Chapter 4, “Professional Issues in Addictions Counseling”

counselors who are most effective at connecting with their clients often exhibit the following characteristics

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

NAADAC certifications

According to the NAADAC (2018a), the National Certification Commission for Addiction Professionals recognizes three levels of substance addiction certifications, including National Certified Addiction Counselor Level I (NCAC I), National Certified Addiction Counselor Level II (NCAC II), and Master Addictions Counselor (MAC). In 2013, the NAADAC announced the addition of more credentials, including the co-occurring competency and the peer-recovery support specialist credential (Brys, 2013). Currently, NAADAC acknowledges additional specialties, such as National Certified Adolescent Addiction Counselor, National Endorsed Co-Occurring Disorders Professional, and Nicotine Dependence Specialist, among others.

Accreditation

Accreditation applies to the specific counselor education program within colleges and universities that educates and trains addictions counselors. It does not apply to individual counselors in the way that licensure and certification does. Accreditation procedures are intended to ensure the quality and standardization of graduate education for the academic preparation of addictions counselors

standardizing addictions training

Accrediting bodies and programs are making attempts to standardize some processes for addictions training for counselors. or example, in 2009, CACREP finalized a set of guidelines and standards for addictions counseling in relationship to knowledge, skills, and practices, as they formalized addictions counseling as a specialization in professional counseling (Iarussi et al., 2013). Furthermore, in 2010, the National Addiction Studies Accreditation Commission was formed at the urging of the Center for Substance Abuse Treatment and the Substance Abuse and Mental Health Services Administration to standardize training of addictions specialists by providing an additional level of accreditation for programs (NASAC, 2018).

NAADAC certification tests

All NAADAC (2018b) certifications require the passing of an examination that requires the tester have strong knowledge of the following topic areas: (1) treatment admission, (2) clinical assessment, (3) ongoing treatment planning, (4) counseling services, (5) documentation, (6) case management, (7) discharge and continuing care, and (8) legal, ethical, and professional growth. Though each exam contains 200 multiple-choice questions, the distribution of questions are diverse related to the content areas of pharmacology of psychoactive substances, counseling practice, theoretical bases, professional issues, and co-occurring disorders

lack of parity with other health providers

Another issue that has impacted the addictions profession was lack of parity with other health providers (Jackson, 2014). Parity means that third-party payers (e.g., insurance companies and managed care) are required to provide both substance addiction and mental health services, just as they offer physical medical services (Wheeler, 2014). Preventive services for substance use disorders would be included, just as for medical conditions. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires most health plans to provide benefits for addiction and mental health treatment, including financial requirements and treatment parameters, that are equivalent to those for other medical services (Duryea & Calleja, 2013). The law went into effect in January 2010; however, insurance health plans do not have to offer mental health or addiction treatment, but if they do, they are then required to provide the same type of coverage as for other illnesses (American Psychological Association, n.d., 2016). The Affordable Care Act has issued new parity rule provisions, but this may not pertain to all clients' insurance plans (Wheeler, 2014).

adolescent and childhood use

As adolescent and childhood use and polysubstance use are both related to an increased rate of SUD diagnosis in adulthood, and children and adolescents are more likely to engage in polysubstance use, it is extremely important that professionals understand the value of early intervention and addressing polysubstance use at every developmental stage

certification vs licensure

Certification for individuals and accreditation for organizations are considered the optimal industry standards, whereas licensure is often regarded as a minimal standard and is generally granted after determining that an individual or organization has met a desired criterion, generally through passing an examination

developmental stage and addiction

Clinicians should always be aware of the developmental stages of their clients and the individual experiences of substance use. For example, children and adolescent substance use and addiction must be conceptualized differently from adult substance use and addiction, but historical intervention strategies for school-based prevention programs have not produced desired outcomes (Pan & Bai, 2009). Early use of substances is damaging to the child or adolescent, but it is also linked to adult substance use disorders later in life

sexual minorities and addiction

Consistently in studies, sexual minority adults and youth show higher rates of substance addiction as compared to members of the sexual majority (Newcomb, Birkett, Corliss, & Mustanski, 2014; Vrangalova & Savin-Williams, 2014). Reasons for increased use in sexual minority youth may be related to stigma, discrimination, bullying, and generally less disinhibition (Newcomb et al., 2014). Adults experience the same issues and are also subject to the gay community's culture, which is more accepting (and occasionally pressuring) of substance use

criteria for credentialing between states and certification agencies

Credentialing agencies and states differ in opinion regarding just how many competencies are needed. When examining the criteria for credentialing between states and certification agencies, it is evident that standards and requirements vary. In making a case for standardized national credentials, NAADAC (2018a) suggests that that type of standard would (1) provide a national standard for knowledge and competence, (2) ensure that standards exceed state standards and encourage professionals to seek continued education, (3) offer a way to measure and monitor professional requirements, and (4) offer clients, agencies, and communities a credential that signifies a quality counselor.

