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Counseling Approaches To Promote Recovery From Problematic Substance Use and Related Issues [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2023. (Treatment Improvement Protocol (TIP) Series, No. 65.)
Counselors can use multiple evidence-based psychosocial interventions and frameworks to help clients achieve their recovery goals, including harm reduction, trauma-informed care, motivational interviewing, cognitive–behavioral therapy, contingency management, mindfulness, acceptance and commitment therapy, and psychoeducation.
Many psychosocial interventions and frameworks can be effectively combined to increase the odds of clients maintaining their recovery and preventing recurrence, regardless of their chosen recovery pathway.
Family and social support are vitally important to facilitating recovery for people who have problematic substance use. Family therapy approaches can help strengthen families, leading to positive outcomes for the person in recovery and improved health and well-being for the entire family.
Peer support services enhance counseling by connecting individuals in recovery to nonclinical professionals who have lived experience with problematic substance use, behavior change, and recovery. Peer support specialists can help clients access community resources; however, counselors also should be aware of recovery services in their local community.
Many people who need treatment for problematic substance use don't receive it. One major reason is that they don't believe they need help.686 Other reasons people don't receive treatment include lack of insurance, the inability to pay insurance deductibles and copays, and the belief that treatment won't work. Others may not feel ready to stop their substance use.687,688 Another key reason that people don't receive treatment is fear of the stigma associated with problematic substance use.689
Although many people enter recovery without professional help, people with substance use–related problems are more likely to experience long-term, stable recovery if they have access to a combination of counseling services, peer-based recovery supports, medications, and community-based recovery supports. Engaging clients in the recovery process includes establishing a collaborative alliance, helping clients resolve ambivalence about engaging in their chosen recovery pathways, working in partnership with clients to identify recovery goals, and supporting their work toward recovery tasks and goals.
Chapter 3 of this Treatment Improvement Protocol (TIP) is intended for counselors who are working with individuals in recovery from substance use–related problems, regardless of the service setting. This chapter reviews counseling approaches and interventions that can support individuals in recovery from problematic substance use, including:
Harm Reduction.
Trauma-Informed Approaches.
Motivational Approaches.
Family Therapy Approaches.
Cognitive–Behavioral Therapy (CBT).
Contingency Management (CM).
Mindfulness and Acceptance-Based Approaches.
Linkages to Peer and Community-Based Support Services.
Psychoeducation.
For definitions of key terms that appear in this and other chapters, refer to the TIP's Executive Summary.
Harm reduction is an evidence-based, proactive approach designed to reduce the negative impacts of problematic substance use.690 It's focused on meeting people “where they are” and on their own terms,691,692 and includes compassionate and pragmatic strategies that aim to minimize harm related to problematic substance use. The goal of harm reduction is to enhance quality of life without requiring or advising abstinence or reduction of use.693 According to the Substance Abuse and Mental Health Services Administration (SAMHSA), harm reduction is a “practical and transformative approach that incorporates community-driven public health strategies—including prevention, risk reduction, and health promotion—to empower people who use drugs (PWUD) and their families with the choice to live healthy, self-directed, and purpose-filled lives. Harm reduction centers the lived and living experience of PWUD, especially those in underserved communities, in these strategies and the practices that flow from them.”694
RESOURCE ALERT: SAMHSA'S HARM REDUCTION FRAMEWORK.
Examples of harm reduction strategies include conducting overdose education and naloxone distribution (OEND) to reduce the risk of opioid overdose; offering test strips to check drugs for fentanyl and xylazine and support safer use; and supporting activities of daily living, including providing services to help people who are using substances obtain food, take showers, or connect with housing. These activities have been found to reduce the risk of injury, illness, and death associated with substance use.695 Some harm reduction activities are also associated with reducing a person's problematic use of substances.696 (Exhibit 3.1 contains examples of harm reduction services.)
EXHIBIT 3.1. Harm Reduction Services.
Harm reduction is an approach designed to encourage positive change and reduce the negative health-related consequences of risky behavior that may be associated with substance use.697,698 It is based on the premise that all people inherently deserve services that promote health, regardless of whether they have problematic substance use.699 Given that each person in recovery has their own recovery goals (which may or may not include abstinence from substances), harm reduction activities can encourage outcomes that help prevent overdose and infectious disease transmission for people who have problematic substance use.700
Harm reduction strategies are also highly effective in supporting safer substance use behaviors. For example, syringe services programs have limited the sharing of syringes, decreased HIV infection rates, and resulted in fewer overdose deaths.701 Harm reduction strategies for opioid use disorder (OUD) have reduced the spread of infectious diseases, resulted in fewer opioid overdoses, and improved retention in and access to care.702 Exhibit 3.2 describes SAMHSA's pillars and corresponding principles and core practice areas of harm reduction.
EXHIBIT 3.2. Harm Reduction Pillars, Principles, and Core Practice Areas.
Several evidence-based harm reduction methods are available to support recovery from problematic substance use. Examples described below include safer injection practices, syringe services programs, OEND, drug checking using fentanyl and xylazine test strips, sexual health education and supports, protective behavioral strategies (PBS), and client goal-setting practices. Each intervention includes information for counselors who want to connect people in recovery with related resources in their community.
People who inject substances are at higher risk of disease transmission, including HIV and hepatitis C virus (HCV), as well as damage to their veins and other potentially serious soft tissue infections.705,706 Those who inject substances may also be more likely to engage in high-risk sexual behaviors, such as unprotected sex, which may put them at higher risk of other sexually transmitted infections (STIs).707 Harm reduction practices that educate people about safer injection practices and offer clean supplies are essential for reducing exposure to infections and supporting safety with continued use.
Counselors can access the resources in this chapter to share information with people in recovery about the importance of ensuring they have access to clean water and supplies; performing handwashing, basic hygiene, and wound care; and understanding other methods for reducing infection. Key areas to discuss include708:
Cleaning hands and skin prior to injections.
Using sterile equipment prior to each injection (the next section discusses syringe services programs).
Cleaning used syringes with bleach if new syringes are not available.
Understanding how to find and care for veins.
Practicing appropriate hygiene to prevent infections following an injection.
Exhibit 3.3 identifies supplies that support safer injection practices.
EXHIBIT 3.3. Supplies To Support Safer Injection Practices.
RESOURCE ALERT: SAFER INJECTION PRACTICES.
Access to clean needles and syringes helps to ensure that people who inject substances are at reduced risk of contracting HIV, viral hepatitis, or other bloodborne infections. More than three decades of research supports the use of syringe services as safe, cost-effective, and life-saving programs for people who have problematic substance use.709 In fact, research indicates that new users of syringe services programs are five times more likely to enter substance use disorder (SUD) treatment and about three times more likely to stop using drugs than are people who inject substances who do not use these programs.710
Most community-based syringe services programs provide access to sterile needles, syringes, and other injection equipment; facilitate safe disposal of used syringes; and offer a range of other services, including712,713,714,715:
Referrals to SUD treatment programs.
Screening, care, and treatment to prevent HIV, STIs, and viral hepatitis.
Sexual health programming, including counseling and condom distribution.
Education about overdose prevention and safer injection practices.
Vaccinations.
OEND.
Referral to a range of other services.
RESOURCE ALERT: SYRINGE SERVICES PROGRAMS.
HARM REDUCTION STRATEGIES FOR ADDRESSING HCV.
Naloxone, a medication that can rapidly reverse an opioid overdose, is an essential harm reduction tool for people who have problematic opioid use. Naloxone attaches to opioid receptors and reverses and blocks the effects of opioids. The medication, which is now available over the counter as a nasal spray as well as by prescription, can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose.723,724 In fact, SAMHSA recommends that every client who has problematic opioid use or OUD receive opioid overdose prevention education and naloxone.725 Naloxone is generally not harmful. In the event of an ongoing overdose, the risk of death associated with opioid overdose is far greater than the risk of experiencing adverse effects from naloxone administration.726
However, counselors should be aware that naloxone may cause individuals to go into withdrawal.727 For those with OUD, connection to medication-assisted recovery services is a critical next step following naloxone administration. Counselors can learn more about these symptoms and naloxone at https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/naloxone.
RESOURCE ALERT: NALOXONE AND OVERDOSE PREVENTION EDUCATION.
Naloxone is accessible in all states. However, the out-of-pocket cost to purchase naloxone may be high, creating a barrier for uninsured patients as well as for those who have insurance with high copays.730 Counselors can learn more about where to access naloxone from their state health or behavioral health department as well as the following sources:
NEXT Distro provides information about community-based naloxone programs and can be accessed at https://www
The North America Syringe Exchange Network's syringe services locator identifies places where naloxone is offered (https://www
NALOXONE AS A HARM REDUCTION TOOL TO PREVENT OPIOID USE–RELATED OVERDOSES.
The use of fentanyl has been associated with a significant increase in overdose and death rates.735 Fentanyl is a powerful synthetic opioid that is 50 times stronger than heroin and 100 times stronger than morphine.736,737 Although pharmaceutically produced fentanyl is prescribed to treat pain, illicitly manufactured fentanyl may be added to other substances, making those drugs more powerful and addictive. It is also difficult to tell whether a substance contains fentanyl, making the substance more dangerous.738,739
Fentanyl test strips, which can now be purchased with federal funding, can detect the presence of fentanyl within 5 minutes. They are an essential harm reduction tool for reducing overdose and deaths related to this substance.740,741,742 The correct use of fentanyl test strips requires education about how to correctly dilute the solution being tested.743
Counselors can learn how to access and use fentanyl test strips through local syringe services programs. The North America Syringe Exchange Network's website has a map with links for locating many of these programs in their communities (https://www.nasen.org/map/).
Xylazine, also called “tranq” or “tranq dope,” is a tranquilizer increasingly being added to other drugs, such as cocaine, heroin, and fentanyl, either to enhance the drug effects or increase street value by increasing their weight. Xylazine's effects can be life-threatening, particularly when combined with opioids, like fentanyl. Although it is FDA-approved for use in animals, xylazine is not approved for use in humans.
There are harm reduction strategies that can help address a potential xylazine overdose, including administering naloxone. Naloxone will not reverse the effects of xylazine. However, it should always be administered to anyone with a suspected overdose because xylazine is often mixed with other opioids. Similar to fentanyl test strips, xylazine test strips can also be used to test for the presence of xylazine prior to use.744
For more information about xylazine test strips, including where you can obtain them, visit https://mattersnetwork.org/harmreduction/.
RESOURCE ALERT: FENTANYL AND XYLAZINE TEST STRIPS.
Sexual health services and education have been documented to prevent the transmission of HIV and other STIs as well as reduce the number of unplanned pregnancies. Studies indicate that problematic substance use may put people at higher risk of getting HIV and other STIs as well as other infections.745
Additionally, some people with problematic substance use may also engage in some form of sex work. In an examination of substance use among sex workers in 86 studies from 46 countries, more than a third of sex workers reported problematic substance use over their lifetime.746 Sex workers who also have problematic substance use may be increasingly vulnerable to infectious diseases, including HIV and other STIs; violence, stigma, and discrimination; and exploitation.747 Clients who are using substances like methamphetamine and cocaine may engage in sex work as a means to obtain a source of income to pay for substances. These clients may feel ambivalent about abstaining from substance use in this case. Thus, for those who engage in sex work, counselors should help them develop safety plans, identify and avoid cues and triggers related to substance use, and take greater control over their reproductive health.748
Sexual health programs are particularly important for reducing harm among people who have problematic substance use, including those engaging in sex work.749 These programs often include750:
Access to HIV prevention methods, such as preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP). PrEP and PEP are effective medications that are part of sexual health programs nationwide. These medications, described below, can prevent HIV transmission and be prescribed by primary care providers, community health centers, and other service providers.
PrEP can prevent infection in people who may be at risk for contracting HIV. The FDA has approved two daily oral medications for PrEP and a long-acting injectable form.751 More information about PrEP can be found at https://www
PEP can prevent HIV when taken within 72 hours (3 days) after a possible exposure.752 More information about PEP can be found at https://www
HIV prevention and testing services can be found at https://npin
Access to birth control options. Offering birth control options, such as long-acting reversible contraceptives, birth control pills, condoms, and other types of contraceptives, is effective in reducing unplanned pregnancies and supporting sexual health. Birth control options should be offered in conjunction with STI testing and treatment services.
Studies indicate that women who inject substances may have unmet needs for reproductive health services, such as access to birth control.753 They also may face many barriers to accessing this kind of care in traditional settings, including personal histories of trauma and judgmental treatment from providers, among other challenges.754
Increased access to sexual health services and contraception are needed and supported by organizations like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, which have also endorsed expanding access to comprehensive contraception services, including long-acting reversible contraceptives, as an essential harm reduction tool in the opioid epidemic response.755
Broader access to these types of contraceptives and other contraceptive methods are important tools for people who have problematic substance use and who are interested in preventing pregnancy.
Condom distribution programs have been implemented in communities across the country and have been shown to be effective for preventing the spread of HIV and other STIs as well as reducing unplanned pregnancies.756
According to the Centers for Disease Control and Prevention, making condoms widely available through distribution programs is essential to successful HIV prevention.757
More information about condom distribution programs, including where programs are located, can be found at https://www
Comprehensive sexual education. Offering comprehensive sexual education, including education on HIV and STI prevention and birth control options, is an essential part of promoting health and well-being for people who have problematic substance use.758
RESOURCE ALERT: SEXUAL HEALTH SERVICES.
