Addictions

Measuring Outcomes and Efficacy of Treatment

•A move toward evidence-based treatments has taken root within the addictions field. •Professional associations and governmental agencies have also issued practice guidelines and treatment algorithms, which support selected treatments or levels of care for specific conditions. •Empirically based practices are developed through clinical trials, consensus reviews, and expert opinions. •In the field of addictions, there are a nu-ber of scientifically based treatment approaches. These include (1) cognitive-behavioral therapy, (2) community reinforcement approaches, (3) motivational enhancement therapy, (4) the 12-step approach, (5) contingency management techniques, (6) pharmacological interventions, and (7) systems treatment

Competency

•Evidence-based or empirically-based practices are interventions for which empirical validation exists to suggest that these treatment protocols improve client outcomes. •Regardless of the specific theory or setting of treatment, practitioners must recognize the value of the therapeutic relationship and prioritize client-centered approaches that focus on shared decision making •Clients can seek treatment through individual therapy, marriage and family therapy, or group therapy as a means to address their substance addiction. •The field of addiction treatment is constantly developing, so counselors treating clients who suffer from SUDs must commit to continually digesting research and staying abreast of the most effective treatment options (Miller & Moyers, 2015).

Counselors who have never used

•For some addictions professionals who have never had an alcohol and other drug (AOD) history, working with clients struggling with addiction can be challenging and frustrating, especially if the client's behavior continues to be self-destructive. •Counselors may unconsciously stigmatize these clients by making assumptions based on media images and stereotypes. •Regardless of a counselor's previous history with substance use, it is essential for counselors to have appropriate training, competence, and align with ethical guidelines as indicated by professional standards • the Substance Abuse and Mental Health Services Administration (SAMHSA; 2015) reported that of the 20.2 million adults age 18 and older who were diagnosed with a substance use disorder (SUD), 39.1% were also diagnosed with a mental illness within the past year. •Because AOD use and addiction-related lifestyles may have the potential to conflict with the counselor's values as a member of his or her culture, it can result in possible negative feelings toward the client. •This may have a deleterious consequence, such as the loss of the counselor's capacity for empathy as well as possible early client termination. Individuals working with substance addiction may benefit from examining their own values, beliefs, and self-perceived competence for treating clients with substance use disorders (ACA, 2014).

Multiculturalism

•Given both social and demographic changes among African American, Latino, Asian/Pacific Islanders, Southeast Asian, and Middle Eastern populations, addictions counselors need to be acquainted with the possible cultural differences and how these might affect the assessment and treatment of addiction disorders in culturally different clients. •Counselors should also note that diversity not only includes ethnicity and race, but also encompasses sexual orientation, gender identity, age, region of origin, religion, language, socioeconomic status, and so forth. •Culture may include a complex assignment of values, beliefs, ethnicities, race, or other distinctions between groups. To be ethically competent, it is essential for the counselor to attend to facets beyond the substance addiction and inclusively consider language, cultural background, and treatments that include the client's perceived culture rather than the counselor's perception of culture and stereo-types (Association for Multicultural Counseling and Development •There are several factors that contribute to the prevalence of substance use disorders, including low socioeconomic status, lack of education, economical challenges, and cultural attitudes toward substances.

Managed Care, Treatment Funding, and Provider Reimbursement

•Managed care refers to any type of intervention aimed at the financing of health care and focused on elimination of unnecessary and inappropriate care and reduction of costs. •While the managed care system has been successful in lessening short-term costs, many consider that it has been at the price of long-term consequences for clients and practitioners. •The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) has helped to rectify this discrepancy in treatment provision. •There are many ethical concerns discussed in the literature specifically regarding managed care. The core of these concerns regard cost-containment practices of setting session limits, restricting provider availability, and issues relating to conflict of interest, confidentiality, informed consent, client abandonment, pressures to breach fiduciary responsibilities, and implementing mandatory DSM diagnostic procedures. •Managed care often dictates what services and interventions will be offered. For example, there is limited reimbursement available for many evidenced-based practices, but older, less effective, and more costly treatments are still being supported, such as opioid detoxification without aftercare. For example, managed care has not always covered addiction treatment equally to that of other types of medical care and there has been a perception that those individuals who suffer from addictions use more resources than others (Quinn et al., 2017).

