily accommodates clients from diverse ethnic, cultural, and other backgrounds. These benefits make the twelve-step approach uniquely beneficial as an important adjunct to comprehensive treatment. Primary drawbacks include: (1) it is difficult to accurately monitor client compliance with step tasks or even meeting attendance; (2) the emphasis on a higher power may be problematic for some clients; (3) smaller communities may not be able to sustain ongoing twelve-step meetings, issue-specific groups, or meetings well suited to dual-diagnosed (psychiatric disordered) clients.

*146.* Clients with an extensive substance abuse history often struggle with impulse control and anger. If a client becomes verbally agitated, angry, and elevated with a counselor, what is the BEST response? a. Threaten to call law enforcement unless he or she calms down. b. Cite the right to expel him or her from treatment if he or she misbehaves. c. Validate his or her affect but not expression (if threatening) d. Ignore the behavior so as not to further escalate his or her emotions

*C: Validate his or her affect but not expression (if threatening)* Substance abuse clients, especially those with a history of abuse themselves, can struggle with impulse control and emotions, especially anger. Acting out anger cannot be tolerated. Usually, however, there are signs of agitation, elevation, and anger well before physical acting out occurs. At this earlier juncture, it can be helpful for the counselor to validate their affect without validating any given verbal expression ("I can see this is something difficult for you . . ." or "This brings up a lot of emotion for you, doesn't it?"). In this way, the counselor moves to constructive address of the client's emotions, defusing the need to act out physically. Prevention is particularly valuable—ground rules for conduct in group, with staff and on site, should be provided at the point of intake. Language, breach of confidentiality, threats, and physical aggression cannot be tolerated. Law enforcement may need to be called if safety becomes an issue. Clients should know in advance that serious threats are taken seriously and will be reported.

*142.* Clients actively in a treatment program need regular chart entries. Typically, state requirements mandate an updating entry no less often than a. daily. b. semi-weekly. c. weekly. d. monthly.

*C: weekly.* Whether the client's treatment includes group or individual session counseling, most states require an updating entry at least weekly. Entries should include session dates and attendance status as well as client progress in terms of recovery phase and movement toward (or away from) recovery or treatment goals and objectives. Entries should clearly indicate whether the progress (or lack of progress) leaves the client on or off track in regards to achieving necessary progress, especially if an associated increase in relapse risk has been identified. Issues of client responsiveness to program staff, involved family, referral services, as well as attendance compliance should be noted in an ongoing fashion. Finally, planned or expected interventions and recommendations should also be included in the weekly update or summary entry.

*1.* A wife refers her husband for substance abuse counseling. His drug of choice is cocaine, which he has been using episodically with friends at a poker game—biweekly to weekly—for some years. She is disturbed at the illicit nature of the drug and the long-standing use. He states that though he recreationally uses, he does not crave cocaine, does not seek it out but rather uses with friends at the game who bring it, and he feels that other than his wife being upset about him using, he has no other social or occupational issues. Given the information provided, how is his use of cocaine BEST described? a. Substance abuse b. Cocaine intoxication c. Cocaine use disorder d. None of the above

*D. None of the above* The DSM lists a set of eleven symptoms, 2 or more of which must have occurred at any time during the past 12 months for a diagnosis of substance use disorder. 1) Tolerance, defined as either the need for larger and larger amounts of the drug in question over time to achieve the desired result, or a decrease in the effect of the drug with continued use of the same amount 2) Withdrawal, defined by either the known withdrawal symptoms for a particular drug, or by the fact that the drug, or a similar drug, is taken to avoid withdrawal symptoms 3) An increase in the amount of the drug taken, or the continued use of the drug past the intended time 4) An inability to control usage 5) A large amount of time and effort devoted to obtaining the drug in question, using the drug in question, or recovering from its effects 6) The giving up of important activities in order to obtain or use the drug in question, or recover from its effects 7) The continued use of the drug in question regardless of the ill effects it has caused. 8) Craving 9) Recurrent drug use which leads to inability to fulfil major role 10) Recurrent drug use though it is physically harmful 11) Recurrent drug use despite it leading to continued social problems. He does not meet the criteria for current intoxication either. Recreational use commonly occurs biweekly or weekly, and the use is typically for reasons of sociality. Substance abuse counseling is therefore not indicated. However, counseling regarding the potential for life circumstances, stressors, or other unexpected losses or burdens to precipitate a future substance abuse problem should be discussed.

*59.* How is the MOST effective relapse-prevention training provided? a. Group therapy is more effective. b. Individual therapy is more effective. c. Structured classes are more effective. d. A and B are roughly equal in effectiveness

*D: A and B are roughly equal in effectiveness* Research reveals that the effectiveness of group therapy is on a par with that of individual therapy. In addition, group therapy allows for a more effective balance of costly individual counseling services. Intensive outpatient treatment (IOT, Level II care) is typically delivered in sequential stages, with greater service intensity and structure gradually reduced as clients progress. This allows for increasing personal responsibility even as structure and staff supervision is reduced. However, it is important to be able to return to more intensive services if changing client circumstances require it. The sequenced nature of IOT can motivate clients toward recovery milestones and stage completion criteria. Celebrating or otherwise marking the transition between IOT stages can provide further motivation. Finally, complex information can be better delivered via sequenced stages as this allows for conceptual units that are more easily understood and that can be revised to meet the unique cognitive, psychological, and transition readiness of each client.

*88.* In what setting is the therapeutic community (TC) treatment model MOST effective? a. A formal full-time residential setting b. An intensive day treatment setting c. Neither A nor B, but in a support group setting d. A and B equally

*D: A and B equally* Researchers investigating therapeutic community (TC) treatment have found that residential and day-only TC treatment program outcomes are not significantly different. Consequently, trends toward intensive outpatient treatment (IOT) using the TC treatment model should be effective. Studies funded by the National Institute on Drug Abuse (NIDA) have revealed that participation in TC treatment is correlated with measurably positive outcomes. For example, treatment outcome data from the longitudinal Drug Abuse Treatment Outcome Study found that completing TC treatment was associated with reduced use of alcohol, cocaine, and heroin, as well as reductions in depression, criminal behavior, and unemployment, as compared against levels experienced prior to treatment. Further, a study of inmates transitioned from an institutional TC program to a TC-oriented outpatient work-release program experienced lower rates of recidivism (re-incarceration) and drug use than those receiving institutional TC treatment alone. Thus, TC treatment appears to be an effective approach to reducing substance abuse, criminal activity, depression, and unemployment among individuals with positive criminal and drug use histories.