Chapter 4 discusses further how counselors can help connect clients to providers, including gynecologists and obstetricians, who can help provide sexual and reproductive health services.
PBS are harm reduction strategies that can reduce the use and severity of consequences from problematic substance use. Regarding problematic alcohol use, examples of PBS include defining limits around drinking and behavior, such as deciding not to exceed a set number of drinks or choosing not to engage in behaviors that lead to drinking quickly.759 Some common activities used with PBS include brief motivational interventions, PBS skills training, personalized normative feedback, and PBS instruction.760 Important considerations when discussing PBS with clients include the client's social environment, how substance use may be embedded in their culture, or how they connect socially.761
PBS have been studied as a harm reduction practice to address problematic marijuana use. By developing specific personal strategies for moderating use, PBS were found to reduce impulsivity and risk taking related to marijuana use. They also were found to enhance protective factors among people with problematic marijuana use.762
Client-driven goal setting can help clients interested in reducing substance use by allowing them to set individual and achievable goals. This type of goal setting does not often focus on abstinence. Rather, clients identify goals related to reducing substance use–related harm or improving quality of life.763
After initial goals are identified, counselors may ask open-ended questions and engage in strengths-based reflections to elicit client progress toward their harm reduction goals.
HARM REDUCTION STRATEGIES TO PREVENT STIMULANT OVERAMPING.
Counselors also can provide affirmations and encouragement to support ongoing goal actualization. Working collaboratively to track progress, counselors and their clients should discuss barriers to progress. However, remaining supportive, regardless of client progress, is an essential part of this intervention.770
Motivational interviewing (MI) can be a critical tool in supporting the development of goals. As discussed in subsequent sections of this chapter, MI is an effective, evidence-based technique for helping clients identify their strengths and goals as well as barriers to progress on those goals that may be preventing change. The core principles of MI are to express empathy and elicit clients' reasons for and commitment to addressing problematic substance use.771,772 Counselors must be trained in skills and strategies involved in MI. These skills are particularly useful for helping clients identify goals to reduce or address problematic substance use.
RESOURCE ALERT: MI AND CLIENT GOAL SETTING.
Many people experience trauma during their lifetime. Trauma can result from physically or emotionally harmful or life-threatening experiences that can cause lasting adverse effects on a person's well-being.773 Trauma is in fact how we experience these events and can be different for various members of a family or community. Some clients may experience trauma directly related to a specific event, whereas others may have trauma resulting from cumulative experiences of childhood abuse and neglect. Trauma and SUD often occur together, and the experience of trauma can result in or from problematic substance use.774,775 For example, one study indicated that of individuals with posttraumatic stress disorder (PTSD), 46 percent also had an SUD.776 Failing to address trauma in people who have problematic substance use can lead to worse outcomes.777
Counselors should be able to recognize the effects of trauma on the lives of people in recovery and develop trauma-sensitive or trauma-responsive services. Those who have survived trauma will vary in how they experience it. A client may have emotional reactions (e.g., anxiety, guilt, sadness, depression); physical reactions (e.g., sweating, nausea, fatigue, sleep disturbances); and cognitive reactions (e.g., difficulty concentrating, memory problems, self-blame); among many others. More information about immediate and delayed signs of trauma can be found in SAMHSA's TIP 57, Trauma-Informed Care in Behavioral Health Services (https://www.samhsa.gov/resource/ebp/tip-57-trauma-informed-care-behavioral-health-services).
Becoming trauma aware and informed is a first step in this process.778 Counselors can use the information below to learn about types of trauma, understand how to recognize trauma, and identify ways to support people in recovery with a trauma history. The trauma-informed therapies in this section can help people in recovery manage trauma-specific symptoms, removing another barrier to their recovery.
Trauma-informed care is grounded in an understanding of and responsiveness to the impact of trauma.779 Trauma-informed care is strengths-based, which requires that counselors be aware of their clients' trauma and understand that clients must be directly involved in their own care. Clients become empowered and invested in the outcome when they have input into their goals and treatment.780 Trauma-informed care means attending to trauma-related symptoms and creating an environment that is responsive to the unique needs of individuals with histories of trauma. Treatment is focused on reducing specific symptoms and restoring functioning, but it also addresses broader goals like building resiliency, reestablishing trust, and preventing retraumatization.781
PROVIDING TRAUMA-INFORMED SCREENING AND ASSESSMENT.
Counselors should understand how to recognize trauma-related reactions, how to incorporate treatment interventions for trauma-related symptoms into clients' treatment plans, and how to help clients build a safety net to prevent further trauma.784 Trauma-informed approaches support both counselors and people in recovery. This approach encourages better understanding of a client's potential trauma history and builds trust between the counselor and the person in recovery. It can also help counselors adapt interventions to ensure they are addressing the unique needs of the person in recovery.
Use of language in trauma-informed care is important. Counselors should ensure that interventions and interactions don't distress or retraumatize clients. Trauma can be grounded in relationships; thus, a counselor's role is essential to supporting their client. They should also avoid being confrontational or argumentative with clients or dismissive of their experiences and feelings. By minimizing or ignoring clients' responses and needs or pushing clients to talk in greater detail about their trauma, counselors run the risk of retraumatizing them.785
SAMHSA has outlined the elements of trauma along with key principles of trauma-informed care in its strategic initiative for trauma and justice (Exhibit 3.4). Counselors should be aware of these foundational concepts as they integrate trauma-informed approaches into their work.786 Being trauma informed requires “recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic.”787 Key elements of a trauma-informed approach include788:
EXHIBIT 3.4. Key Principles of a Trauma-Informed Approach.
Realizing the widespread effects of trauma and the various paths to recovery.
Recognizing the signs and symptoms of trauma.
Responding by putting this knowledge into practice.
Resisting retraumatizing people in recovery by working to provide a supportive environment and examining language.
LANGUAGE MATTERS.
RESOURCE ALERT: TRAUMA-INFORMED CARE IN BEHAVIORAL HEALTH.
UNDERSTANDING PERPETRATION-INDUCED TRAUMA.
As discussed in Chapter 1, people in recovery may have experienced trauma, defined by SAMHSA as a result of an event or series of events that are physically and emotionally harmful, or life threatening, and that have lasting adverse effects on a person's mental, physical, social, emotional, or spiritual well-being.799 People experience trauma in different ways and may experience multiple traumatic events. Trauma can be acute, chronic, or complex.800
Counselors should be aware of the range of trauma that people in recovery may have experienced. They should also be conscious of the fact that clients may have experienced many different forms of trauma within their lifetimes.
Adverse childhood experiences are traumatic events that occur during childhood, such as physical or emotional abuse, or parental neglect.801,802 Stress from these events can affect brain development, resulting in long-term negative health and emotional consequences for the person, including SUD.803,804,805 Sexual abuse, which may occur during childhood, is closely linked with SUDs and has also been shown to disrupt the efficacy of SUD treatment.806 Problematic substance use can also expose people to traumatic experiences, such as homelessness or gun violence.807,808
People in recovery may have also experienced historical, racial, or intergenerational trauma. Historical trauma refers to traumatic experiences or events shared by historically oppressed groups. Racial trauma results from exposure to racism, bias, and discrimination. Intergenerational trauma passes down from those who directly experience the trauma to subsequent generations. Intergenerational trauma can occur because of historical or racial trauma. People who experience these forms of trauma may be more likely to have problematic substance use.809 Intimate partner violence is also associated with problematic substance use. People who experience substance use coercion, defined as controlling or interfering with a partner's SUD treatment or forcing a partner to use substances, are more likely to have problematic substance use.
Other forms of trauma associated with problematic substance use may include the experience of poverty, homelessness,810 and food insecurity. Trauma may also result from involvement in the criminal justice system. In fact, trauma is disproportionately present in individuals with exposure to the criminal justice system, and trauma exposure among people who are incarcerated has been associated with alcohol and substance use.811 Another form of trauma, military combat trauma, is also associated with development of problematic substance use (more information can be found in the “Understanding Perpetration-Induced Trauma” box).812 Each of these forms of trauma requires an individualized, trauma-informed, and culturally responsive approach by counselors.
Working with a person in recovery who has a history of trauma can be challenging. Counselors should be aware of trauma-informed care before working with individuals in recovery who have a history of trauma. SAMHSA's TIP 57, Trauma-Informed Care in Behavioral Health Services, includes information for counselors about trauma awareness; understanding the impact of trauma; clinical issues; and trauma-specific services. The TIP can be accessed at https://www.samhsa.gov/resource/ebp/tip-57-trauma-informed-care-behavioral-health-services. Counselors can use the following treatment principles to guide them in developing trauma-informed approaches that meet the needs of people in recovery who have a history of trauma. They include813:
Promoting trauma awareness. Counselors should recognize the prevalence of trauma and its role in problematic substance use. For example, research indicates that there are high rates of comorbidity between SUD and posttraumatic stress disorder.814 In fact, data indicate that those with SUD are 6.5 times more likely to have PTSD that those without SUD.815 With the understanding that trauma and problematic substance use may often co-occur, counselors can tailor their work with those in recovery. However, counselors should not assume everyone has experienced trauma. Screening and assessment tools can help counselors to better understand the range of traumatic experiences that clients may have experienced. They should keep in mind that clients may avoid openly discussing traumatic events as these may evoke feelings of shame, guilt, or fear of retribution by others associated with the event. Thus, in some cases clients may be more likely to report trauma when they use self-administered screening tools.816
Recognizing trauma. Once aware of a person in recovery's trauma history, a counselor can begin to understand where they may be coming from, working with them from a hopeful, strengths-based position, and building upon the belief that their “responses to traumatic experiences reflect creativity, self-preservation, and determination.”817
Examining trauma in the context of the person in recovery's environment. To understand a client's trauma history, a counselor must consider the environmental and individual, interpersonal, community, societal, cultural, and historical factors that played a role. The context of traumatic events can help inform and guide the counselor's approach to a client's treatment and recovery.
Minimizing retraumatization. Counselors should ensure that they don't offer treatment or use language that may inadvertently retraumatize people in recovery. They should review their practices to determine whether they may retraumatize a person in recovery.
Creating a safe environment. People in recovery should feel safe and supported in the environment where they meet with counselors. Avoiding potential triggers is critical to creating a safe environment for people in recovery. Asking clients to discuss the trauma can be a potential trigger and may retraumatize them in the process. Instead, educating clients about how discussing trauma may affect them may be the first step. Acknowledging the relationship between problematic substance use and trauma and educating clients on the impact of trauma may allow them to begin to develop trust with their counselors so that they feel more comfortable sharing their trauma.
Identifying recovery as a primary goal. Counselors need to bridge the gap between a person in recovery's problematic substance use and the traumatic experiences they may have had. If people in recovery engage in treatment for problematic substance use without addressing the role that trauma has played in their lives, they are less likely to experience recovery overall.818 Helping clients develop the skills to recognize their own trauma and triggers and responses to that trauma may help them as they work towards their recovery.
Viewing trauma through a sociocultural lens. Counselors should learn about the life experiences and cultural background of people in recovery as these are key elements for building culturally responsive practices. Culturally responsive practices should guide the recovery process.
Developing strategies to address secondary trauma and promote self-care. Secondary trauma refers to the trauma that behavioral health service and other providers may experience through exposure to their clients' traumatic experiences.819 Working with survivors of trauma may cause additional trauma-related symptoms for counselors. Counselors can reduce the risk of secondary trauma by monitoring their own mental health needs, seeking assistance from behavioral health service providers, and engaging in self-care activities.
AVOIDING RETRAUMATIZATION.
Trauma-informed therapies may include821:
Providing psychoeducation, especially about the relationship between trauma and problematic substance use.
Teaching coping and problem-solving skills about how to manage stress.
Discussing retraumatization and developing strategies to prevent further victimization.
Helping clients feel empowered and in control of their lives.
Establishing a sense of safety in clients' daily lives and in treatment.
Promoting resilience and offering hope for change and improvement.
Teaching clients how to identify and respond adaptatively to triggers.
Building a strong relationship, which includes trust, confidence, and self-worth.
Counselors can select from many trauma-informed therapies to support people in recovery with a trauma history (Exhibit 3.5).
EXHIBIT 3.5. Overview of Trauma-Informed Therapies.
MI is an evidence-based counseling approach that helps people engage in and comply with treatment. It is a person-centered counseling approach837,838 designed for helping people resolve ambivalence about changing risk behaviors. MI focuses on enhancing intrinsic motivation (motivation from within a person).
MI has been used in counseling for a wide variety of SUDs, smoking cessation, gambling disorder, eating disorders, anxiety, depression, co-occurring disorders (CODs), and medication and treatment adherence. It has also demonstrated success as a culturally sensitive counseling approach because the counselor's focus is on understanding clients' cultural contexts and distinctive perspectives.839 MI is particularly useful in heightening clients' motivation to engage in behavioral health services, become actively involved in continuing care activities, and make lifestyle changes (e.g., engaging in health-promoting behaviors like weight management, diabetes management, healthy sleep habits, smoking cessation, and exercise) that support recovery.