TABLE 4.3 NAADAC Certification Eligibility Requirements

•NCAC I : Education: GED, high school diploma, or higher Credentials: state credential as a Substance Use Disorder/Addiction counselor Training: minimum of 3 years full time or 6,000 hours of supervised experience; at least 270 contact hours of education with 50% occurring face-to-face Exam: passing score on the NCAC I exam within 4 years of application •NCAC II: Education: bachelor's degree or higher in Substance Use Disorder/Addiction and/or related counseling subjects from regionally accredited institution Credentials: state credential as a Substance Use Disorder/Addiction counselor Training: minimum of 5 years full time or 10,000 hours of supervised experience; at least 450 contact hours of education with 50% occurring face-to-face Exam: passing score on the NCAC II exam within 4 years of application •MAC: Education: master's degree or higher in Substance Use Disorder/Addiction and/or related counseling subjects Credentials: state credential as a Substance Use Disorder/Addiction coun-selor or professional credential including professional counselor, social worker, mental health counselor, marriage and family therapist, psychologist, psychiatrist, or medical doctor Training: minimum of 3 years full time or 6,000 hours of supervised experience; at least 500 contact hours of education with 50% occurring face-to-face Exam: passing score on the MAC exam within 4 years of application the Substance Abuse and Mental Health Services Administration (SAMHSA; 2015) reported that of the 20.2 million adults age 18 and older who were diagnosed with a substance use disorder (SUD), 39.1% were also diagnosed with a mental illness within the past year.

Managed Care, Treatment Funding, and Provider Reimbursement

•Perhaps in recognition of addiction recovery issues, as well as other medical health concerns, the federal Patient Protection and Affordable Care Act of 2010 was passed. This act strives to ensure access to services and better coordination of care. In addition, SAMHSA has proposed what is called a "recovery-oriented system of care (ROSC)," which coordinates care and focuses on the multiple aspects of addiction recovery. It is person-centered and highlights the strength and resiliency of the person in recovery (DiClemente et al., 2016; Humphreys & Lembke, 2014). These services are not clinical in nature but provide a range of supports for the person in recovery and are specialized to the needs of individuals. •This new system of care has ushered in a determination to understand how this new model aids recovery, program performance, treatment efficacy, and client outcome (Humphreys & Lembke, 2014). Research thus far on the ROSC has been promising; for example, some results show that individuals engaged in ROSC care have had a higher rate of abstinence and long-term recovery. Some findings show more stability for individuals in terms of housing and employment (Humphreys & Lembke, 2014). •However, a variety of issues have been noted in terms of difficulty for researchers. These are that (1) not all areas provide the same ROSC services or provide the services in the same way, (2) the individuals providing the support services can range from a volunteer to a professional, and (3) ROSC services may not be offered at the same time in each person's recovery (Cousins, Antonini, & Rawson, 2012). In general, more research needs to be conducted on the effectiveness of ROSC services (Kidd, McKenzie, & Virdee, 2014). •

Counselors in Recovery

•Recovering counselors are more likely to diagnose substance use disorders, use a wider range of interventions and techniques, and report higher levels of commitment to their work. •Additionally, clients may feel more connected to counselors who understand addiction personally and that can help with an expedited rapport-building process. However, the dynamic of being in recovery can create dual relationship challenges beyond the normal experiences of counselors. •Counselors in general struggle with burnout in the profession due to the intensity of the environment and the exposure to the trauma and suffering of clients. For addictions counselors in recovery, there is an added stressor of shared experiences or understanding that may be difficult for counselors to manage. •In the area of addictions counseling, it is not uncommon to find counselors who are previous users and are currently in recovery, as recovering former addicts have been working as helpers since the mid-19th century (Racz et al., 2015). •Counselors who are in recovery often report that becoming a helper was a significant part of their recovery process as a shift in identity (Racz et al., 2015). •There are multifaceted ethical concerns related to counselors in recovery, and one in particular includes boundary issues. Perhaps as a way to mitigate this concern, the Alcoholics Anonymous (AA; 2003) guidelines for AA members employed in the alcoholism field specifies that counselors in recovery should have at least 3-5 years of abstinence before working as an addictions counselor. Although the AA guidelines are geared toward those in recovery from alco-hol, they can be extended to recovery from all mind-altering substances.