*86.* Traditionally, what has the term therapeutic community (TC) referred to? a. An informal group organized for mutual support b. A court-ordered treatment environment c. A formal mutual-help or twelve-step support group d. A drug-free residential treatment environment

*D: A drug-free residential treatment environment* From the first therapeutic community (Synanon, founded in 1958 in California by Chuck Dederich), treatment communities (TCs) were organized as controlled, drug-free residential treatment settings providing intensive and comprehensive treatment. The central goal is to produce a holistically healthy lifestyle, engaging emotional, psychological, and social issues that may lead to substance use. Residents learn from each other, staff members, and other authority figures. This has come to be referred to as community-as-method perspective, which sees the whole community (clients, staff, social structure, and daily activities) as the active therapeutic agent. Many early TCs utilized punitive contracts, privilege losses, and extreme peer pressure to produce change. The more harsh aspects have since been significantly modified, though peer pressure remains a key motivator. The TC model has been expanded to include additional services, such as mental health and medical services, educational and vocational services, and family education and therapy. Today, many TC programs are carried out in intensive outpatient treatment (IOT) programs, serving clients transitioning out of residential or incarceration settings or bypassing residential treatment altogether.

*76.* What does a dual relationship refer to? a. Dyads assigned in addiction-recovery groups for added support b. The sponsor-sponsee relationship in twelve-step groups such as A.A. c. The mentor relationship with those newly entering addiction treatments d. A working relationship with a client outside the professional domain

*D: A working relationship with a client outside the professional domain* Dual relationships are unethical during and immediately following the course of any counselor-counselee relationship. More broadly, dual relationships arise when multiple roles are created outside the therapeutic-fiduciary relationship. Examples include: (1) allowing a client to provide automobile repair work for a therapist, whether it is paid or not; (2) hiring a client to paint a therapist's home; (3) allowing a client to provide volunteer clerical work in the program office; and so on. Multiple roles such as these compromise the integrity of the therapeutic process, making it more difficult to provide client services that are untainted by the ancillary roles. Working through difficult issues becomes highly problematic—is it really about the issue at hand or the quality or willingness with which the ancillary role is carried out? Termination, closure, referrals, and so on all become laden and troublesome.

*110.* The MAST screening test is a twenty-five-question instrument that is used to explore the degree and severity of a client's problem with which type of abuse? a. Cocaine abuse b. Mescaline abuse c. Methamphetamine abuse d. Alcohol abuse

*D: Alcohol abuse* The Michigan Alcoholism Screening Test (MAST) is used in more in-depth interviews as well as in confinement or brief holding scenarios. It is administered to explore a number of important treatment issues: (1) the severity of the alcohol abuse problem; (2) a client's maturity and readiness for treatment; (3) the potential existence of a co-occurring psychiatric disorder; (4) the intervention technique needed to address the presenting problem; (5) the extent of potential support resources (including family, social, educational, and employment resources, along with individual motivation for change); and (6) facilitation of the engagement process leading to treatment. MAST is among the oldest and most accurate alcohol screening instruments and is able to identify dependent drinkers with as much as 98 percent accuracy. Its two drawbacks are (1) it is longer than many other screening tools, and (2) MAST questions explore drinking over a client's lifetime (not just currently), which makes the test less likely to detect early-stage drinking problems. Several variations of the MAST have been developed, including the brief MAST, the short MAST, and the self-administered MAST.

*2.* What does the experienced effect of a drug depend upon? a. The amount taken and past drug experiences b. The modality of administration c. Poly drug use, setting, and circumstance d. All of the above

*D: All of the Above* The amount of a drug ingested will typically affect the user's experience, with higher doses often producing a greater effect (though potentially diminishing over time as tolerance develops). The modality of administration can greatly influence the rate of the drug's uptake into the system. Normally the rate of effect, from greatest to least, is: inhalation (snorting or smoking), injection (intravenous, intramuscular, or subcutaneous), and ingestion (sublingual or swallowing with or without food). Generally, the faster the systemic uptake, the shorter and more intense the high experienced. Polydrug abuse greatly complicates the drug experience, particularly if the drugs used are chemical antagonists (e.g., stimulants and depressants—such as meth and alcohol), additive (producing a cumulative effect), synergistic (more than cumulative), or potentiating (each enhancing each other). The setting in which the substance use occurs is also often a significant contributor to the experience. The feelings engendered by the surroundings, the people with whom the experience is shared, the attitudes and reactions of others involved, as well as personal past drug experiences and individual biology all combine to produce a drug experience.

*117.* Education regarding substance abuse includes topics such as triggers, patterns of abuse, and relapse prevention. What should treatment MOSTLY be focused on? a. Substance abuse issues and recovery only b. Substance abuse issues and health issues c. Substance abuse issues and co-occurring disorders d. All of the above

*D: All of the above* Clients need positive education and skills in substance abuse triggers, patterns of use, and relapse prevention. However, failures in other key areas of clients' lives can also trigger substance abuse relapses. Consequently, holistic treatment planning and interventions are essential to the recovery process. Establishing routine schedules early on can help clients to better organize their lives and sustain abstinence following program completion. Efforts directed toward improvement in the development of life skills can be especially important. Examples include counseling and education in areas such as self-esteem and assertiveness training, communication and anger management skills, relationship training, counseling for co-occurring disorders and personal psychological issues, vocational-educational training and interviewing skills, as well as home maintenance, budgeting and personal hygiene instruction—all are important contributors to clients' abilities to maintain clean and sober lifestyles.