countertransference with recovered counselor

Depending on the populations reviewed, anywhere from 37% to 75% of addictions helpers are themselves in recovery (Racz et al., 2015). Given this high percentage, what are the implications if an addictions counselor is working with someone who may be struggling with the same addiction from which the counselor, or a member of the counselor's family, is recovering? Given counselors' own history of struggle with addiction, counselors in recovery may be able to empathize with clients in rehabilitation at a higher level than those who do not have a history of addiction. However, helping professionals in recovery may use their personal experiences in treatment planning, expectations for prognosis, and clinical decisions (Novotna et al., 2015). This may either help or hinder the recovery process. To minimize the potential negative effects of countertransference, counselors in recovery need to maintain regular supervision, especially when working with clients who suffer from similar addictions.

Education requirements for substance addiction counselors

Education requirements for substance addiction counselors have developed over time and vary with state requirements. In early licensing and certification of substance abuse counselors, training programs and coursework-specific credentialing was prioritized over degree programs (Iarussi, Perjessy, & Reed, 2013). Over time, counselors serving clients with SUDs have experienced an increase in expectations regarding their knowledge and skills related to practice, but training programs have not met the increasing need for education and preparation (Duryea & Calleja, 2013). Currently, while there are still no national curriculum standards or credentialing and while training requirements still vary from state to state, they sometimes differ greatly even within states (Counselor License Resources, 2018).

possible cultural differences

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 stereotypes

relationship between addictions counseling and professional counseling

Historically, the relationship between addictions counseling and professional counseling has been distanced. It was 2009 before CACREP standards required addictions education for professional counselors and added addictions counseling as a specialized program within accredited programs (Bobby, 2013). Even in modern texts that provide an overview of the counseling field, addictions counseling is covered in the chapters on credentialing and licensure (Neukrug, 2017). A final note regarding the licensure process for addictions counselors is the fact that professional counselor licensures, marriage and family therapy licensures, and clinical social work licensures offer the holders the credentialing to treat clients with SUDs without specialized licensure or credentialing. These nuances provide evidence that, though great strides have been made to connect the counseling field to addictions specializations, there is much work to be done for the establishment of continuity between the professions.

Issues with ROSC

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).

four central concepts of TTM

In terms of its theoretical underpinnings, TTM posits four central concepts essential for client or clinician behavior change: (1) stages of change (e.g., Precontemplation, Contemplation, Preparation, Action, and Maintenance); (2) processes of change (e.g., cognitive, behavioral, and affective activities that facilitate change); (3) self-efficacy (e.g., client's/clinician's confidence in making changes); and (4) decisional balance (e.g., advantages and disadvantages of change) (Prochaska et al., 2004).

armed forced and addiction

Members of the United States armed forces experience a more varied relationship to substances than do the general population. Likely due to the zero-tolerance policy on illicit drugs by the Department of Defense (DOD), military personnel have rates of use significantly below the general population—2.3% versus 12% in one DOD study (NIDA, 2013). However, NIDA (2013) reported that military personnel use prescription drugs at a higher rate than the general population and has increased drastically, with 11% reported misuse in 2008, an increase from the reported 4% in 2005 and 2% in 2002. Alcohol use is much higher in military personnel, with nearly half (47%) reporting binge-drinking behavior and 20% reporting binge drinking every week for the past month (NIDA, 2013). Unlike other populations, military personnel report concern of stigma related to seeking mental health treatment (especially regarding employment-related discrimination), which decreases their likelihood to seek treatment

preventing burnout

One of the most important aspects of preventing burnout and compassion fatigue is self-care, which is defined as any activity that relaxes, centers, or cares of oneself

Unity Among Self-Help Groups

Rather than standing alone and working in parallel lines, more and more self-help groups are joining forces and pooling resources, including combining advocacy efforts, which has led to a greater public voice (Krentzman, 2013). The national advocacy group that came out of these collaborations is the Faces and Voices of Recovery and the Association of Recovery Community Organizations (Krentzman, 2013).