Motivational enhancement therapy (MET) is a brief, evidence-based, manualized intervention that applies MI principles and processes to problematic substance use. It was initially developed for a study conducted by the National Institute on Alcohol Abuse and Alcoholism's Project MATCH, which evaluated the efficacy of several treatments for alcohol use disorder (AUD).840 Although the basic components of MET are similar to the components of MI, MET offers providers the chance to link their work with clients to individually tailored assessment feedback and to offer a menu of choices that can help clients make progress toward their desired behavior changes.841 MET's structure as a brief intervention makes it particularly useful for providers who have limited time or opportunity to elicit change conversations with their clients.842
MI focuses on helping clients resolve ambivalence about changing specific risk behaviors. It is essentially a conversational style that encourages clients to reflect on their personal values and to consider how engaging in risk behaviors does not align with those values. MI also can heighten a clients' awareness that recovery is possible and increase confidence in their ability to make difficult lifestyle changes that sustain ongoing recovery. MI is consistent with the person-centered, strengths-based counseling focus of recovery-oriented behavioral health services.
For core interviewing skills of MI, remember the acronym OARS843:
Ask Open questions, which elicit a story, instead of simply gathering information.
Offer Affirmations of the client's strengths, skills, abilities, and inherent worth.
Engage in Reflective listening to help build the alliance, improve self-efficacy, and reinforce “change talk” (i.e., the desire, ability, reasons, need, commitment, activation, or preparation to take steps to change risk behaviors and adopt lifestyle changes that support recovery).
Summarize the client's experience and understanding of the problem; values, hopes, dreams, and goals; ambivalence about treatment and change; and action steps for change.
Underlying this core interviewing method is the spirit of MI, which includes working in collaboration with clients, accepting their inherent worth and autonomy, showing compassion for their distress, striving to understand their perspective, and helping them draw on their own wisdom.
The core interviewing method and the underlying spirit of MI establish a collaborative, respectful treatment alliance and fosters client engagement in treatment. Exhibit 3.6 offers some simple ways for counselors to evaluate whether they are engaging clients in a conversation in the spirit of MI.
EXHIBIT 3.6. MI Conversational Strategies for Engaging With Individuals In or Seeking Recovery.
Several elements of MI are effective at helping engage clients in their recovery goals. This section focuses on two of those elements: the FRAMES approach and decisional balancing.
The FRAMES approach uses an acronym to describe six components designed to elicit clients' self-awareness and develop clients' confidence in their ability to change unhealthy behaviors. The six components are feedback, responsibility, advice, menu of options, empathy, and self-efficacy. Using the acronym, counselors should844:
Provide personalized feedback to clients about their problematic substance use.
Empower clients to engage in behavior changes that support their recoveries by taking responsibility for their choices.
Ask the client if they can offer directive or educational advice in the form of suggestions.
Give the client a menu of options to help them make choices that will promote engagement and facilitate their recoveries.
Demonstrate empathy by using reflective listening.
Help clients enhance their self-efficacy. Review past successes, identify strengths, and build confidence.
Decisional balancing is a strategy that is used to help clients make decisions without favoring a specific direction of change. This strategy can be a way for clients to assess their readiness for change. However, decisional balancing may increase ambivalence among clients who are contemplating change.
Counselors can help clients who are in recovery from problematic substance use explore the benefits and drawbacks of change by communicating the positive and negative aspects of using substances. The positive aspects of substance use serve as the reasons for not making a change (sustain talk). Alternatively, the negative aspects of substance use indicate reasons that support making a change (change talk). When the costs of use outweigh the benefits, motivation to reduce or stop substance use increases. It may be preferable to explore with clients what they “get out of” substance use before exploring possible reasons for change. Thus, clients are left with their own arguments for why they may want to change.
Counselors can use the following strategies to help clients practice decisional balancing:
Assessing where clients view themselves on the decisional scale. Use validated instruments that provide scores, such as the Alcohol Decisional Balance Scale and the Drug Use Decisional Balance Scale. The University of Maryland Baltimore County's Decisional Balance Scales resource contains more information (https://habitslab
Exploring the benefits and drawbacks of substance use and behavior change with clients by:
Inviting clients to develop written lists highlighting the positives and negatives of changing substance use behaviors.
Recognizing that the strength of each reason for change is as important as the number of reasons for change.
Discussing the relative strength of each motivational factor and the weight that clients place on that factor when considering whether to make behavior changes.
Listening for statements that suggest ambivalence, exploring both sides of the ambivalence cautiously to avoid reinforcing sustain talk.
Helping clients determine how their core values may influence reasons for and against change.
Emphasizing that clients have the sole responsibility to make choices for themselves. It is up to clients to decide if and how they want to address their problematic substance use.
Exploring clients' understanding of the change process and managing expectations about recovery from problematic substance use.
Listening for statements that imply self-efficacy when discussing behavior change. For individuals in recovery, self-efficacy statements may be geared toward the ability to successfully recognize cues and triggers, handle high-risk situations, and manage recurrence of substance use–related problems.
Summarizing clients' change talk and reinforcing commitments to change.
More information about additional MI elements, such as analyzing discrepancies between goals and behavior, flexible pacing, and maintaining contact with clients, can be seen in SAMHSA's TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment (https://store.samhsa.gov/product/TIP-35-Enhancing-Motivation-for-Change-in-Substance-Use-Disorder-Treatment/PEP19-02-01-003).
USING THE STAGES OF CHANGE TO ENHANCE MOTIVATION FOR BEHAVIOR CHANGE IN RECOVERY.
Individuals in recovery are likely to experience ambivalence at some point in their treatment, recovery, and journey to wellness. Although ambivalence is normal when making behavior changes, it is also frequently a roadblock.846
Counselors can help clients resolve ambivalence by distinguishing between sustain talk and change talk. Clients who are ambivalent will use a lot of sustain talk, but clients who are motivated and ready to change will engage in more change talk. The acronym DARN-CAT is used to delineate different types of change talk:847,848
Desire to change: “I want to start attending a mutual-help group.”
Ability to change: “I could start going to a mutual-help group.”
Reasons to change: “Going to a mutual-help group would teach me about recovery.”
Need to change: “I need to find a way to get my alcohol and drug use under control.”
Commitment: “I guarantee that I will start going to a mutual-help group by next month.”
Activation: “I'm ready to go to my first meeting.”
Taking steps: “I went to my first meeting.”
Using MI with individuals in recovery from problematic substance use has many benefits. MI is effective in a wide variety of populations (e.g., adolescents,849 veterans,850 people in criminal justice settings,851,852 people who have SUDs and co-occurring mental disorders, college students, young adults) and formats (e.g., individual, group).853,854,855 Research has consistently shown that using MI approaches can help:
Reduce substance use, including alcohol, tobacco, and drug use.856,857,858
Improve treatment attendance.859
MI can also be effectively combined with other treatment approaches. Using MI with CBT for clients who have problematic substance use may help increase the odds of clients maintaining long-term positive behavior changes.860,861 Research has also evaluated using MI strategies in combination with CM. Results from a meta-analysis indicated that although CM produces the greatest reductions in substance use within the first 3 months after treatment, MI produces the greatest reductions in substance use between 3 and 6 months after treatment.862
The use of MI with clients with problematic substance use can increase the likelihood of their adopting long-term behavior change. However, the effectiveness of MI, in part, depends on the counselor's ability to deliver the intervention with fidelity (i.e., the extent to which it is administered accurately and consistently for all clients and for the duration of the intervention). There are resources available to support counselors as they are learning MI to ensure they are delivering MI with fidelity. The Motivational Interviewing Network of Trainers, for example, is an organization of trainers in MI who are available to provide support to those new to MI, and can help improve the quality and effectiveness of counseling with clients about behavior change. A list of trainers and other MI-related resources can be found at https://motivationalinterviewing.org/.
Family and social support are vitally important to long-term recovery for people who have problematic substance use. As such, families should be included in treatment and recovery services with the client's permission. Family therapy approaches, including those described below, can help strengthen families, leading to positive outcomes for the person in recovery and improved health and well-being for the entire family.863 In fact, family-based interventions are considered among the most effective approaches for treating SUD864 and are widely used to support recovery.
Family therapy includes a series of family-based interventions that use family dynamics and strengths to address challenges. Family therapy can increase motivation for people in recovery to continue in recovery and foster healing for family members by providing tools and the support they need to sustain hope and growth.865 Families should be included early and frequently in their own recovery. Counselors should also take a trauma-informed approach to supporting the family of clients.866
Family therapy can help family members understand867:
How problematic substance use affects the person in recovery.
How problematic substance use affects the whole family.
How family members can adjust or change behaviors to support people in recovery on their recovery path.
Rather than focusing solely on the needs of the person in recovery, family therapy supports the needs of each individual family member.
Defining family is a complex task. Although many people consider the group of people with whom they share close emotional connections or kinship their “family,” family has no single definition. Some consider family as those connected by birth, marriage, or adoption.
Family can also include people who share a household or emotional connections. Some families are blended or intergenerational within the household and include extended family members, such as grandparents, other relatives, and close friends. Other families arise from adoption and foster processes. Some families have members that do not share biological connections but consider themselves family.
Regardless of their makeup, all families function as complex systems working to keep equilibrium. Problematic substance use can interrupt that balance in several ways.868 Understanding the type of family and how problematic substance use affects its members helps counselors anticipate potential issues related to the person in recovery's problematic substance use.869
Problematic substance use affects more than just the person who uses substances; it can affect their entire family in significant ways, depending on the severity, family type, and patterns of use, among other areas.870 Families experience hardships, losses, and trauma as a consequence of problematic substance use of a loved one.871 For example, compared to couples who don't have SUDs, couples who have SUDs exhibit worse relationship functioning, more frequent intimate partner violence, and greater risk of marital dissolution.872 Exhibit 3.7 showcases examples of how problematic use of different substances can affect families.
EXHIBIT 3.7. Effects of Problematic Substance Use on Families.
Family therapy has a robust evidence base. In fact, studies over the past 40 years indicate that partner- and family-involved treatments produce better outcomes across several domains of functioning, such as reduced substance use and improved marital and family functioning, compared with individual-based interventions.893 Family therapy is designed to reduce problematic substance use by altering elements of the family dynamic that directly or indirectly support substance use, while simultaneously improving the quality of family relationships. Although many of these therapies are designed to support adolescent populations, they can also be adapted for adult populations who have problematic substance use.894
Integrating family counseling into problematic substance use leverages the vital role families can play in helping their family members in their recovery goals. Family therapy differs from more general family systems approaches because it shifts the primary focus from the process of family interactions to planning the content of family sessions. Family counseling approaches help clients and their family members understand substance use and recovery and their effects on family functioning.895
If family therapy is not available in the counselor's setting, family education groups may be offered to educate family members and dispel stigma and misconceptions about problematic substance use. This can help support both family members and the person in recovery. These groups can be offered to family members or other concerned persons and attended with the person in recovery.
RESOURCE ALERT: SUD TREATMENT AND FAMILY THERAPY.
Counselors can work with clients and family members to initiate and sustain recovery by896:
Discussing issues around safety and the cultural appropriateness of including family members and recovery supports, including boundaries around confidentiality.
Having the client sign releases to have family members and recovery supports involved.
Collaborating with the client to develop a plan for identifying supportive family members and recovery supports.
Offering culturally appropriate information regarding the nature of the client's problematic substance use or mental disorders; early warning signs of returns to use; the impact of these chronic conditions on family members and recovery supports; and the importance of family and recovery support involvement in treatment.
Improving communication skills to help the client and his or her spouse or intimate partner address conflicts and stressors in their relationship.
Getting input from family and recovery supports on the client's early warning signs of recurrence.
Discussing the importance of self-care with family members.
Collaborating with the client and their family members to develop an emergency plan (in the event of a recurrence) that includes appropriate roles for family members.
Outlined below are select evidence-based family therapies that can be used to support recovery for family members. The need for families to initiate their own recovery path is critical. Too often, families are involved in the context of the client's recovery. Effective family interventions, including those described below, help families create their own recovery pathway.
Multidimensional family therapy (MDFT) is an integrated, comprehensive family-based therapy combining individual counseling and other approaches to treat and support recovery from problematic substance use.897 The focus of this therapy is on strengthening family functioning to create a new, developmental, adaptive lifestyle supporting recovery. MDFT is designed to support change that is multifaceted, with individualized interventions to foster various competencies. Primarily used with adolescents, MDFT can be adapted for adults in recovery from problematic substance use and can support reducing problem behaviors.
Traditionally, counselors work in several MDFT treatment domains898:
People in recovery: Enhancing their emotional regulation, social, and coping skills; communicating more effectively; and reducing involvement with peers who use substances
Family members: Decreasing family conflict, increasing emotional attachments, improving communication, and enhancing problem-solving skills
Community: Enhancing family members' competence in advocating for themselves
MDFT can be delivered one-on-one, in family sessions, or in sessions with various family members, and can also occur in the home or in other settings. Therapy sessions can be modified to meet the needs of the population and family. MDFT can be offered in 16–25 sessions over 4 to 6 months, and can occur multiple times per week.899
Studies indicate that MDFT can be effective in improving substance use treatment outcomes.900 MDFT is recognized as an empirically supported intervention.901 It can also be adapted to diverse populations and is available in English, Spanish, and French. Research shows that most families in MDFT studies are from low-income, inner-city communities; adolescents in these studies range from youth in early adolescence who are at elevated risk, to older adolescents with multiple problems, juvenile justice system involvement, and co-occurring substance use and mental disorders.902
The outcomes associated with MDFT are also supportive of its effectiveness. Randomized controlled trials (RCTs) show clinically significant effects of MDFT on improving family functioning and reducing adolescents' substance use and related behavioral problems in controlled and community-based settings.903
RESOURCE ALERT: MDFT.