*19.* What factors can affect screening instrument validity? a. The screening setting and privacy b. The levels of rapport and trust c. How instructions are given and clarified d. All of the above

*D: All of the above* Experienced counselors and researchers are aware that the setting in which screening occurs (home, office, clinic, or voluntary vs. involuntary facility) can significantly affect the results of any screening tool used. How instructions are given can substantially influence the findings as poorly chosen words and presenting attitudes can unquestionably taint client thinking, presumptions, and willingness to disclose. The presence or absence of privacy can also be a significant factor, as distractions, fears of disclosures or being overheard, and other such elements can bias and the screening and intake process. Further, the levels of rapport and trust between the client and the intake counselor may also alter client perceptions and, consequently, client responses during any screening interview or when completing any screening instrument. New counselors must, therefore, be alert to these factors and quickly learn to overcome any deleterious influences.

*111.* The relapse and remitting model addresses cycles of relapse and recovery common to addiction. What else can it be usefully applied to? a. Medication management b. Unemployment c. Issues of anger and violence d. All of the above

*D: All of the above* The relapse and remitting model of addiction has been successfully applied to a great many other situations, such as unemployment, poor medication compliance, anger management, and so on. Indeed, virtually any situation that tends to return (relapse) can benefit from this model. The relapse and remitting model recognizes that some issues tend to return cyclically over time. Recognizing this can help both the counselor and the client make advance contingency plans to avoid having a brief lapse return to a full relapse in negative circumstances or behaviors. This is particularly important in addiction management as lapses or relapses in any area of life tend to draw clients back into addiction relapses as well. Therefore, careful recognition and following of relapse-prone issues can result in quality advance planning, prompt responses, and minimization or outright prevention of further concurrent addiction relapse problems as well.

*116.* Given a client's history, referrals for co-occurring disorders as well as medical, educational, and psychological needs should be ongoing as discovered. When should planning for aftercare be engaged? a. During the last few sessions, addressing specific, continuing needs b. When a client is roughly halfway through a program c. After measurable progress has been demonstrated d. At the point of the initial counselor-client contact

*D: At the point of the initial counselor-client contact* The initial contact provides the counselor with the opportunity to gather both positive and negative client history, which should not only be used in treatment plan development and ongoing modification over time but which will be relevant in the aftercare planning process as well. Family members should be drawn into aftercare planning and education early on to ensure ongoing understanding and support. Aftercare planning should also include education regarding health maintenance and prevention against sexually transmitted infections (STIs) - especially human immunodeficiency virus (HIV), tuberculosis, and hepatitis C, among others. Screening for STIs and tuberculosis should be an important part of programming as substance abuse clients may well not recall high-risk behaviors and thus may have encountered diseases of which they are not aware.

*121.* Confidentiality is particularly stringent in situations of alcohol abuse, drug abuse, and HIV infection. When are limited confidentiality breaches permitted? a. In situations where an individual is at real risk of harming him- or herself or others b. In situations of suspected child abuse and (in some states) in situations of suspected elder abuse c. Neither A nor B d. Both A and B

*D: Both A and B* Every state and all federal regulations allow the limited breach of confidentiality in situations of credible suicidality and threats of serious harm to others. Credible suicidality is a plan for self-harm and the means to carry out the plan. Dangerousness to others typically involves voiced threats regarding a third party and the real intention of harm (possibly including intentional human immunodeficiency virus [HIV] exposures). Tarasoff regulations require a counselor to notify the intended victim or someone reasonably able to notify the intended victim as well as law enforcement. Mandated reporting of child abuse typically involves physical or sexual abuse, though other conditions may apply. Many states have similar laws governing reporting abuse of the elderly or dependent adults. Finally, conditions of grave disability may also require that confidentiality be breached to keep an individual and others safe. Grave disability tends to be defined as compromise from a mental disorder to the extent an individual is not able to pursue basic personal needs (food, clothing, or shelter) or otherwise sustain health and personal safety.

*68.* Disulfiram (Antabuse) is contraindicated for clients whose alcohol abuse is combined with which of the following circumstances? a. Cocaine use b. Methadone use c. Both cocaine and methadone use d. None of the above

*D: Both cocaine and methadone use* Disulfiram (Antabuse) is indicated even with cocaine use or methadone maintenance. Disulfiram interferes with acetaldehyde metabolism, which produces a profound physical reaction if drinking occurs within twelve hours to seven days, depending on dose. The reaction involves facial flushing, followed by a throbbing headache, tachycardia, tachypnea, and sweating. Some thirty to sixty minutes later, nausea and vomiting occur, often accompanied by hypotension, dizziness, fainting, and collapse. The full cycle takes one to three hours. Careful blood alcohol monitoring is needed to ensure that no alcohol is present before administering disulfiram. Low doses (125 mg) can be given as quickly as the blood alcohol reaches zero. An initial dose of 250 to 500 mg may be used, though lower doses may be better for small women, the elderly, and those with liver impairment. Clients have taken the drug as long as sixteen years. Episodic use is effective to guard against drinking in high-risk situations (e.g., special events or celebrations, etc.). Food that contains alcohol usually does not cause a problem if it has been evaporated during the cooking process.

*45.* What does the DAP progress note acronym stand for? a. Description, Assessment, and Progress b. Details, Assessment, and Progress c. Documentation, Actions, and Pending d. Data, Assessment, and Plan

*D: Data, Assessment, and Plan* DAP notes assist clinicians record clear and organized notes to better understand client thinking, select appropriate goals, and track client progress. The data section includes facts such as client statements, observations regarding mood and behavior, past assignment reviews, and so on. This section is typically the longest portion of a DAP note. The assessment section includes client current status and evaluation of treatment progress. It may also include tentative or working diagnoses, potential treatment requirements, requirements, and information regarding a client's motivation or ability to proceed. The plan section includes session scheduling and the expected focus for upcoming treatment sessions. In this area, updates or alterations in treatment are recorded, along with comments regarding homework assignments. DAP notes allow others to understand events during each therapy session and evolutions in treatment and can aid in tracking long-term progress and program and intervention effectiveness in a consistent manner.