Recovering counselors

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 (Nielson, 2016). 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). Additionally, clients may feel more connected to counselors who understand addiction personally and that can help with an expedited rapport-building process (Racz et al., 2015). However, the dynamic of being in recovery can create dual relationship challenges beyond the normal experiences of counselors (Veach, 2015). 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 (Dreison et al., 2018). For addictions counselors in recovery, there is an added stressor of shared experiences or understanding that may be difficult for counselors to manage.

value of the therapeutic relationship

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

treatment settings

Regardless of the theory or model used, the delivery of substance addiction treatment can occur in many settings. Clients can seek treatment through individual therapy, marriage and family therapy, or group therapy as a means to address their substance addiction. However, depending on the severity of the SUD, counselors must be able to determine if outpatient services are appropriate for their clients or if inpatient programs are necessary or optimal for care.

recovery-oriented system of care (ROSC)

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 (DiClemente et al., 2016, p. 94). 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 (DiClemente et al., 2016). 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).

positive psychology

Some in the field are increasingly calling for the addictions field to forgo the labels and pathological perspective and take a wellness and positive psychology and recovery approach in treating those with addictions. Positive psychology focuses on client strengths and supports over the lifespan and embraces the notion that there is more than one way to obtain sobriety and recovery

can addictions counselors diagnose mental health disorders?

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

Managed care

The advent of managed care has changed the way health care provisions are administered in this country (Quinn et al., 2017). 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 (Hines, Raetzman, Barrett, Moy, & Andrews, 2017). 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 (Hines et al., 2017). 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). The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) has helped to rectify this discrepancy in treatment provision (Quinn et al., 2017)

ethical concerns 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 (Hines et al., 2017). 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

concerns that exist about the implementation of evidenced-based practice

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

ethical concerns related to counselors in recovery

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 alcohol, they can be extended to recovery from all mind-altering substances. Additionally, the AA guidelines suggest maintaining strict boundaries between one's clients and those one sponsors, should a counselor participate in both processes.In terms of counselors in recovery, there are two other key issues impacting this population. These include countertransference issues and self-disclosure.

factors that contribute to the prevalence of substance use disorders

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. Researchers have found that individuals who are unemployed reported higher rates of substance addiction compared to those who had full-time employment (United States Department of Health and Human Services [DHHS], 2013). Other findings include the differences among races in reported drug use, including Native Americans (12.7%), African Americans (11.3%), Caucasians (9.2%), Hispanics (8.3%), Native Hawaiians (7.8%), and Asians (3.7%)

Self-disclosure with recovered counselor

There are several reasons why a counselor may disclose his or her own struggle with an addiction. For instance, it may help to enhance client engagement, counter resistance, minimize shame and isolation, engender hope, and illustrate a particular problem-solving strategy. However, too much or improperly used disclosure yields unintended issues like an inappropriate level of intimacy within the therapeutic relationship or lack of trust by the client (Shadley & Harvey, 2013). Therefore, when disclosing such information, it is suggested that counselors proceed with caution and be mindful of the timing, duration, and suitability of the disclosure. An effective consideration process includes questions related to some of the core professional values of the counseling profession (ACA, 2014). Specifically, before self-disclosing, addictions counselors should consider beneficence (helpfulness and promotion of well-being to the client), nonmaleficence (avoidance of causing harm), and justice (equity and appropriateness beyond the single client interaction).

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 (Smith & Liu, 2014).

homelessness and addiction

Though rates are varied, people who are homeless have higher rates of substance addiction (including tobacco, alcohol, and other drugs) and drug-related overdoses than the general population (Baggett et al., 2015). Due to lack of resources, the homeless population experiences many barriers to securing addiction services and treatment

disconnect between research and clinical practice

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

Alcoholics Anonymous (AA)

a voluntary support group located in 180 countries for individuals who wish to stop drinking alcohol. Its companion group for those who use other drugs is Narcotics Anonymous. AA was founded in 1935 by a New York stockbroker and an Ohio surgeon, and it is estimated there are currently over 2 million members worldwide. The only requirement for membership is the desire to stop drinking or using other substances. There are no fees or costs associated with membership, and AA is self-supporting through member donations. The philosophy behind AA is that alcoholism is an illness that cannot be cured, but can be controlled through hard work and perseverance "one day at a time." Therefore, one is always in "recovery" unless one has relapsed. The goal is to help one another through fellowship, understanding, and by working the 12 steps and 12 traditions. Each step and tradition helps the individual make changes to behaviors, beliefs, and emotions so he or she can obtain sobriety and good health.

move toward evidence-based treatments

along with other counseling and medical specialties, a move toward evidence-based treatments has taken root within the addictions field (Kidd et al., 2014). Professional associations and governmental agencies have also issued practice guidelines and treatment algorithms, which support selected treatments or levels of care for specific conditions (Horvath & Yeterian, 2012). Empirically based practices are developed through clinical trials, consensus reviews, and expert opinions

polysubstance use or addiction

broadly describes the use of multiple substances simultaneously or within a specific time frame. 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. Within the United States, there continues to be a high incidence rate of substance and polysubstance use and addiction, especially among adolescents and young adults.