Community reinforcement and family training (CRAFT) is an evidence-based, family-focused, positive reinforcement approach that provides family members with strategies for encouraging the family member who has problematic substance use to change his or her behaviors. It can be used to support both SUD treatment and recovery.904,905,906 CRAFT uses community reinforcement, the goal of which is to develop community supports to create positive incentives for people who have SUDs to remain in treatment or recovery.907
The CRAFT intervention consists of eight components908:
Motivational strategies. Establishing positive expectations by describing CRAFT in a way that increases the motivation of the concerned significant other (CSO)
Functional analyses of the client's substance-using behavior. Outlining the triggers and consequences of the client's use and using the tool to plan the CSO's intervention strategies
Domestic violence precautions. Assessing the potential for violence on the part of the client
Communication training. Teaching and practicing positive communication skills to improve communication with the client
Positive reinforcement training. Teaching the CSO how to use small rewards to reinforce recovery
Discouragement of using behavior/negative consequences. Teaching the CSO how to allow negative consequences in using and teaching a standard problem-solving strategy
CSO self-reinforcement training/quality of life. Exploring the CSO's dissatisfaction in life and evolving goals and a plan to increase the CSO's own quality of life
Suggesting treatment or recovery for the client. Planning the best time for suggesting treatment or recovery and giving the CSO information about the options available
Although CRAFT is traditionally a structured approach, it can be adapted to a less structured module, focusing on psychoeducation for families and people in recovery909:
Refraining from blaming and shaming
Expressing concern about the problematic substance use behavior and its effects on the family
Expressing hope that the family member will get help
Offering affirmations for positive change in problematic substance use behaviors
RESOURCE ALERT: CRAFT-SP.
Mutual-support groups for families are also an effective and evidence-based approach for supporting families of people who have problematic substance use. These support groups encourage family members to reflect on challenges and solutions through group participation. They can support the development of family members' coping skills by building strong connections with other families who may be facing similar challenges. These approaches can also support a range of populations and are available in communities around the country.
Strategies for incorporating family recovery support group participation in family counseling include910:
Exploring family members' understanding of and prior participation in recovery support or mutual-help groups.
Discussing and dispelling misconceptions about family recovery support groups.
Exploring the challenges and benefits of participation in family recovery support groups.
Actively linking family members to community-based recovery support groups.
Offering space in family counseling sessions to explore family concerns about recovery support group participation.
Counselors will need to be able to provide information to families about support groups. Some family support groups are listed below.
Adult Children of Alcoholics® & Dysfunctional Families is a 12-Step group for adults who have a parent with an AUD (https:
Co-Anon Family Groups® offer support for family members of people with cocaine use disorder (https://co-anon
Al-Anon Family Groups support families and friends of those with an AUD (https://al-anon
Families Anonymous is a 12-Step group for the family and friends of those individuals who have problematic substance use or related behavioral issues (https://www
Nar-Anon is a 12-Step group for family members of people who have SUDs, but not AUD (https://www
SMART Recovery® Family & Friends is a support group for families of individuals who have substance use–related problems (https://www
Couples-based approaches for problematic substance use work to reduce substance use and support recovery, while also working to enhance relationship quality within intimate partnerships. Clients are taught strategies to maintain recovery and engage in relationship-building practices with their partners to improve relationship quality and functioning.911
Studies indicate a direct relationship between problematic substance use and marital conflict, related to the often-unpredictable behavior associated with substance use as well as instability, conflict, and stress.912 Couples counseling can be a valuable tool to harness partner support to positively reinforce the person in recovery and change relationship dynamics to make them more conducive to ongoing recovery.913
Approaches to support couples who are dealing with problematic substance use draw on techniques from behavioral couples therapy (BCT) to reduce substance use and strengthen relationships. Within these approaches, clients are given behavioral techniques aimed at reducing substance use, maintaining recovery goals, and engaging in relationship-building practices with their partners to improve relationship quality.914
RESOURCE ALERT: CONNECTING FAMILIES WITH MUTUAL SUPPORT GROUPS.
BCT is a structured counseling approach for people with problematic substance use and their intimate partners. Its focus is on partner support to address or reduce substance use, and it promotes a family environment conducive to ongoing recovery. BCT aims to lessen relationship distress and build more cohesive relationships to reduce the risk of recurrence. The goals of BCT are to support recovery from problematic substance use and improve relationship functioning. BCT is offered in 12 to 20 weekly sessions and includes substance-focused interventions to build support for abstinence and relationship-focused interventions to enhance caring behaviors, shared activities, and communication.915
Through this therapy, the counselor works with the couple to develop a recovery contract that outlines specific future work as well as activities and home exercises to support the contract. Much of the intervention takes place outside of work with the counselor. However, each session includes three specific tasks916:
Reviewing any substance use, relationship concerns, and home exercises
Introducing new material
Assigning home practice
BCT has a convincing evidence base for its effectiveness in both treating SUDs and supporting recovery. BCT is associated with better substance use- and relationship-related outcomes than the use of individual therapy, and may be effective in supporting SUD treatment in lesbian and gay couples.917
RESOURCE ALERT: UNDERSTANDING BCT.
CBT is one of the most common, evidence-based treatments for individuals who have problematic substance use918,919 and is included in multiple addiction-based practice guidelines.920 Research shows that CBT is not only efficacious, but effective.
The cognitive–behavioral model is based on the assumption that individuals are continually interpreting and responding to information perceived from their internal and external environments. Individuals develop representations of their environments in the form of thoughts, attitudes, and beliefs. These representations can affect how individuals feel and behave. The relationship between thoughts, feelings, and behaviors in response to clients' appraisals of their environments is known as the cognitive triangle and is depicted in Exhibit 3.8.
EXHIBIT 3.8. The Cognitive Triangle.
When representations of the environment are inaccurate or unhelpful, they can be examined, challenged, and modified. As clients learn to reappraise situations and develop helpful thinking patterns, they may notice that they feel better and make healthier behavior choices.
CBT for substance use–related problems is based on social learning theory, such that alcohol and drug use occurs in the context of learned behavior (i.e., modeling, classical and operant conditioning).921 As patterns of alcohol and drug use emerge, individuals have more difficulties coping with distressing thoughts and emotions.
Multiple variations of problematic substance use interventions use components of the cognitive–behavioral framework, including the relapse prevention model, guided self-change, BCT, and the community reinforcement approach.922 More recently, CBT is being augmented by third-wave approaches, such as behavioral activation and mindfulness and acceptance-based interventions. Although this section focuses on describing CBT components that counselors can use to support individuals in recovery, some of these specific interventions are discussed elsewhere in this chapter.
In recovery, the cognitive–behavioral model focuses on helping clients replace thinking patterns and risk behaviors that undermine recovery efforts with thinking and behavioral patterns that support and sustain recovery. Cognitive changes that support recovery from problematic substance use vary according to the substance used, but generally emphasize challenging or deconstructing positive beliefs about substance use or engaging in other risk behaviors and negative beliefs about identity that decrease self-efficacy. Exhibit 3.9 demonstrates how components of CBT and theoretical mechanisms of change contribute to improvements in substance use–related problems among individuals in recovery.
EXHIBIT 3.9. Using Traditional CBT To Support Recovery.
Prior to engaging clients in CBT, counselors should complete a comprehensive biopsychosocial assessment. The goal of a biopsychosocial assessment is to identify factors within three primary domains (i.e., genetic/biological, psychological, and social) that contribute to the client's overall physical and mental health, including the development of problematic substance use and CODs. This type of assessment helps counselors determine the extent of difficulties in multiple life domains (e.g., medical, legal, vocational, housing, social networks) and clarify how problematic substance use and CODs interact with the problems in each domain. A biopsychosocial assessment is used to support a cognitive–behavioral case conceptualization and to select the best-matched, evidence-based model for counseling. Throughout the course of working with clients in recovery, counselors should continue to use a biopsychosocial assessment to evaluate progress and make necessary changes to their treatment plan. (The diagram in Exhibit 3.10 highlights the components of the biopsychosocial model.)
EXHIBIT 3.10. The Biopsychosocial Model.
The American Society of Addiction Medicine offers a free, paper-based assessment interview guide that incorporates aspects of a biopsychosocial assessment (https://www.asam.org/asam-criteria/criteria-intake-assessment-form).923
In addition to a biopsychosocial assessment, counselors should conduct a functional analysis of situations and warning signs that place clients at high risk for recurrence of problematic substance use. Functional analysis is a crucial step in CBT that evaluates the reasons behind why clients engage in specific behaviors and what factors contribute to maintaining those behaviors. Clients can use this information to engage in problem-solving in a way that reduces the probability of problematic substance use.
For example, unhelpful thinking patterns can contribute to the development and maintenance of problematic substance use. In the context of CBT, identifying and challenging unhelpful thinking patterns can lead to changes in behavior. A functional analysis of behavior can be particularly helpful for clients who are not aware of their substance use–related behaviors.
THE ICEBERG ANALOGY.
To conduct a functional analysis, counselors should ask questions that assess the following926:
Antecedent (what happened before the behavior)
How often does the behavior occur?
What is going on in the client's environment when the behavior occurs?
Who is involved in the behavior besides the client?
Did the client have thoughts about what happened?
Behavior
What did the client do in response to the antecedent?
Was there a thought that occurred in response to the antecedent that contributed to the behavior?
Consequence
What happened because of the client's behavior?
How does the client feel about the consequence?
After completing the functional analysis, counselors and the client can work together to determine what contributed to the behavior and how that factor can be modified.
RESOURCE ALERT: USING A FUNCTIONAL ANALYSIS IN CBT.
One of the most important skills clients can learn is how to cope with the situational cues that trigger physical cravings to use substances and impulses to engage in risk behaviors. Exhibit 3.11 outlines a structured coping skills training exercise on coping with craving that counselors can adapt for clients who experience strong physical cravings or situational cues to engage in risk behaviors. It applies several key strategies of a CBT approach to prevent recurrence of problematic substance use, including psychoeducation, assessment of risk for recurrence with a focus on craving, identification of craving cues and situational triggers, coping skills training, and a between-sessions practice exercise.
EXHIBIT 3.11. Coping With Craving: A Structured Coping Skills Training Exercise.
Cognitive distortions are the ways the mind works against the client's commitment to recovery and intention to refrain from problematic substance use. These distortions are early warning signs for a recurrence. They include:
All-or-nothing thinking.
Overgeneralization.
Mental filtering or dwelling on the negative.
Discounting the positive.
Jumping to conclusions.
Magnification or minimization.
Emotional reasoning.
“Should” statements.
Labeling or identifying with mistakes.
Personalized blaming.
Cognitive distortions bring clients closer to situations where temptation is strong and difficult to resist. Help clients lessen the power of cognitive distortions by teaching them how to slow down their thinking process and identify steps leading up to a decision. Counselors can also invite them to evaluate whether their choices are consistent with their recovery goals and explore alternative choices.
DEALING WITH THE ABSTINENCE VIOLATION EFFECT.
A current or relatively recent conflict associated with a relationship with a spouse, friend, family member, employer, or other person can result in frustration, hostility, or aggression. Other feelings related to interpersonal interactions that can trigger a recurrence of problematic substance use include guilt, shame, anxiety, fear, tension, worry, concern, apprehension, and evaluation stress (i.e., fear of being judged or criticized by another person or group).929 Further, interpersonal relationships that involve the use of alcohol or drugs can cause stress for individuals in recovery, as they continue to learn and practice alcohol and drug refusal skills.
Counselors can use CBT techniques with clients to improve interpersonal skills and encourage the development of healthy social relationships. Clients can engage in role-playing exercises to rehearse various interpersonal interactions that have occurred or might occur in day-to-day routines and address thoughts that contribute to emotions and behaviors. Exhibit 3.12 features a sample conversation between a counselor and a client who is focused on coping skills training related to alcohol and drug refusal.
EXHIBIT 3.12. Using CBT To Build Interpersonal Skills—Alcohol and Drug Refusal.
Although CBT is well supported by research studies, the effectiveness of CBT depends on the counselor's ability to deliver the intervention with fidelity. In the absence of fidelity, clients may not receive the full benefits of CBT. To ensure that CBT is being delivered with fidelity, counselors can seek supervision or consultation from colleagues who are trained in CBT, including occasional direct observation. Using treatment manuals can also be prudent, as it helps ensure that counselors provide services to clients that research has shown to be effective. However, they will need to stay within the scope of their license, offering therapies for diagnoses that they are licensed to provide.
To ensure that clients are committed to the work that is necessary to engage in CBT, clients need education about how CBT can support recovery and what they can expect when they engage in CBT.