*80.* As a substance abuse counselor, you work in a treatment program and also personally attend a twelve-step program in the community. A treatment program client asks you to become his or her twelve-step sponsor. What is the proper, thoughtful response? a. Accept, knowing that it may benefit the therapeutic alliance. b. Accept, knowing how much this client needs help. c. Decline, concerned that the client could be difficult to support. d. Decline, recognizing the potential conflicts in multiple roles.

*D: Decline, recognizing the potential conflicts in multiple roles.* Many substance abuse counselors have a past history of substance use and thus also hold membership in mutual-help programs. Where a client from a treatment program is encountered in a mutual-help setting, it is essential for a counselor to maintain appropriate boundaries between these separate roles (professional vs. consumer). To this end, it would not be proper for a counselor to become a client's sponsor. To minimize potential conflicts, counselors should not attend meetings where current or former clients attend. Where this cannot be avoided, the counselor should not share his or her personal issues at that meeting. If a counselor needs to talk, he or she should share with other non-clients privately after a meeting or contact his or her sponsor. To prevent such dilemmas, some cities host counselor-only meetings. These are typically not listed in the general mutual-help directories. To locate a mutual-help program of this composition, a counselor should contact the intergroup office or consult with other counselors in the area.

*4.* Which of the following is NOT a "drug cue"? a. A prior drug-use setting b. Drug use paraphernalia c. Seeing others use drugs d. Drug avoidance strategies

*D: Drug avoidance strategies* Intense drug euphoria produces extremely intense, emotionally imprinted memory engrams, coupled with long-term changes in the amygdala area of the brain, which operate outside of conscious control. Key euphoric memories become integrally connected to sights, sounds, smells, people, and places previously associated with drug use. The reappearance of any of these past drug cues will often effectively trigger intense, amygdala-driven cravings for a drug. Cravings are further intensified by lingering imbalances in brain metabolism patterns, receptor availability, hormone levels, and other hypothalamus and pituitary-mediated sensations of dysphoria and distress. The cascading nature of these effects frequently induces a drug-use relapse.

*15.* Which of the following subcategories of alcohol use disorder onset is NOT found in the elderly? a. Late-onset alcoholism b. Delayed-onset alcoholism c. Late-onset exacerbation drinking d. Early-onset alcoholism

*D: Early-onset alcoholism* Early-onset alcoholism refers to an onset of alcohol abuse in adolescence or young adult life. This represents about two-thirds of all individuals with an alcohol use disorder. Late-onset exacerbation drinking refers to individuals with an intermittent history of alcohol abuse that only became chronic in late adulthood. Late-onset alcoholism refers to individuals with no prior life history of alcohol abuse who developed an alcohol problem solely in later life. This category of alcoholism may be more amenable to treatment than the earlier-onset forms. Detoxification can be protracted in the elderly, requiring a longer treatment stay, due to the metabolic changes of aging. Group treatment can be complicated by the group milieu, where younger participants may leave the elderly feeling estranged and out of sync with the other participants. Careful efforts at inclusion or an alternate group composed of older participants may be required.

*82.* What does the Twelve-Step Facilitation Approach refer to? a. Program counselors also serving as twelve-step group facilitators b. Twelve-step program facilitators working within a treatment program c. Teaching twelve-step principles during treatment program work d. Encouraging clients to enter a community twelve-step program

*D: Encouraging clients to enter a community twelve-step program* Using a modified Minnesota Model of treatment (i.e., first used at Hazelden Foundation and Willmar State Hospital in Minnesota in the late 1940s), twelve-step facilitation, involves a thorough introduction to twelve-step principles, education about the disease of alcoholism (or other drugs), and strong encouragement toward participation in twelve-step groups. Twelve-step fellowships, such as Alcoholics Anonymous (AA), are guided by the philosophy that alcoholism (or other addiction) is a progressive disease with psychological, biological, and spiritual aspects. The twelve-step approach gradually evolved for use with drug addictions and various compulsive disorders (e.g., eating disorders). Treatment programs that use twelve-step facilitation teach twelve-step principles, begin working the twelve steps, achieve abstinence, and move clients to community-based twelve-Step groups (e.g., AA, Cocaine Anonymous [CA] or Narcotics Anonymous [NA]). In these programs, educational efforts present alcoholism as a disease marked by denial and loss of control. Outside work includes reading twelve-step materials, journal writing, and other personal recovery-oriented tasks.

*30.* Which of these key elements does NOT bolster a client's desire to complete the program? a. Knowledge of the benefits of treatment b. Understanding of the treatment process c. Fully assuming the patient role d. Frequent interdisciplinary consultations

*D: Frequent interdisciplinary consultations* Clients are largely unaware of the consultations that treatment team members engage in throughout the treatment process. However, an awareness of the benefits of treatment—not only for the issue of substance abuse or alcohol but for other related life concerns—can substantially increase a client's commitment to a treatment program. In like manner, the client needs to fully understand the treatment process. In this way, the purpose and goals of interventions can be clear, and motivation to adhere to treatment consequently increases. Finally, fully assuming the patient role is important because, in this way, the client resolves to put him- or herself completely into the hands of treatment provides. A relinquishment of this nature removes attitude and behavioral barriers and results in more effective treatment functioning.

*104.* What is the trend for cultural diversity in the United States? a. Decreasing slowly but steadily b. Remaining approximately unchanged c. Increasing slowly but steadily d. Increasing rapidly and steadily

*D: Increasing rapidly and steadily* As recently as 1990, about 23 percent of adults were from ethnic and racial minority groups. By 2025, it is estimated that 40 percent of adults (and 48 percent of children) will be from these same groups. Even among the four most representative ethnic and racial minority groups, great diversity exists. For example, Asians and Pacific Islanders consist of at least forty-three distinct subgroups speaking more than one hundred different languages. Hispanics may be further divided into Central and South Americans, Cubans, Mexican, and Puerto Ricans, among many others. More than five hundred tribes fall under the heading of American Indian or Alaskan Natives, each with different ancestry, cultures, and languages. African Americans are also an increasingly diverse group as immigrants continue to arrive from Africa, the Caribbean, and South America. Degrees of acculturation and mainstream assimilation vary widely. Higher birth and immigration rates have resulted in a 56 percent increase in Hispanics—the fastest-growing minority group in the United States. Mometrix Test Preparation. Addiction Counselor Exam Practice Questions (First Set): Addiction Counselor Practice Tests & Review for the Addiction Counseling Exam (Kindle Locations 1315-1322). Mometrix Test Preparation. Kindle Edition.