training for counselors not specializing in addiction

counselors who are not specializing in addictions may not receive any training beyond one course (Chasek & Kawata, 2016). Though CACREP programs require addiction coursework, there continues to be a lack of standardization regarding content taught, as some courses focus only on information education rather than practice and treatment (Iarussi et al., 2013). The most effective method of training counselors for addictions specific competencies is to incorporate training that includes both constructive methods for understanding addictions-related knowledge and experiential practice to solidify the ability to use the new skills

Minnesota model of substance abuse treatment

developed in the mid-20th century as an early model of multidisciplinary treatment for addictions (Klein & Ross, 2014). The model gained significant attention due to its comprehensive approach, which included medical, psychological, social, recreational, and spiritual evaluation and treatment planning. Based on the same philosophy as Alcoholics Anonymous, Minnesota model-based treatment programs emphasize SUD as a disease and emphasize the need to work through the 12 steps of recovery. While a multidisciplinary team is not available in all substance addiction settings, aspects of the Minnesota model's multidisciplinary approach are used across substance addiction treatment modalities

comorbidity

existence of multiple diagnosable disorders or diseases that occur simultaneously or sequentially and influence the outcomes of the present illnesses. The prevalence of comorbidity can be complicated to determine due to the overlap of diagnostic criteria and symptoms. 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. Overall, SAMHSA (2015) reported that 3.3% of the adult population and 1.4% of adolescents experienced comorbid SUD and mental illness. Dual or multiple diagnoses may pose challenges for accurate diagnosis; therefore, it is necessary for counselors to utilize assessment tools that encompass a broad spectrum of screening processes

Prochaska and DiClemente's (1984) transtheoretical model of change (TTM)

garnered increased empirical attention among addictions professionals over the course of the past 20 years. Historically, this model has been one of the leading approaches for explanation and intervention across a variety of health-related behaviors, such as smoking cessation, alcohol abuse, dieting, gambling, and substance addiction. This model has also been used to assess an addictions counselor's "readiness for change," in terms of adapting new treatment protocols, because one of the barriers to implementing evidenced-based practices is the clinician's inexperience or lack of understanding of what it takes to change attitudes and practices

Evidence-based or empirically-based practices

interventions for which empirical validation exists to suggest that these treatment protocols improve client outcomes

collaboration when working with comorbid disorders

it is a counselor's responsibility to ensure competent treatment; therefore, if an addiction counselor is not trained in working with the diagnosis beyond the substance use disorder, collaborative action may be necessary. It is difficult to determine the directionality of comorbid mental illness and substance use disorders. While each may be causative or a result, it is also likely that risk factors may influence the development of both (NIDA, 2018). Recognizing the need for more training and competency for comorbid conditions, the NAADAC will be offering a credential in "co-occurring competency"

future trends in addictions counseling

positive psychology, unity among self help groups, changes in US drug laws

professional issue faced by addictions counselors

postsecondary trauma and self-care. It is becoming increasingly recognized in the field that substance addiction work incurs stress and trauma for those who work with this population. Burnout occurs at high rates, and the effects of burnout on counselors include physical and mental health issues (Oser et al., 2013). Addictions counselors may be faced with increased stresses, be inundated by heavy workloads, experience work-setting challenges, and be tested to find a balance between role expectations and client work

Certification

provides a professional standard and guideline, which is governed by an organization, educational requirements, and passing a standardized exam, thus establishing a common minimum competency for professionals (NAADAC, 2018a). While there are state requirements for substance addiction counseling licensure and certification guidelines, there is a lack of nationwide continuity; therefore, requirements, education, and certification may vary, contingent upon each state's standards

he National Board of Certified Counselors certification

provides a voluntary certification of National Certified Counselor for state licensed counselors who want to demonstrate a high commitment to education and standards in their profession. In addition to the general certification, NBCC offers additional certifications for counselors to choose, including Master Addictions Counselor (MAC). Counselors who want to obtain this credential must pass the Examination of Master Addictions Counselors exam and commit to following the NBCC guidelines for continuing education in addictions-related topics for recertification

federal Patient Protection and Affordable Care Act of 2010

strives to ensure access to services and better coordination of care

Licensure

the most rigorous form of professional regulation. Historically, the movement to license addictions counselors was not as advanced as that of certification, but this has changed in recent years. Unlike certification, which can be granted nationally (e.g., national certified counselor), state law establishes licensure, and each state determines the requirements for licensure. Each state has differing names and requirements for licensure, so determining how to find information can be confusing. States use different terms for addictions counselor licenses, including Licensed Chemical Dependency Counselor (LCDC), Chemical Dependency Counselor (CDC), Certified Alcohol Drug Counselor (CADC), Substance Addiction Counselor (SAC), Alcohol and Drug Counselor (ADC), Addiction Counselor, and Substance Addiction Professional