Clients who are in recovery from problematic substance use may not understand how CBT can help them achieve their recovery goals. Sharing the rationale for using CBT can empower clients to commit to using CBT concepts and skills as part of their recovery journey. Counselors should provide clients with the following key points930:
Short-term, brief approach. CBT is typically time limited. Ultimately, with consistent practice, clients will master skills and be able to apply them in their day-to-day lives without needing their counselor's guidance.
Strong evidence base supporting its use. Many well-designed studies show that CBT is an effective approach for individuals who have substance use–related problems.931,932
Structured and goal oriented. The core components of CBT, when delivered with fidelity, can help clients meet their recovery goals by modifying thoughts, feelings, and behaviors that contribute to core beliefs underlying their problematic substance use.
Flexible, individualized approach. CBT can be used with many recovery populations. Clients can access CBT in a variety of settings and formats.
Compatible with other therapies. CBT can be used effectively in combination with other evidence-based approaches, including pharmacotherapy, MI/MET, CM, and mindfulness and acceptance-based approaches.
Generalizable to broad areas of recovery. Clients can apply CBT skills to a variety of recovery situations to promote recovery growth and manage recurrence.
Counselors should make sure that clients understand what occurs during CBT sessions. This can help clients feel more comfortable about what they can expect when they meet with their counselor. Counselors should talk to clients about the structure of CBT sessions, including the following:
Checking in and reviewing the previous sessions. The beginning of each session will likely start with a brief check-in so that the counselor and their client can review how they have been doing and address any new questions or concerns that the client may have from the previous session. Counselors should review topics and skills discussed at the previous session and elicit feedback from the client about any independent practice that occurred in between sessions.
Setting the agenda by identifying session goals. Based on feedback and review from the check-in and review of previous sessions, counselors should collaborate with their client to set the agenda for the session by identifying goals that support the client's progress. The agenda can include discussion of new or existing concepts and skills, in-session practice, and plans for independent practice.
Learning new skills and practicing existing skills. After the agenda is set, counselors can work with their client to learn new CBT skills and practice existing CBT skills. Depending on the goals for the session, the client may reflect on old experiences or use recent experiences to apply and practice skills.
Engaging in ongoing evaluation of progress. Together, counselors can work with their client to identify barriers to achieving stated goals and overcoming barriers by finding alternative strategies. This may occur when the client is learning and practicing CBT skills, or it may be discussed at the end of the session when the counselor summarizes what happened in the session. Clients may complete questionnaires at regular intervals so that counselors can assess progress and make adjustments, as needed.
Setting expectations for independent practice and real-life application. Counselors should explain to their clients that practicing CBT skills outside of session is essential to mastery and real-life application. The more that clients use the skills they have learned, the easier it will become to apply those skills to situations that arise in their daily routines.
Research has shown that CBT is an effective intervention for people who have substance use–related issues, especially when combined with medication. For example, a systematic review and meta-analysis that examined the use of combined CBT and medication for adults with AUD and other SUDs found greater improvements in clinical outcomes among individuals who received a combination of CBT and medication, compared to individuals who received a combination of usual care and medication.933 However, unique benefits of combined CBT and medication were not observed when compared to medication combined with other evidence-based interventions (e.g., CM, MET, 12-Step facilitation, interpersonal therapy) or as an add-on to usual care combined with medication.934
Another meta-analysis showed that CBT alone was more effective at improving clinical outcomes associated with problematic substance use (e.g., alcohol or other drug use frequency and quantity) than no treatment, minimal treatment, or a nonspecific therapy.935
CBT has also been effective for problematic substance use when it is combined with other evidence-based treatments, such as MI and CM.936 These combination therapies have been used to strengthen treatment engagement and adherence, and evidence shows that using motivational enhancement strategies at the beginning of CBT can help increase motivation and improve treatment retention.937 Multiple studies evaluating a combination of CBT and CM have found that the combination of the two evidence-based approaches may result in greater abstinence after treatment.938
DIGITAL SUPPORTS FOR CBT.
CM is one of the most effective behavioral interventions for problematic substance use. CM provides incentives to change behavior. Unlike MI techniques, which are based on an individual's intrinsic motivation (i.e., motivation that arises from within), CM strategies are based on extrinsic motivation (i.e., motivation derived from sources outside the individual).
CM is most often used with individuals in recovery from stimulants, such as cocaine, methamphetamine, and prescription stimulants. However, it can be used with individuals in recovery from other substances as well.940 For people in recovery, CM can be used to identify healthy alternatives to problematic substance use and grow recovery strengths.
CM approaches aim to sustain client engagement in treatment and promote recovery by providing positive incentives to clients who engage in and sustain behavioral changes, such as abstinence from alcohol or drugs; medication adherence; attendance at continuing care groups, mutual-help groups, or 12-Step recovery meetings; or maintenance of a job or stable housing arrangement.
More information about CM can be found in SAMHSA's TIP 33, Treatment for Stimulant Use Disorders (https://store.samhsa.gov/product/treatment-for-stimulant-use-disorders/PEP21-02-01-004).
The goal of CM is to increase desired behaviors by providing immediate reinforcing consequences when a specific behavior occurs and withholding reinforcing consequences when that behavior does not occur. Reinforcing consequences are provided in the form of tangible incentives. These incentives are often administered in two forms941:
Voucher-based reinforcement: This type of incentive uses vouchers that have monetary value. The vouchers can be exchanged for items, such as food, movie passes, or other goods and services that align with a drug-free lifestyle. The monetary value of vouchers typically increases over time as the client successfully completes recovery tasks. Voucher-based reinforcement has been used with individuals with OUD or stimulant use disorders to reinforce providing drug-free urine samples.
Prize incentives: Like voucher-based reinforcement, prize incentives offer clients an opportunity to win cash prizes in varying amounts. This type of CM traditionally uses a “fishbowl model,” where clients draw a piece of paper out of a large bowl. On some pieces of paper are reaffirming phrases, such as “well done.” On others, there will be small cash prizes, and on one piece of paper will be the “jumbo” prize. Clients can increase their number of chances to win each time they achieve a specific behavior. However, if a recovery task is not completed, the chance to win resets to one.
Incentives may be delivered immediately or on a delayed schedule. For example, clients may receive incentives immediately following their attendance at a recovery meeting or they may receive the opportunity to “bank” their attendances at meetings to earn a larger incentive in the future. Some research indicates that clients who have problematic substance use may respond better when immediate and delayed incentives are used together, offering clients the chance to receive an immediate incentive and the chance to win larger incentives later.942 Regardless of the model chosen, the immediacy of incentives is important. This means that if abstinence is the intended behavior, the point-of-care urine test must be sensitive, rapid, and easy to administer. The incentive must immediately follow reading of the rapid point-of-care test. Sending a specimen to a lab for analysis creates a delay between the test being performed and the incentive. This delay between the test and incentive is not consistent with CM approach and will not help the client.
RESOURCE ALERT: IMPLEMENTING CM.
Counselors should incorporate CM incentives into treatment and continuing care activities. Several CM approaches aim to sustain client engagement in treatment and promote recovery by providing positive incentives to clients who engage in and sustain behavioral changes, such as:
Abstinence from or reductions in alcohol or drug use.
Medication adherence.
Attendance at continuing care groups, mutual-help groups, or 12-Step recovery meetings.
Reductions in infectious disease risk behaviors.
Maintenance of a job or stable housing arrangement.
Counselors should work with clients to identify goals for behavior change, including quantifying objective measures of specific behaviors. Once goals are agreed upon, the counselor and their client can create and employ a written CM agreement that outlines the following:
Duration
Mechanisms for verifying specific behaviors and task completion
Contingencies and any changes to those contingencies over time
Some positive reinforcements include social reinforcement in the form of congratulatory letters from the counselor or family members for attending continuing care groups and certificates or medallions for various levels of completing a residential or continuing care program. Financial incentives can include cash for clients submitting substance-free urine samples and chances to win prizes after completing recovery activities, including attendance at counseling sessions, recovery group participation, and maintenance of activities that promote overall well-being.
Using CM with individuals in recovery from problematic substance use is well supported by studies. CM has shown to be effective in improving outcomes for a variety of SUDs, including stimulant,943,944 opioid,945 cannabis,946 and nicotine use disorders.947
A systematic review of 27 studies evaluating CM for methamphetamine use found that the majority (26 of the 27) reported reduced methamphetamine use among participants.948 Another systematic review of 44 studies examining psychosocial interventions for methamphetamine use found that CM showed the strongest support for improved outcomes (e.g., reduced drug use, better treatment retention, fewer psychiatric symptoms, better quality of life).949
A systematic review and meta-analysis of 74 RCTs looking at individuals taking medication for OUD found that the effectiveness of CM was associated with abstinence from substance use (including comorbid substance use, such as stimulant use and cigarette smoking) as well as improved treatment attendance and medication adherence.950
CM has also been found to be effective when it is combined with other evidence-based interventions. A review of 50 RCTs examining 12 different psychosocial interventions for individuals with cocaine or amphetamine use found that CM plus community reinforcement was the only approach that showed higher rates of abstinence at the end of treatment as well as at short- and long-term follow up.951
CM remains effective over time, despite concerns about whether improvements in outcomes would remain after taking away reinforcers. A meta-analysis of 23 RCTs testing the effectiveness of CM after 1 year of treatment compared to other forms of psychosocial treatment for problematic substance use found that individuals who received CM interventions were 1.22 times more likely to be abstinent than individuals who did not receive CM interventions.952 Additionally, the long-term benefit of CM in reducing problematic substance use was greater than the long-term benefits seen with other active, evidence-based treatments and community-based intensive outpatient treatments.953
Although CM is an evidence-based treatment for problematic substance use, counselors may face challenges in its implementation. Some commonly cited challenges include delays in offering incentives related to time to conduct drug screening, scheduling challenges with clients, and ensuring continued funding for incentives.954 Counselors should be aware of such challenges when implementing CM to determine potential solutions prior to delivering this treatment to clients. For example, there are new technologies available that can help deliver CM easier.955
Digital CM, which uses virtual, Internet-, and smartphone-based treatment delivery, incorporates remote monitoring of drug status using biochemical sensing and remote delivery of incentives.956 The use of digital CM may reduce equity issues in access to care and the number of staff needed to conduct individual monitoring.957 Systematic reviews of digital CM, which uses remote therapeutic monitoring, found that this intervention is both clinically meaningful and consistent with the results from studies of in-person delivery of CM.958,959,960 The studies also indicated that clients were willing to accept remote methods to monitor substance use and incentivize abstinence.961,962
DIGITAL SUPPORTS FOR CM.
Helping clients develop proactive strategies and improve their emotional regulation skills is an important component of recovery. Research indicates that stress—and how an individual responds to stressors—can be significant factors both in developing problematic substance use and in recurrence.965,966 Increasingly, researchers have identified certain aspects of the brain's response to stress that can predispose a person to substance use967 and to the effects that continued drug use can have on executive function, decision making, and inhibition control,968 which are factors that can lead to recurrence.
Mindfulness falls into the category of coping skill strategies. Although mindfulness has its origins in Eastern meditation and spiritual traditions,969 Western treatment methods have widely adapted it for recovery from problematic substance use and mental issues, such as anxiety, depression, eating disorders, PTSD, and borderline personality disorder. In addition, mindfulness-based interventions are culturally sensitive and have shown promise with racial and ethnic minorities and women.970,971
Various approaches for treating problematic substance use and preventing recurrence feature mindfulness practices, including mindfulness-based relapse prevention (MBRP), mindfulness-based stress reduction (MBSR), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT). (The next section, “Models of Mindfulness-Based Intervention,” discusses mindfulness-based approaches specific to substance use issues.) Different models may be appropriate for different audiences and/or behaviors, but they each work from a fundamental framework of what constitutes mindfulness.
Mindfulness is a meditative coping strategy that can increase a person's ability to manage stress and enhance emotional regulation. Mindfulness can also decrease anxiety, help people manage cravings and urges, decrease the likelihood of recurrence of depression and other mental issues, and lower the desire to use substances in response to negative emotions and cognitions.972,973
Essentially, mindfulness is the intentional act of paying attention to an experience as it happens, whether that experience is pleasurable or painful, without judging the experience as good or bad. Qualities of mindfulness include974,975:
Feeling alert but relaxed.
Nonjudgmental awareness of the present moment.
Kindness and compassion.
Curiosity and acceptance about distressing or uncomfortable thoughts or sensations.
In practice, mindfulness is nonjudgmental, present-moment awareness of thoughts, mental images, feelings, physical sensations, urges, and impulses. Mindfulness can be learned in formal meditation or practiced through greater awareness of everyday activities, such as eating, walking, washing dishes, or folding clothes. Developing the traits of mindfulness can enhance a person's ability to observe (or witness) thoughts, feelings, and sensations without acting on them impulsively.976,977,978,979
MBSR was the first formalized mindfulness model introduced in Western medicine in the early 1980s.980,981,982 MBSR was designed to treat chronic pain and improve body image issues and certain mental problems. The success of MBSR led to mindfulness-based approaches for a variety of health and life issues, from mental disorders to acceptance and commitment to childbirth and parenting. Recent years have seen a rise in mindfulness-based approaches to recovery from problematic substance use:
Mindfulness-Based Addiction Treatment, adapted from an earlier protocol that addressed depression, uses an eight-session format to help clients first learn mindfulness techniques and then apply those techniques to various types of substance use recovery, including smoking cessation.