*145.*The Code of Federal Regulations, Title 42, Part 2, Subpart E, addresses situations where law enforcement or courts can breach client confidentiality. What is a subpoena signed by a judge? a. Sufficient for release of information, provided it is delivered by a law officer b. Sufficient for information release, if signed by a federal court judge c. Insufficient for information release, unless signed by two qualified judges d. Insufficient, unless a qualified hearing is first held in court

*D: Insufficient, unless a qualified hearing is first held in court* The Code of Federal Regulations, Part 2, Subpart E, requires that information, even about the mere presence of a client in treatment, is not to be released under any circumstances unless a qualified court hearing has first been held wherein the issue of confidentiality and client needs have first been addressed. Following this, a special authorizing order must be issued. At a hearing, the court must determine: (1) if the alleged crime is sufficiently serious to warrant breaching confidentiality in this sensitive area (e.g., homicide, rape, assault with a deadly weapon, etc.); (2) if the records disclosure will be of sufficient value in the investigation; (3) if other reasonably effective options exist; (4) if the potential for damage to the client, to the client-provider relationship, and to the program's ability to continue providing services outweighs the release of this very sensitive information; and (5) if the applicant is acting in a true law enforcement function and if adequate counsel has been obtained by the records holder or agency.

*106.* As compared with current older adults, what is the upcoming baby boomer generation (born between 1946 and 1964) expected to have? a. Much lower treatment needs b. Somewhat lower treatment needs c. Somewhat higher treatment needs d. Much higher treatment needs

*D: Much higher treatment needs* It has been estimated that, not only will there be a 50 percent increase in the number of seniors needing substance abuse treatment, but there will also be a 70 percent rate of increase in the treatment needed by these older adults. In part, this may be because baby boomers have had a higher baseline of use throughout their lives than the generations that preceded them. In addition, the baby boomer generation and beyond is more racially and ethnically diverse, with all the unique needs this entails. Barriers to treatment among older adults include: (1) high levels of shame; (2) relatives who either rationalize the problem away or are ashamed to acknowledge it on behalf of their loved one; (3) diagnosis and treatment is more difficult because of collateral mental and physical health problems; (4) transportation is more limited; (5) social networks are dwindling; and (6) financial constraints are tighter.

*11.* In terms of difficulty quitting (dependence), which of the following four drugs ranks the highest? a. Alcohol b. Cocaine c. Heroin d. Nicotine

*D: Nicotine* In terms of difficulty quitting, relapse rates, cravings ratings, and persistent use despite known harm, nicotine is substantially more dependency producing than cocaine, heroin, and alcohol. In terms of withdrawal symptom severity, nicotine exceeds that of cocaine and is only slightly behind heroin. Thus, fewer than 7 percent of those trying to quit each year will succeed. Given that nicotine use greatly increases the risks of heart disease, stroke, lung diseases, and cancer, nicotine abuse is a serious public health issue. Even only occasional smoking produces lung and vascular damage, and almost one-fifth of all heart disease deaths are linked to smoking.

*144.* The Code of Federal Regulations, Title 42, Part 2, addresses client confidentiality. Other than through a written information release, when do exceptions to confidentiality exist? a. When program funding requires it b. When a police officer demands it c. When a subpoena requests it d. None of the above

*D: None of the above* In general, the language in 42 CFR Part 2 prevents all information releases (as well as client-identifying information), even to other uninvolved staff. Key exceptions do, however, exist: (1) written information releases—if properly completed—oral consent, however, is not permitted; (2) emergency medical situations—limited essential information may be given to treating medical personnel but not to law enforcement directly; (3) other agencies working with a client—if a Qualified Service Organization Agreement (QSOA) that guarantees confidentiality at the same level has been signed; (4) mandated reports—notifying authorities of child abuse, and (sometimes) dependent adult and elder abuse, releasing only limited essential information; (5) qualified researchers under limited conditions; (6) crime on site or against staff—limited release to law enforcement; and (7) court order or subpoena, search warrant, or arrest warrant—only if it also meets 42 CFR Part 2 criteria. Language in 42 CFR Part 2 also applies to all staff and volunteers as well as past, current, and even potential (applicant) clients, living or deceased.

*62. How are pharmacotherapy and medication management in substance abuse treatment described? a. Of little importance outside a hospitalization program b. Of some but limited value but without a central role c. Of moderate value in treatment but not crucial d. Of considerable, albeit limited, value in treatment

*D: Of considerable, albeit limited, value in treatment* Pharmacotherapy and medication management are of critical importance in effective substance abuse treatment. They must not be overlooked or isolated from other therapies and interventions. Even so, medications cannot alter lifestyles or recover the functional damage that results from drug abuse. Due to the three- to five-day weekly schedules of most intensive outpatient treatment (IOT) programs, they are an ideal setting for identifying medication needs and then initiating and monitoring the necessary medications. IOT program-based pharmacotherapy and medication management can facilitate: (1) ambulatory detoxification; (2) withdrawal symptom relief; (3) craving reduction; (4) blocking the reinforcing effects of drugs; (5) reducing the health risks that accompany the use or injection of illicit drugs; (6) mitigation of certain underlying psychopathologies that may predispose substance abuse or relapse; (7) the monitoring and treatment of numerous potential medical conditions that may result from acute or long-standing substance abuse.