Measuring Outcomes and Efficacy of Treatment

•Some concerns regarding adopting evidence-based practices: •The role of ethical values in shaping practice • Disagreement about the supporting evidence needed to validate some treatment protocols • Lack of therapist adherence to treatment protocols • Difficulty of implementation • Lack of availability of some treatment manuals • Lack of availability of training, consultation, technical assistance, and supervision • Difficulty in learning the treatment protocol • Cost of implementation • Lack of insurance reimbursements • Concern about how the new model impacts existing practices • How well the clients like it and will adhere to it •Another concern has been the issue of a disconnect between research and clinical practice. While this type of research is viewed as progress in the field, it has not been without challenges. Some of the noted difficulties with doing these kinds of multisite collaborative studies include (1) not all sites are equal in resources and client population (e.g., some have insured or wealthy clients whereas others cater to the uninsured or mandated client); (2) the research takes massive collaboration, cooperation, and coordination among a host of professionals in different cities or states; (3) it can be difficult to get protocol standardization at each site; and (4) training on protocol implementation and data collection are often very intensive and time-consuming. •To address this concern, an alliance has been formed among researchers and addictions specialists, called the National Drug Abuse Treatment Clinical Trials Network (CTN). The purpose of this alliance is to not only research current treatments, but also to formulate and empirically validate new ones (NIDA, 2015). For example, the CTN collaborated on a large study incorporating many treatment facilities to develop and then research the efficacy of an outpa-tient behavioral intervention incorporating both individual and group counseling modalities with 12-step support (Donovan et al., 2013). Choices for the developed intervention sought to address some of the aforementioned concerns about empirically based practice and revolved around cost effectiveness, utility of the intervention in a treatment facility, efficacy of outcome, and empirical support (Donovan et al., 2013). Another part of this research experience was that counselors were trained and supervised in the delivery of the treatment protocol to ensure standardization across the client population and support for practitioners in utilizing the new treatment (Donovan et al., 2013). This training has been found crucial for staff implementation of a new protocol (Donovan et al., 2013). Therefore, a new important direction for the addic-tions field is the focus on "clinically significant patient outcomes" and the belief that the training and support of counselors in implementing these treatment protocols will make the adoption of evidence-based treatments more likely (Donovan et al., 2013). It has been reported within the last few years that the number of practitioners using at least one evidence-based practice has increased (Carroll, 2012). • •Therefore, it is clear that more effective outcome research is needed to support empirically based interventions. Many organizations are moving in this direction. For example, evidence-based practice in psychology has been written into the guidelines of the American Psychological

Ethics

•The National Association for Alcoholism and Drug Abuse Counselors (NAADAC; 2016) Code of Ethics indicates that addictions counselors are not ethically allowed to diagnose mental disorders without the proper mental health licensing; therefore, addictions counselors need to be cognizant of their limitations within their scope of practice and must provide referrals when necessary.

Boundary Violations

•The relationship between the client and the counselor is vital to the recovery process; therefore, it is essential that counselors provide quality, connected, and ethical care to act in the best interest of the client in order to empower and promote positive change (ACA, 2014). •According to Rogers (1961), counselors who are most effective at connecting with their clients often exhibit the following characteristics: (1) warmth, (2) dependability, (3) consistency, (4) unconditional positive regard, (5) empathy, (6) nonjudgmental understanding, and (7) a belief that individuals strive toward self-actualization.

Comorbidity

•the existence of multiple diagnosable disorders or diseases that occur simultaneously or sequentially and influence the outcomes of the present illnesses. •The term polysubstance use or addiction is not well defined in literature, but broadly describes the use of multiple substances simultaneously or within a specific time frame. •Additionally, polysubstance use and addiction is related to clients who seek an intoxicated state rather than a specific drug, which results in the use of a variety of substances. the Substance Abuse and Mental Health Services Administration (SAMHSA; 2015) reported that of the 20.2 million adults age 18 and older who were diagnosed with a substance use disorder (SUD), 39.1% were also diagnosed with a mental illness within the past year.