MBRP is a manualized approach to preventing recurrence of problematic substance use (more information on MBRP is provided on the following pages).
Mindfulness-Oriented Recovery Enhancement is a 10-session protocol based on the core elements of mindfulness of triggers for substance use, reappraisal of stressful events from negative to more positive experiences, and savoring the constructive, growth-inducing aspects of an event.983,984
Moment-by-Moment in Women's Recovery is designed specifically for racially and ethnically diverse women of low income actively enrolled in residential SUD treatment.985,986
Mindfulness Training for Smokers is an eight-session protocol adapted from MBSR and MBRP but tailored specifically for tobacco use cessation.
One of the most extensively studied and manualized mindfulness approaches for problematic substance use is MBRP,987 which incorporates mindfulness practices into preventing the recurrence of problematic substance use. Adaptations of MBRP also incorporate material on such topics as smoking cessation, CM, and ACT.988,989 MBRP consists of training in mindfulness meditation, yogic breathing, physical exercises, other challenges specifically designed for people who have SUDs, and skill-building exercises that can help to prevent the recurrence of problematic substance use.
MBRP shows decreases in alcohol, marijuana, crack cocaine, and cigarette use; decreases in craving; increases in acceptance; reduced craving associated with depressive symptoms; and longer term benefits than nonmindfulness-based approaches.990 This TIP references some of the components of MBRP as well as other mindfulness sources in the following discussion of implementing mindfulness-based strategies.
Mindfulness may be particularly useful in helping clients resist the temptation to use substances or re-engage in risk behaviors. Feelings of craving can be among the most difficult experiences for people who have SUDs to tolerate and can trigger recurrence to problematic substance use. Mindfulness heightens awareness and acceptance of physical craving without analyzing or judging it. This attention to (or witnessing) of craving can reduce discomfort and enhance people's ability to cope with and manage the discomfort of craving without returning to substance use to quiet or escape from it.
Exhibit 3.13 displays the mechanisms of mindfulness training, as hypothesized by researchers,991 that can interrupt the process of recurrence and create awareness of a risk situation. Specifically, researchers suggest that mindfulness training may prevent an occurrence of a high-risk situation, reduce phasic (immediate) risk, and prevent substance use by increasing awareness, kindness, and self-compassion.992
EXHIBIT 3.13. Mechanisms of Mindfulness in Interrupting the Process of Recurrence to Problematic Substance Use.
In addition to its therapeutic qualities, mindfulness techniques are cost effective, as they can be implemented into a variety of programs and can be done in group format or as a self-help intervention.993,994 If counselors believe that mindfulness may be useful for some of their clients, the following sections describe some useful strategies to help them incorporate mindfulness practices into recovery promotion.
Clients should be offered information about the relationship of stress to recurrence of problematic substance use, the benefits of mindfulness, and the ways that mindfulness could be a useful tool against the recurrence of problematic substance use (Exhibit 3.14).
EXHIBIT 3.14. Introducing Clients to the Benefits of Mindfulness in Preventing Recurrence of Problematic Substance Use,,.
If counselors want to incorporate mindfulness practices into recovery promotion, they should receive training in the fundamentals of mindfulness, incorporate it formally or informally in their own lives, and practice any mindfulness exercises themselves before encouraging clients to try them.998 Practicing mindfulness enhances empathy and the ability to be present, stay grounded, and maintain a focus in sessions. Equally important is the idea that counselors should practice what they teach so that they can anticipate the possible reactions, responses, benefits, and challenges that clients may experience. The Resource Alert titled “Mindfulness and Recovery From Problematic Substance Use” at the end of this section contains learning opportunities related to mindfulness-based practices.
When designing mindfulness exercises for clients, counselors should consider the same two factors that they would keep in mind with any other treatment activity they recommend to their client: The exercises must fit the clients' needs and must be something clients will actually practice. This requires counselors to observe and track their clients' reactions to each exercise and to determine which exercises they are committed to practicing.999 Exhibit 3.15 lists basic exercises, along with their objectives, as outlined in MBRP and other mindfulness approaches.
EXHIBIT 3.15. Mindfulness Exercises1000.
Counselors can help clients identify one or two simple mindfulness practices they can use daily and bring into situations where the potential for recurrence of problematic substance use is high, to step out of automatic reactivity and cope with intense emotions. Here is a simple mindfulness practice called SOBER1002:
Stop or slow down.
Observe what is happening right now.
Breath focus—center your attention on your breath.
Expand awareness to include a sense of your whole body.
Respond to the situation with full awareness and ask yourself what is needed.
Counselors should teach and practice mindfulness exercises in session before encouraging clients to practice them in everyday life. Counselors may want to begin with brief exercises to allow the client to become comfortable and understand the mindfulness process. Individuals taking part in mindfulness exercises can sometimes feel awkward or “silly” at first, before getting more comfortable.1003 Then counselors can move to longer or more complex types of meditations.
In each case, before introducing the mindfulness practice, counselors should elicit their client's interest in trying it, and ask them for their ideas about ways to adapt the exercise to match their needs, abilities, and preferences. Counselors should make sure they leave plenty of time at the end of the exercise to discuss the experience, explore client reactions, and invite them to evaluate the practice. Here are some questions that may help engage clients in this discussion:
What were their general reactions to this exercise?
What was helpful and not helpful about this mindfulness practice?
Are there ways they would change this practice that would make it more helpful to them?
How confident are they that they will practice this exercise at home?
What would help make them more likely to practice this exercise at home?
Counselors should follow up with clients at their next meeting. They should also continue to elicit their reactions to the mindfulness practice and evaluate its effectiveness.
Research shows that mindfulness-based interventions can reduce craving and the frequency and severity of problematic substance use, and improve other symptoms related to problematic use, including negative mood, emotional regulation, stress, anxiety, and symptoms of depression.1004,1005,1006,1007 MBRP specifically has demonstrated decreases in alcohol, marijuana, crack cocaine, and cigarette use; decreases in craving; increases in acceptance; reduced craving associated with depressive symptoms; and longer term benefits than nonmindfulness-based approaches.1008
In addition to their therapeutic qualities, mindfulness techniques have the added advantage of being cost effective, as they can be implemented in a variety of programs and can be done in group format or as a self-help intervention.1009,1010 In addition, mindfulness-based interventions are culturally sensitive and have shown promise with racial and ethnic minorities and women.1011,1012
RESOURCE ALERT: MINDFULNESS AND RECOVERY FROM PROBLEMATIC SUBSTANCE USE.
ACT, which includes components of mindfulness, teaches people how to accept and live with, rather than avoid, difficult thoughts, emotions, and sensations.1013 When used to address problematic substance use, ACT can help people in recovery learn to live with the discomfort of cravings,1014 rather than attempting to eliminate or avoid it. ACT also can help people in recovery learn to live with distressing feelings, memories, and other internal experiences that can trigger cravings.1015,1016
The goal of ACT is to build psychological flexibility. Psychological flexibility is the ability to recognize and understand our thoughts and emotions in any given situation and then continue or change our behavior depending on what we value (or see as a positive outcome in the situation).1017,1018 It can be reflected in how a person1019:
Adapts to changing situational demands.
Reorganizes mental resources.
Shifts perspective.
Balances competing desires, needs, and life domains.
When someone is psychologically inflexible, their patterns of behavior are overly controlled by their feelings and internal experiences, or they may take actions to avoid those feelings and experiences.1020 Though this experiential avoidance may work in the short term, its long-term effect is to increase distress.1021 ACT attempts to break this cycle by helping clients recognize and accept uncomfortable feelings and commit to actions that support their values.
To develop psychological flexibility, clients learn six interrelated core processes. Each process builds on the one before it, helping clients navigate triggering situations. Exhibit 3.16 outlines these six processes.
EXHIBIT 3.16. Core Processes of ACT1022.
The first step is recognizing an uncomfortable situation is occurring, identifying the thoughts and feelings that accompany it, and consciously choosing to remain present with them. This is followed by learning to see oneself objectively and separate from those feelings and thoughts (e.g., “I'm hopeless” versus “I'm successful, but I feel hopeless today”), identifying the values and goals one has for their life, and committing to action that aligns with those values and goals. The final steps involve willingly accepting (again) any uncomfortable feelings that come from taking action and recognizing them for what they are.
A key part of psychological flexibility is developing the ability to notice the difference between how individuals physically experience a given situation (i.e., through the senses of sight, sound, taste, touch, and smell) and how they mentally experience it (e.g., what people perceive as meaning, people's goals, whether the person feels “good” or “bad” about the situation). In ACT theory, this allows individuals to notice differences between feelings and actions that move them toward the outcome they value, rather than away from unwanted experiences or outcomes.1023 Psychological flexibility is not defined as escaping or avoiding difficult or painful experiences, but rather as being able to be aware of them and work through them so that they no longer control or determine behavior.1024
The ACT Matrix is a visual tool designed to help individuals better understand the toward/away concept and enhance their psychological flexibility. The diagram in Exhibit 3.17 consists of a vertical line intersecting with a horizontal line, creating four quadrants into which an individual can map their physical (i.e., sensory) experiences and their emotional/mental experiences. Sensory experiences are mapped above the horizontal line, and mental experiences are mapped below it. These experiences are mapped to the left or right of the vertical line, depending on whether they move the individual toward a desired outcome or value (on the right-hand side) or away from a goal or an unwanted experience (on the left-hand side).1025
EXHIBIT 3.17. The ACT Matrix1026.
For people in recovery, using the ACT Matrix will not simply take the form of thinking about what does or doesn't motivate them to use substances. It requires that they more fully examine their lives and values to determine who or what is important to them (e.g., relationships, family, work, health, personal growth). This process can help individuals begin to identify the thoughts, feelings, and behaviors that move them toward valued individuals and goals, and which thoughts, feelings, and behaviors act as barriers.1027 (“Resource Alert: Learning More About ACT” contains a link to a video of an ACT trainer and facilitator going through the Matrix exercise, specific to recovery.)
As clients use the ACT Matrix to evaluate their experiences, they may improve their awareness about their internal experiences (i.e., increased psychological flexibility), allowing them to more readily choose actions that move them toward their values or desired outcomes (e.g., to stop or reduce substance use, improve personal health, improve relationships).1028
ACT has proven beneficial in terms of individual wellness and outcomes related to SUD treatment (including from a cost and administration perspective). Research has shown that ACT can result in1029,1030:
Relieved anxiety and guilt.
The ability to experience negative thoughts and feelings without fixating on them or judging them.
Increased psychological flexibility.
Improvements in mental health and medical and behavioral health outcomes.
Improved achievement of long-term goals.
ACT has been shown to be as effective as comparable treatment approaches (e.g., CBT, counseling, 12-Step program). Results also indicate that abstinence is better maintained at follow-up for individuals who participate in ACT, compared to other approaches.1031,1032 From a cost and administration perspective, ACT offers advantages in that it can be used with a wide variety of audiences, age groups,1033 and formats (e.g., individual treatment, group treatment, web-based treatment, self-guided treatment1034). Implementing ACT techniques using a mobile app has also shown promise.1035
If counselors are considering implementing the ACT model, they should keep in mind that the fundamental goal of ACT is not simply to reduce problematic substance use, but to improve overall functioning (e.g., living a meaningful, valued life). A reduction in substance use might lead to improved functioning for many clients, but it is not the only focus of ACT, and researchers caution against a reduction in problematic substance use being the only measure of treatment success.1036 The ACT approach is also relatively new, with limited study of the ACT Matrix thus far1037 and limited availability of counselors qualified to coach individuals in the ACT process.1038
RESOURCE ALERT: LEARNING MORE ABOUT ACT.
Peer support services (PSS) enhance counseling by connecting individuals in recovery to nonclinical professionals who have lived experience with problematic substance use, behavior change, and recovery. These nonclinical professionals have varied titles, including peer worker, recovery specialist, peer navigator, peer provider, peer recovery coach, peer support provider, peer specialist, recovery support navigator, recovery support specialist, wellness coach, or health navigator. Peer workers who have received certification or credentialing to provide PSS are known as certified peer specialists.
PSS help individuals with substance use–related problems initiate and sustain recovery, regardless of their chosen recovery pathways. PSS are offered in a variety of settings, including emergency departments, primary care offices, SUD treatment programs, and community-based settings. Although research supporting PSS for problematic substance use is still emerging, studies show that peer services enhance and extend the continuum of care1039 and improve recovery outcomes.1040,1041,1042 When integrated into care, peer services can offer a means to support recovery and to help clients attain other goals.1043 Counselors can learn more about PSS, including how peers can be incorporated into clinical settings in TIP 64, Incorporating Peer Support Into Substance Use Disorder Treatment Services.
Community-based support services, including case management, recovery houses, social networks, and transitional living opportunities, are particularly important for promoting long-term recovery for people with problematic substance use. Peer specialists can help connect clients to community-based support services. Chapter 4 contains an indepth discussion about how community-based support services can promote recovery and overall well-being for clients who have substance use–related problems.