*46.* The mnemonic DIG-FAST evaluates which psychological state? a. Depression b. Anxiety c. Paranoia d. Mania

*D: Paranoia* The acronym DIG-FAST is a tool prompting the full evaluation of the symptoms of mania. Each letter addresses one of the key potential features of mania: distractibility (easily distracted as evidenced by an inability to concentrate), indiscretion (excessive pleasure activities), grandiosity (larger-than-life feelings of superiority, wealth, power, etc., often experienced during manic, hypomanic or mixed episodes), flights of ideas (mind is racing, seemingly unable to control or slow down thoughts), activity (markedly increased activity, with weight loss and increased libido), sleep deficit (unable to sleep for extended periods well below normal sleep needs but not drug induced), talkativeness (pressured speech: rapid, virtually nonstop, often loud and emphatic, seemingly driven, and usually hard to interrupt).

*49.* What is the BEST distinction between substance abuse treatment programs and mutual-help groups, such as a twelve-step support groups? a. Programs offer help, and groups offer support. b. Programs are expensive, and groups are free. c. Programs are run by professionals, and groups are run by laypersons. d. Programs offer treatment, and groups offer support.

*D: Programs offer treatment, and groups offer support.* The policy of the American Medical Association (AMA) is that clients coping with substance abuse disorders should receive formal treatment from qualified professionals. Mutual-help groups may provide adjunctive services and may be a part of a successful treatment plan. The American Psychiatric Association (APA), the American Academy of Addiction Psychiatry (AAAP), and the American Society of Addiction Medicine (ASAM) have concurred, asserting in a joint policy statement that treatment involves at least: (1) a qualified professional providing services; (2) a thorough evaluation to determine the severity and stage of the illness and to screen for other mental and medical disorders; (3) a properly developed treatment plan; (4) that the treating professional or program remains accountable for the treatment and additional service referrals as necessary; (5) that the treatment professional or program remains in contact with the client until the recovery process is complete. While mutual-help groups are important, they cannot substitute for professional treatment.

*51.* Which of the following is NOT a core feature or service that the Center for Substance Abuse Treatment *(CSAT)* consensus panel agreed upon? a. Biopsychosocial assessment b. Individualized treatment planning c. Case management d. Recreational therapy

*D: Recreational Therapy* Recreational therapy was not one of the core features and services referenced by the Center for Substance Abuse Treatment (CSAT). The CAST consensus panel agreed that intensive outpatient treatment (IOT) core features and services must include the following: intake and orientation; full biopsychosocial assessment; individualized treatment planning; individual, family, and group counseling; psycho-educational programming; case management; linkages with mutual-help and community-based support groups; twenty-four-hour crisis support; medical treatment; formal drug screening and monitoring (urine or breath tests); educational and vocational services; psychiatric evaluation and psychotherapy; medication management; and discharge planning and transition (discharge) services. They further defined potential enhanced services to include: adult education; recreational activities; housing and food resources, smoking cessation treatment; transportation referrals; child care; and parenting skills education.

*75.* What is a client's family of choice used to describe? a. Step-parents and step-and half-siblings b. Common-law relationships only c. Planned pregnancies as opposed to those unplanned d. Relationships created by marriage, friendship, and other associations

*D: Relationships created by marriage, friendship, and other associations* The family of origin refers to blood relationships (parents, siblings, cousins, grandparents, etc.). The relationships in both family types are important in substance abuse treatment. Either group may bring factors and influences that contribute to substance abuse (e.g., alcoholism, culture or traditions supportive of drug experimentation, etc.). Where outright drug or alcohol use was not condoned, families may have interactive patterns that predispose substance abuse. Troubled families often have too few or too rigid rules, difficulties with intimacy, and ineffective problem solving. Such families often perpetuate a don't-trust-don't feel-don't-talk paradigm that allows isolation, damaging alliances, enmeshment, or other dysfunctions to persist. It is essential for counselors to learn about both the positive and negative resources in a client's family. Referrals for family counseling may be essential to this end. When the family becomes ready to change negative behaviors and adopt new, healthier ones, they become supporters in the treatment process.

*17.* What does motivational interviewing primarily involve? a. Focused confrontation b. Behavioral accountability c. Reality testing d. Supportive persuasion

*D: Supportive persuasion* The goal of motivational interviewing is to help the client discover his or her own desire to change. Thus, confrontation, stern accountability, overt reality testing, and other coercive or argument-inducing approaches are avoided. Five fundamental principles to guide the motivational interviewing process are: (1) reflective and empathetic listening, (2) identification of variances between behavior and personal goals, (3) deflection of confrontation or argument to more positive, goal-oriented dialogue, (4) redirection of client resistance to desires and goals rather than opposing it outright, and (5) nurturing optimism and a sense of self-efficacy when confronted with obstacles, challenges, and negative expressions.

*12.* Which of the statements below is MOST correct? a. THC content in all marijuana is about the same. b. THC content in hashish is lower than in a joint. c. THC content in marijuana is predictable. d. THC content in marijuana varies widely.

*D: THC content in marijuana varies widely.* . Historically, the level of delta9-tetrahydrocannabinol (THC) in domestic U.S. marijuana was less than 0.5 percent. Recent cultivation and cross-breeding practices, however, have changed this, and some domestic marijuana has substantially higher levels. The THC in Mexican marijuana can range as high as 4 percent, and sinsemilla can reach concentrations as high as 8 percent. The potency of hashish (cannabis plant resin) can be as great as 10 percent, and hashish oil may contain as much as 20 percent THC. Street marijuana products may be diluted or cut with other adulterants (oregano, catnip, etc.) and may also be laced with other undisclosed psychoactive ingredients such as opium or LSD. Unexpectedly high doses of THC or the addition of other psychoactive substances can greatly affect the unsuspecting user in potentially troubling ways. Thus, caution is in order.