Counselors can facilitate linking clients to peer- and community-based support services by learning about the services available at their agency and in their community, developing collaborative working relationships with case managers and peer specialists, and inviting case managers and peer specialists to participate in transition counseling groups and continuing care planning meetings.
Recovery support (also known as mutual help) group participation improves long-term recovery through increased self-efficacy, social support, and quality of life for individuals in recovery.1044 It is not simply attendance at support group meetings, but active participation (e.g., getting a sponsor, “working” the 12 Steps, becoming a sponsor or peer support volunteer, setting up and cleaning up the meeting space, speaking at meetings) that enhances long-term recovery. Specific social and cognitive changes associated with recovery support group participation include increased self-efficacy and commitment to abstinence, reductions in substance use, meeting other recovery goals, and greater use of positive coping skills. Recovery support groups also provide social support, role models for recovery, and a sense of belonging to a community as a responsible citizen.
Counselors can reinforce their clients' recovery by actively exploring and supporting their participation in these programs, while respecting individual, spiritual, and cultural diversity, needs, norms, and appropriateness. The professional literature demonstrates increased participation in recovery support groups when counselors use active techniques like Twelve-Step Facilitation (TSF) therapy to promote client involvement.
TWELVE-STEP FACILITATION THERAPY.
A NOTE TO CLINICAL SUPERVISORS: COUNSELOR ATTENDANCE AT RECOVERY SUPPORT GROUPS.
In addition to recovery support groups, other types of peer- and community-based recovery supports that counselors should be familiar with and be prepared to help their clients access include:
Drop-in centers.
Social clubs.
Faith-based or church-affiliated recovery programs, such as Celebrate Recovery®.
Wellness recovery action planning groups.
Community-based supports, such as:
Drop-in centers.
Peer services, advocacy, training, and support groups.
Vocational and housing programs.
Recovery high schools and collegiate recovery programs.
Recovery-oriented employment services.
Recovery residences.
Recovery community centers.
Recovery cafes.
Internet-based support services.
Exhibit 3.18 lists strategies for linking clients to peer and community support services.
EXHIBIT 3.18. Strategies for Linking Clients to Peer and Community Support Services.
Psychoeducation is a therapy focused on providing clients with information about aspects of their disease and/or its treatment. The intent of psychoeducation is to provide information to motivate action through education. Psychoeducation is also used to promote client empowerment by managing varied aspects of disease, in this case, problematic substance use. Psychoeducation can be offered as an ongoing therapy or a one-time intervention. Its effectiveness is premised on research indicating that understanding one's condition, in this case, problematic substance use, can be therapeutic.1048 Psychoeducation is an important component of treatment and recovery for people with SUDs who may lack insight into symptoms, the negative consequences of behaviors, and the need for treatment.1049
Psychoeducation must, above all, be understandable to the client. To achieve this, counselors should use plain language and deliver information at a pace that is comfortable for the client. Psychoeducation should also occur as a structured dialog between the counselor and the individual in recovery, rather than a one-way lecture. Ensure that the information delivered is being understood. This can be achieved by asking clients open-ended questions about the topics being covered.1050 Key principles of psychoeducation are outlined in Exhibit 3.19.
EXHIBIT 3.19. Principles of Psychoeducation.
Psychoeducation can also be offered one-on-one with clients or with their family. It can also be delivered in a group or community-based setting. Counselors in SUD treatment programs, for example, often deliver prevention-related information in psychoeducation groups.1051 These groups offer education, peer support, and recovery-oriented therapy. During sessions, the counselor provides information or shows a short video on a topic relevant to the group, then encourages the group to discuss the issue as it relates to them. The counselor may also encourage members to share current problems, challenges, and successes.1052
Psychoeducation can support clients by helping to build their knowledge of recovery literacy, including providing basic information about SUDs as diseases and offering an understanding about what recovery “looks like.” In this section, counselors will learn about information they can provide to people in recovery about problematic substance use through psychoeducation. This includes an overview of the substance use disease model; what clients should know about addiction, including what causes addiction, symptoms, and prevention; and other areas. Information about medications for SUDs and resources is also discussed. Counselors can use these tools and resources to develop a psychoeducational intervention that they can use to educate their clients about problematic substance use, treatment, and recovery.
Evidence suggests that psychoeducation can effectively support treatment and recovery from problematic substance use. Use of psychoeducation has resulted in reduced rehospitalization rates, symptom burden, and the likelihood of recurrence to substance use. It has also supported clients' compliance with treatment.1053 For example, in one study of a 10-session psychoeducation program for people with SUDs, the authors found that the individuals receiving the intervention had a lower recurrence rate and positive outcomes in terms of social functioning, perceived wellness, and ways of coping compared with individuals who did not receive the intervention.1054
An understanding about SUD and its impact on the brain is important for people in recovery to help sustain them on their recovery journey. As one study notes, adding information about the impact of SUD on the brain and neuroscientific evidence to the content of psychoeducation could be helpful in communicating the impact of substance use as well as the beneficial impact of treatments and recovery on brain function, thus enhancing motivation for action.1055
A more recent effort to integrate neuroscientific information into psychoeducation can improve a counselor's ability to answer questions from people in recovery and their families about the impact of problematic substance use on the brain.1056 Counselors should share this information and resources with people in recovery, including providing an overview of brain recovery following abstinence from or a reduction in use of substances.
The brain is made up of many parts with interconnected circuits that work together. These circuits coordinate specific functions. Networks of neurons, brain cells or information messengers in the brain, send signals back and forth to each other and other parts of the brain as well as to the spinal cord and nerves in the rest of the body.1057
To send a message, a neuron releases a neurotransmitter (chemical) into the gap (or synapse) between it and the next cell. The neurotransmitter then crosses the synapse and attaches to receptors on another neuron. This results in changes in the receiving neuron. Other molecules, called transporters, bring neurotransmitters back into the neuron that released them, thereby recycling them and limiting, or shutting off the signal between neurons.1058 Dopamine is the neurotransmitter responsible for signaling pleasure, which occurs when it is released into the nucleus accumbens, the brain's pleasure center. There are natural rewards that lead to a release of dopamine, (e.g., food and sex). Substances can cause a greater release of dopamine than natural rewards, which can reinforce problematic use.
Substances interfere with the way neurons send, receive, and process signals via neurotransmitters. Substances, such as marijuana and heroin, can activate neurons because their chemical structure is like that of a natural neurotransmitter in the body. This allows the drugs to attach to and activate the neurons.1059
Other substances, such as alcohol, benzodiazepines, amphetamine, and cocaine, cause the neurons to release large amounts of natural neurotransmitters or prevent the normal recycling of these brain chemicals. This disrupts the normal communication between neurons.1060
When some substances are taken, they cause large surges of neurotransmitters to be released, which results in feelings of euphoria and pleasure.1061 Long-term use of substances is associated with alterations in brain function and cognitive performance deficits (e.g., working memory and attention).1062 Individuals with prolonged substance use may require medications to treat the changes in brain chemistry caused by SUD, including medications for OUD.1063 Exhibit 3.20 contains information about how substances affect the brain's pleasure center.
EXHIBIT 3.20. Impact of Substances on the Brain's Pleasure Center.
Over time, the use of substances can become less rewarding, and the craving for the substance becomes more prominent. People who develop an SUD find that the substance does not give them as much pleasure as it used to, and they must take greater amounts of the substance more frequently to have the same effect.1064
Research shows that reduced use or abstinence from substances can allow the brain to recover.1065 Although studies have not supported a specific length of time for the brain to recover, it may take several years. Counselors can communicate this information to help their clients identify that their brain is “in recovery,” which may provide hope and motivation to remain in recovery.1066 Exhibit 3.21 illustrates brain recovery following a period of abstinence.
EXHIBIT 3.21. Brain Recovery After Abstinence From Problematic Substance Use.
Counselors should offer an overview of addiction and key resources to support a person in recovery's understanding of SUDs and problematic substance use. Several topics and resources to help counselors as they develop this information are included below.
The National Institute on Drug Abuse (NIDA) defines addiction as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. Addiction is considered a brain disorder because it changes brain circuits involved in reward, stress, and self-control. These changes may last a long time after a person has stopped taking substances.1067
Like other chronic illnesses, SUDs disrupt the normal, healthy functioning of an organ in the body (brain) and have serious harmful effects. Both chronic illnesses and SUDs are, in many cases, preventable and treatable. If left untreated, SUDs can have lasting effects on a person's health and may even result in death.1068
Addiction is characterized by behaviors that include1069:
Impaired control over substance use.
Compulsive use of substances.
Continued use despite harm.
Cravings for substances.
RESOURCE ALERT: WHAT IS ADDICTION?
Several biological and environmental factors may put people at higher risk of developing an SUD.1071 Biological factors, including genetics, stage of development, gender, or ethnicity, can make a person more likely to develop an SUD. Genes, including the effects environmental factors have on a person's gene expression, called epigenetics, account for between 40 and 60 percent of a person's risk for developing an SUD. Other factors that may put a person at higher risk of an SUD include starting use at an earlier age, having a mental disorder, ready access to substances at home, emotional or physical abuse, and a lack of family or social support.1072 Exhibit 3.22 provides an overview of risk factors for addiction.1073
EXHIBIT 3.22. Risk Factors for Problematic Substance Use.
Evidence also suggests that neurocognitive risk factors, such as abnormalities in brain structures and deficits in cognitive functions (e.g., decision making, learning, memory) may increase a person's vulnerability to addiction. However, counselors should let people in recovery know that having these risk factors will not dictate whether they develop an SUD. Other factors may have even stronger influences on whether a person develops SUDs.1074
SUDs occur when the recurrent use of substances causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.1075 Counselors should help clients understand the basics of SUDs, including symptoms and specific criteria used to diagnose an SUD (the following Research Alert contains information about clinically diagnostic criteria for an SUD). Counselors can discuss which criteria their client may meet and use this information to inform a broader discussion about areas to focus their recovery.
RESOURCE ALERT: CLINICALLY DIAGNOSTIC CRITERIA FOR AN SUD.
Although there are general criteria for diagnosis of an SUD, symptoms can vary by substance and are wide ranging. Thus, it can help clients to learn details about the symptoms specific to their own substance use.
Early use of drugs increases a person's chances of developing an SUD. Preventing early use of substances may help to reduce these risks. Periods of transition and stress may also trigger problematic substance use.1076 Education about substance use, self-care, and family and social support can help to reduce the risk or prevent problematic substance use. Exhibit 3.23 reviews common myths about SUDs and provides facts to dispute these myths.
EXHIBIT 3.23. Myths Versus Truths About SUDs.
RESOURCE ALERT: PREVENTING PROBLEMATIC SUBSTANCE USE.
Harm reduction is an evidence-based, proactive approach designed to reduce the negative impacts of problematic substance use.1078 It's focused on meeting people “where they are” and on their own terms,1079,1080 and includes compassionate and pragmatic strategies that aim to minimize harm related to problematic substance use. The goal of harm reduction is to enhance quality of life without requiring or advising abstinence or reduction of use.1081 Examples of harm reduction strategies include OEND to reduce the risk of opioid overdose, and offering testing strips to check for fentanyl or xylazine in drugs and support safer use. These activities reduce the risk of injury, illness, and death associated with substance use.1082
RESOURCE ALERT: HARM REDUCTION.
Individuals in recovery should understand the importance of using appropriate, culturally sensitive, recovery-oriented language in talking about problematic substance use. Use of language that stigmatizes SUDs or people with problematic substance use can create additional barriers to recovery. For example, stigma can negatively affect people who have problematic substance use by making them less willing to seek treatment.1083 Stigma toward people with SUDs may include inaccurate or unfounded thoughts that they are incapable of managing treatment or at fault for their condition.1084 Addiction is a chronic, treatable medical condition. Recovery is possible. How problematic substance use is discussed helps set the tone that recovery is possible.1085
NIDA offers the following advice using language that avoids stigmatizing SUDs:1086
When talking to or about people who have SUDs, counselors should make sure to use words that aren't stigmatizing.
Counselors should use person-first language, which focuses on the person—not their illness. It focuses on removing words that define a person by their condition or have negative meanings. For example, “person with an SUD” has a neutral tone and separates the person from his or her disorder.
Counselors should let people choose how they are described. If a counselor is not sure what words to use, they should just ask! Counselors should check in with friends or loved ones about how they refer to themselves and how they would like others to refer to them.
Modeling the use of language that avoids stigmatizing problematic substance use and that is trauma informed can better support individuals in recovery.1087
RESOURCE ALERT: RECOVERY-ORIENTED TERMINOLOGY.
Counselors should be aware of periods when clients may be more vulnerable to stopping treatment or beginning substance use again. Studies indicate that early treatment, particularly within the first 30 days, may be a challenging period for clients. For example, one study of 5,707 participants in intensive outpatient treatment for SUD found that 13.8 percent dropped out before 14 days of treatment, and 31.6 percent dropped out before 30 days of treatment.1088 Thus, it is critical for counselors to share information about issues such as how to understand cravings and manage withdrawal, which may contribute to this increased vulnerability. Counselors providing psychoeducation to support people in recovery from problematic substance use should cover topics such as1089:
Understanding cravings. Cravings are strong psychological desires to consume a substance or engage in an activity. They are symptoms of the abnormal brain adaptations that result from addiction. In fact, the brain becomes accustomed to the presence of a substance, which, when no longer there, produces a powerful desire to obtain and consume it.1090 Being able to identify cravings and manage them is essential to recovery from problematic substance use.