*136.* Research reveals that science-validated community and school prevention programs do work. Which of the following is NOT a category of youth prevention substance abuse programs? a. Universal programs b. Selective programs c. Indicated programs d. Targeted programs

*D: Targeted programs* A great many science-informed, effective prevention programs have been designed to target youth of varying ages in a variety of settings. There are three types of youth substance abuse prevention programs: (1) universal programs—designed to address both risk and protective factors in the general community or in school settings; (2) selective programs—oriented to engage youth that possess specifically identified risk factors that increase their likelihood of developing a substance abuse disorder; and (3) indicated programs—designed to address issues relevant to youth who have already allowed substance abuse into their lives. When programs such as these are properly applied to age-appropriate target audiences, research reveals that abuse of drugs, alcohol, and tobacco are all reduced. Central to all these programs is education regarding the harms caused by substance abuse as such education has proven to reduce experimentation and lower the rates of continued substance abuse in youth.

*9.* What is/are the organ(s) most damaged by cocaine abuse? a. The brain b. The lungs c. The kidneys d. The heart

*D: The Heart* Considerable medical research demonstrates that cocaine not only causes arterial constriction secondary to the drug's stimulant effects, but it also causes a cumulative effect, with more cocaine causing increased arterial narrowing. Atherosclerosis (artery hardening and plaque buildup) greatly magnifies this deleterious process. The result is that permanent disability or death due to sudden cardiac arrest or hemorrhagic cerebral stroke is an increasingly real possibility the longer the drug is abused. Finally, cocaine-induced damage to the prefrontal lobes (where behaviors are modified and controlled) often results in impaired judgment, disinhibition, loss of foresight, decisional incapacity, and chronic unpredictability and irritability.

*40.* What does it mean if an assessment instrument is valid? a. The instrument is licensed for use by professionals. b. The instrument consistently provides accurate information. c. The instrument has been approved by the government for use. d. The instrument assesses what it purports to assess.

*D: The instrument assesses what it purports to assess* Reliability addresses how well an instrument consistently gives accurate information. Accuracy is of little value if the aspects or issues being measured are not those the instrument was intended to measure. In like manner, an instrument that accurately addresses the intended aspects or issues is still of little value if the measurements taken by it are inaccurate. Thus, to be truly useful and effective, assessment instruments and tools must be both reliable and valid. In multiple studies, the Addiction Severity Index has been proven both reliable and valid.

*140.* What is the key difference between a current treatment plan and a current progress note? a. The treatment plan evaluates client achievements, while a progress note ensures action steps are taken to meet objectives. b. The treatment plan assesses client needs, while a progress note coordinates service providers' interventions. c. The treatment plan records events and activities, while a progress note captures the client's current clinical presentation. d. The treatment plan provides an action blueprint, while the progress note captures what did or did not occur.

*D: The treatment plan provides an action blueprint, while the progress note captures what did or did not occur* Properly written progress notes chart the trajectory of the client's progress toward the goals, objectives, and action steps that make up the treatment plan. Progress notes are used to explain and inform any changes to the treatment plan in the context of what is actually happening in the client's daily lived experiences, behaviors, and level of functioning. In order to maintain a current and effective treatment plan, progress notes must be recorded within fourteen days or less of counseling sessions and fully reviewed at the time of a treatment plan update. These updates occur at regularly scheduled intervals or whenever it becomes apparent that changes in client functioning, behavior, motivation, or intent warrant the update. In this way, the treatment plan remains informative, effective, and transformational.

*14.* Among psychiatric disorders in the elderly, where does alcohol abuse rank? a. twenty-fifth b. fifteenth c. fifth d. third

*D: Third* Alcohol use disorders rank third among psychiatric disorders of the elderly. Some 2 to 4 percent of the elderly have a substance use disorder (including alcohol, drugs, or both). Approximately 15 percent of the elderly with an alcohol disorder will also have a concurrent drug abuse problem. Due to physical changes of age, researchers recommend only one drink per day as the upper limit. Detecting alcohol and drug abuse in the elderly can be difficult as the symptoms are often very similar to other health problems associated with age. Isolation, poor health, pain, or depression often motivates substance abuse in the elderly. Many are ashamed of the abuse and further avoid family and others to hide the problem. Suicide rates climb as people grow elderly, and 25 to 50 percent of all attempts by the elderly involve alcohol. Some 10 percent of the elderly misuse their prescription medication, intentionally or accidentally. Substance abuse may greatly complicate a potentially tenuous status for many on complex medication regimens.

*150.* In providing services, an agency needs to maintain a vision of purpose and important objectives. Of the following, what is the MOST significant mission? a. To ensure the survival and funding of the agency to continue offering services b. To ensure that staff have jobs so that they may continue offering services c. To earn a reputation of stability and consistency in offering services d. To break the cycle of abuse and neglect and its negative impact on others

*D: To break the cycle of abuse and neglect and its negative impact on others* While an agency must continue to receiving funding, provide employment, and maintain a consistent reputation in order to continue offering services, its most important purpose and function is to break the cycle of abuse and relieve the individual, involved families, and society as a whole from the suffering involved. To accomplish this, staff must receive appropriate support. This involves proper supervision and training, avoiding over-scheduling caseloads, allowing time for colleague consultations and support, facilitating quality outside support and consultation as needed, providing policies and procedures that ensure a safe, effective, and positive work environment, and so on. In this way, staff can be supported, quality services will be provided, agency longevity will be maintained, and turnover and burnout will be kept to a minimum. Administrators must recognize that counselors can only be expected to perform optimally if agency leadership provides adequate support.

*26.* What is the purpose of screening? a. To prepare the client for program admission b. To determine client readiness for change c. To establish client diagnoses and treatment needs d. To determine the need for placement or referral

*D: To determine the need for placement or referral* The purpose of screening is to methodically review a client's presenting circumstances by which to determine the appropriateness (or lack thereof) for placement or referral for further assessment and evaluation. Screening tools are also used to identify the presence or absence of co-occurring disorders, particularly those that might contribute to substance abuse. Screening tools do not attempt to diagnose a presenting co-occurring disorder but rather to establish the likelihood that one may be present. Where a client presents as potentially having a significant co-occurring disorder, the client is then referred to the proper clinician (psychologist, psychiatric social worker, psychiatrist, etc.) for further evaluation and diagnosis. Once a diagnosis is obtained, a treatment plan can be formulated that addresses the co-occurring disorder as well.

*27.* What is the primary purpose of substance abuse assessment? a. To determine the current level of health deterioration b. To identify a substance abuser's drug of choice c. To provide co-occurring disorder( s) diagnosis d. To determine the severity of the substance problem

*D: To determine the severity of the substance problem* The primary purpose of substance abuse assessment is to develop a full understanding of the severity and extent of a substance user's drug or alcohol abuse problem. However, the assessment process should also identify and explore other closely related issues such as co-occurring disorders (both mental and physical), significant others, employment and education, finances, and other social and legal concerns. The overarching goal of assessment is to gather sufficient information to establish (1) a working diagnosis of current substance abuse, (2) significant co-occurring disorders, (3) the quality and availability of important supports, (4) readiness for change, and (5) all other necessary information sufficient to establish a meaningful and successful treatment plan.

*60.* Which of the following is NOT a type of intensive outpatient treatment *(IOT)* group? a. Psychoeducational groups b. Skills development groups c. Interpersonal process groups d. Transitional care groups

*D: Transitional care groups* Psycho-educational groups teach key concepts regarding substance use disorder and its consequences. Time-limited, these groups are ideal for education at the outset of treatment. The low-key educational nature (as opposed to emotionally intense therapy groups) allows more objective examination of dysfunctional beliefs, problem thinking patterns, along with relapse prevention and skills training. Skills-development groups focus on refusal training, relapse prevention, assertiveness training, and stress management. Support groups address immediate issues along with ways to change negative thinking, emotions, and behavior, learning new ways of relating, managing conflict without violence or relapse, and evaluating how actions affect others. Interpersonal process groups include single-interest groups (focused on specialized issues, usually later in treatment) and family or relationship, and to the program's ability to continue providing services outweighs the release of this very sensitive information; and (5) if the applicant is acting in a true law enforcement function and if adequate counsel has been obtained by the records holder or agency.

*92.* With regard to co-occurring disorders, what does the term integrated treatment refer to? a. Meeting both medical and substance abuse treatment needs b. Using an eclectic treatment paradigm in the treatment process c. Incorporating sociocultural issues in the treatment process d. Treating both psychiatric and substance abuse issues concurrently

*D: Treating both psychiatric and substance abuse issues concurrently* The old view that one disorder should be stabilized before another can be treated has been found to be flawed. It is important to coordinate the treatment of co-occurring disorders as treatment may otherwise be counterproductive and otherwise ineffective. For example, many substance abuse treatments are confrontational, tightly scheduled, and semi-authoritarian in nature—particularly those programs for court-ordered clients. However, clients with psychiatric disorders may do very poorly in such treatment paradigms. Many suffer from depression, anxiety, paranoia, self-abuse (cutting, etc.), suicidal ideation, or personality disorders, among other possible symptomatology. Others struggle with fears about psychotropic medications to treat their co-occurring conditions and may also resist pharmacological treatment of their substance abuse. Clients struggling with such issues are far less likely to cope well with common substance abuse treatment approaches. Consequently, program adaptation and specialized staff training may be required.

*115.* After referrals are made, it is important to track the associated outcomes for measures of referral success. What are the three MOST important evaluative aspects? a. How, where, and when b. Why, what, and where c. Where, when, and who d. Who, what, and how

*D: Who, What, and How* Referrals are of limited value if they do not contribute measurably to important goals and needed outcomes. These measures of success are evaluated by tracking the results of the referral—ideally, by means of a referral form. The who portion of the form identifies the client and the involved counselor. It may also include demographic information as well as information on the substances the client uses, any legal issues, and family concerns. The what section addresses the issues that generated the need for the referral—substance issues (and symptomatology), work issues, family issues, goals and commitments, and so on. The form's how section should address how the client was engaged and dealt with. In this way, the referrals made for any given client in the how section can be evaluated for interventions provided and outcomes realized.

*103.* Racism may jeopardize the mental health of minorities in all of the following ways EXCEPT that a. negative racial images and stereotypes adversely affect social and psychological function. b. racism and discrimination result in diminished socioeconomic status, where poverty, crime, and violence affect mental health. c. racism and discrimination lead to physiological changes and psychological distress that affect mental health. d. discrimination and racism limit recreational and leisure opportunities to improve mental health.

*D: discrimination and racism limit recreational and leisure opportunities to improve mental health.* Discrimination and racism limit recreational and leisure opportunities to improve mental health. While leisure and recreational activities are important to mental health, racism and other forms of discrimination are not typical sources of limiting these resources and opportunities. The terms racism and discrimination refer to attitudes, beliefs, and practices that prejudge and denigrate individuals or groups solely based on disparate phenotypic characteristics (e.g., skin color, hair texture, facial features, etc.) or ethnic minority group affiliation. Despite some improvements, racial discrimination continues and has been documented in the area of health care. Examples include fewer medical diagnostic and treatment procedures for African Americans as compared with whites, demeaning and belittling expressions, and less time and attention given to eliciting and addressing other health care needs. Racism and discrimination can be intentional or unintentional and can be perpetrated by individuals, groups, and institutions. Because racism and discrimination can be insidious and go unrecognized, it is crucial that it be continuously evaluated, especially in cross-cultural situations.

*18.* What percentage of individuals with a dual diagnosis (co-occurring disorders [COD]—i.e., substance abuse disorder and an existing mental illness) received treatment for only their mental illness? a. 32.9 percent b. 27.6 percent c. 12.4 percent d. 8.8 percent

18. A: According to the 2009 National Survey on Drug Use and Health, when individuals have co-occurring disorders (dual diagnoses) consisting of substance abuse and mental illness, only 7.4 percent will receive treatment for both disorders, 32.9 percent will receive only mental health treatment, and 3.8 percent will receive only substance abuse treatment. Where mental illness is severe, the existence of a substance abuse problem is particularly likely (25.7 percent). And among individuals with a substance use disorder in the past year, 17.6 percent will have a concurrent mental illness disorder. Thus, where either a substance abuse disorder or a mental illness disorder is known to exist, treatment professionals should be particularly careful to screen further and ensure that any coexisting disorder is identified, if one exists.