Managing withdrawal. Withdrawal includes the physical, cognitive, and affective symptoms that occur after chronic use of a substance is reduced abruptly or stopped among individuals who have developed tolerance to it.1091 The best way to help clients manage withdrawal is to offer education about the symptoms and help them develop realistic attitudes toward recovery. Counselors should also be able to direct them to withdrawal management to support their recovery, remind them that recovery is a process that may include managing long-term symptoms, and explain to clients that it is normal to not feel fully recovered within the first weeks after reducing use or beginning abstinence. Clients should be reassured that, although symptoms may continue indefinitely, they can be managed. Counselors should advise clients about ways to reduce or cope with symptoms, encouraging them to focus on incremental improvements.1092 Some clients may experience postacute withdrawal symptoms (PAWS), also known as postwithdrawal syndrome, prolonged withdrawal syndrome, or protracted withdrawal syndrome. This refers to withdrawal symptoms that can last for months to years after withdrawal from a substance. For clients experiencing PAWS, counselors should provide education about the symptoms to normalize that this can occur in some people in recovery. This can help decrease the potential for a recurrence.1093
Developing coping and stress-management skills. Helping clients to develop coping and stress management skills can further support their recovery process. Counselors should interview clients to gain more information about situations or triggers that may have put them at higher risk for recurrence in the past. Once these are identified, counselors should work with clients to develop specific coping and stress management skills tailored to individual triggers and give them tools to address similar events in the future. Understanding these triggers helps clients use specific strategies for coping with these triggers.1094
Enhancing self-efficacy to deal with high-risk situations. While working towards recovery, individuals with problematic substance use develop skills for negotiating high-risk situations for recurrence. Clients should learn about how to identify cues and triggers, develop action plans for cues and triggers, and manage withdrawal symptoms. Developing this self-efficacy is a key part of this process.1095 Many clients will find it difficult to believe they can maintain behavior change.1096 Because self-efficacy is so critical to the recovery process, counselors should work with clients to ensure they develop these skills. The Confidence Ruler in Exhibit 3.24 offers an example of questions to assess a client's level of confidence in addressing these issues.1097
Developing a balanced lifestyle, which includes healthy leisure and recreational activities. Clients need to learn the value of developing a balanced lifestyle that includes recreational and leisure activities, including how to incorporate them into their recovery.1099 Leisure activities may offer opportunities for clients to develop or practice social skills as well as improve mood and reduce cravings for substances. Counselors should provide psychoeducation that encourages clients to develop recreational or healthy leisure activities, noting that these can help them feel better during and after active participation in the activity.1100
Responding safely to recurrences of use to avoid escalation of substance use. Recurrence of problematic substance use does happen, and clients should be made aware of this. After recurrence occurs, counselors can schedule a meeting to reassure their clients that they can get back on track. Counselors and their clients should review the events leading up to the recurrence and identify warning signs, including events of the previous weeks.1101 They should provide psychoeducation about how to manage the negative thoughts and feelings caused by a recurrence to use.1102
Addressing health and wellness to support recovery, including through healthy nutrition, physical activity, and sleep. Counselors can help clients develop new health and wellness goals to support them in their recovery. These can include setting goals to improve work, education, health, and nutrition; spending time with family, significant others, and friends; participating in spiritual or cultural activities; or developing new hobbies.1103 Vigorous physical exercise has been shown to enhance self-esteem, decrease anxiety and depression, and improve sleep.1104 Counselors can help clients learn about the value of regular exercise in their recovery process.
EXHIBIT 3.24. Confidence Ruler.
Medications to support recovery from problematic substance use can be instrumental in managing withdrawal symptoms and cravings and can help reduce the potential of a recurrence to use. For some people, medication is a time-limited adjunct to treatment, but for others it is an integral part of their long-term, chronic disease management, much like people with diabetes or hypertension. For those with OUD, the use of medications has been determined to be the only intervention associated with a significant decrease in opioid overdose risk.1105 Several medications are FDA approved for treating SUDs, such as OUD and AUD. Medications to treat OUD are characterized as agonists and antagonists. Opioid receptor agonists are substances that have an affinity for and stimulate physiological activity at cell receptors in the central nervous system that are normally stimulated by opioids.1106 Opioid receptor full agonists (e.g., methadone) bind to the mu-opioid receptor and produce actions similar to those produced by the endogenous opioid beta-endorphin.1107
Opioid receptor partial agonists (e.g., buprenorphine) bind to the mu-opioid receptor. Unlike with full agonists, increasing their dose may not produce additional effects once they have reached their maximal effect.1108 An opioid receptor antagonist is another term for a substance that has affinity for opioid receptors in the central nervous system but does not produce the physiological effects of opioid agonists. Opioid receptor antagonists (e.g., naltrexone) can block the effects of externally administered opioids.1109
Acamprosate calcium, disulfiram, and naltrexone (oral and long-acting injectable) are the medications available to treat AUD.1110 Exhibit 3.25 contains more information about medications that may be taken to support recovery from OUD and AUD. The exhibit includes information about the most common side effects reported for each medication. A complete list of side effects can be found in the National Library of Medicine's DailyMed database located at https://dailymed.nlm.nih.gov/dailymed/.
EXHIBIT 3.25. Medications for OUD and AUD.
Counseling combined with medication can be effective for addressing problematic substance use. In fact, medication may be the most effective treatment and standard of care for people with OUD.1144 In some cases, clients who take medication for SUD (e.g., methadone) are required to receive counseling along with their prescription. As SAMHSA notes, medication is more effective when counseling and other behavioral health therapies are included to provide clients with a whole-person approach.1145 While counseling combined with medication can be effective, some clients may not receive or decide not to engage in counseling. Counseling should not be a requirement to receive medications to support recovery. Recovery services that include medication may be offered in a three-pronged approach that includes:
Medication offered in coordination with the clinician and support of counselors.
CBT, which can help clients develop tools to prevent recurrence and, when combined with medication, can be a valuable tool for recovery.1146 Individuals in CBT learn to identify and modify unhelpful thinking patterns and underlying core beliefs that contribute to problematic behaviors by applying a range of different skills that can be used to address problematic substance use.1147
Recovery services, including ongoing supports for clients to ensure individuals have the tools to maintain ongoing recovery.
Although medication is a recovery pathway for many people with problematic substance use, some providers and treatment programs may put up barriers for clients interested in starting or continuing medication.
Also, family members of clients may have concerns about their family member taking medications or may not understand how it can help. This can be a challenge for those who are considering medication or have had a recurrence of substance use–related problems. Removing the stigma and barriers around taking these medications is important to ensuring clients have the support they need in treatment.
As mentioned, stigma is associated with the use of medications for problematic substance use. This is, in part, because of misconceptions about these medications being used as substitutes for harmful substances or the belief that abstinence is the best method for promoting recovery. However, medications for SUDs may be the most effective treatment; clients who want to pursue this as a path toward recovery should be fully supported if they desire to pursue medication options.1148
Counselors can play an important role in supporting people in recovery who take medications for problematic substance use, particularly by talking about any concerns with both the client and their prescribing provider. Developing a relationship with their prescribing provider can be particularly important if clients are at risk of a recurrence while taking medication.
At some point, those who are taking medication may feel a desire to stop. People may come to this decision for several reasons; for example, they may feel they are in a good place with their recovery. Other reasons may include concerns about medication side effects or stigma they may be facing in taking the medication. Counselors should discuss any concerns about medication side effects or stigma with their clients and the prescribing provider, particularly if these are related to a client's desire to stop taking medication. Clients should also be encouraged to discuss questions about stopping medication with their prescribing provider. Counselors can also help to normalize their clients' feelings through this conversation with the client, which can help address stigma they may be facing. Whatever the reason, clients who make the decision to discontinue medication will need ongoing support from their care team to ensure that they have the resources they need to support their recovery process. Counselors will want to make sure they continue to communicate with their clients' providers throughout this process to ease the transition.
Also, as with other chronic diseases, some people need and continue taking medication for years to manage their disease. Remaining on medications for problematic substance use for long periods is often part of successful management of the disease.
DECIDING TO STOP MEDICATION FOR PROBLEMATIC SUBSTANCE USE.
New medication combinations are being studied for treating SUDs. As the research evolves, medications that are easier to administer, have fewer side effects, and are more effective are emerging. For example, although not yet FDA-approved, a recent clinical trial found that the combination of two medications—injectable naltrexone and oral bupropion—may be safe and effective for treating adults with moderate or severe methamphetamine use disorder.1149 With additional research comes more opportunities to find effective treatment options for problematic substance use.1150 More information about new medications under study can be found by visiting NIDA's Clinical Trials Network at https://nida.nih.gov/about-nida/organization/cctn/clinical-trials-network-ctn.
RESOURCE ALERT: ADDITIONAL SUPPORT FOR PEOPLE IN RECOVERY TAKING MEDICATIONS TO SUPPORT RECOVERY FROM SUDS.
A growing body of evidence indicates that religious and spiritual beliefs and practices contribute to better recovery outcomes for individuals who have problematic substance use. This includes research suggesting that participating in prayer and mindfulness meditation may help reduce harmful drinking and support the treatment of and recovery from AUD.1151 For example, two-way prayer meditation—a “spiritual intervention that employs conversational prayer techniques”1152—is a promising intervention to decrease psychological distress, increase self-esteem, and improve some components of spiritual well-being for adults who have SUDs.
The use of the Alcoholics Anonymous® (A.A.) members' prayer has also been associated with reducing and staving off cravings.1153,1154 In addition, preliminary evidence links prayer with reduced alcohol consumption.1155 However, one study noted that such factors as religious denominations and drinking styles played a role in prayer's mitigating effects on alcohol consumption.1156
In the broadest sense, yoga is a practice that encompasses breathing, movement, and meditation that seeks to cultivate mindfulness and awareness.1157,1158 The body of evidence on the positive outcomes of yoga as a complementary treatment modality1159,1160 is increasing and demonstrates that yoga can be used as a safe, effective, holistic complementary approach to recovery from problematic substance use.1161
More specifically, encouraging evidence supports yoga as a modality for treating substance use–related problems, preventing a return to use, and promoting recovery. Research has shown that practicing yoga is associated with improved emotional and physical well-being, including the ability to manage depression, anxiety, pain, and stress.1162,1163,1164 Evidence also suggests that yoga helps quiet cravings and has a positive impact on mood states.1165 Moreover, yoga interventions also are associated with significant reductions in rates of alcohol and substance use.1166,1167
Positive outcomes and impacts were also noted with trauma-informed and gentle yoga classes led by trained volunteers or noncertified yoga instructors.1168,1169 In turn, reducing the training requirements for instructors may increase the accessibility of yoga as a complementary treatment modality to a wider population in a cost-effective manner.1170,1171
Resiliency counseling is an approach that can help individuals in recovery from substance use–related problems. In resiliency counseling, individuals work with a counselor to develop and learn to apply resilience abilities and skills to real-life situations and challenges. Several types of therapies (e.g., CBT, DBT, trauma-focused therapy, group therapy, expressive therapies) are based on the concept of resilience. Goals of resiliency counseling include gaining personal insights, developing a growth mindset, and preventing recurrences of mental issues.1172
Although the literature supporting the effectiveness of resiliency counseling approaches for problematic substance use is limited, research notes that one form of resilience is recovery from problematic substance use itself. Considerable evidence exists on the role of internal strength in avoiding future drug use. More information is needed about the role of external resources.1173
From the perspective of problematic substance use, resilience is commonly understood through an outcome-based lens, with positive adaptations being associated with abstinence and recovery, and negative outcomes being associated with drug use and recurrence. However, the concept of resilience has also been noted for inconsistency in its definition and operationalization, including whether it is being understood as an outcome, trait, or process.1174 In turn, the recent shift in trauma research to focus on and understand how resiliency is not just an innate trait or outcome, but something that can be harnessed through therapy, is particularly relevant in the context of resiliency counseling for individuals with substance use–related problems.1175
Healing circles—also referred to as talking circles, peacemaking circles, sharing circles, or the circle process—are rooted in the traditional practices of indigenous people1176 and have been used in a variety of settings (e.g., tribal inpatient and outpatient drug and alcohol centers, adolescent prevention and intervention programs) to help individuals deal with stress and other life difficulties. Within recovery, examples include Waccamaw Siouan healing and youth circles that support Native American students and individuals with drug, alcohol, and other life difficulties. Aboriginal communities also use healing circles for recovery from AUD, particularly in communities where some of the tenets of A.A. are viewed as incompatible with their traditional spirituality.1177
Although some variations of healing circles exist, the practice involves participants sitting in a circle to consider or discuss issues, problems, or questions. The process is typically peer-led and involves regulating communication through a sacred object, such as a talking piece or talking stick. Only the person who holds the object may speak while other group members remain quiet. The object is passed within the group to ensure everyone has an opportunity to speak. Healing circles support open listening.1178,1179,1180
Recent evidence suggests several potential benefits of healing circles for clients in recovery from problematic substance use. For example, healing circles are associated with improved client outcomes when combined with primary medicine in multiple studies.1181 Cultural and traditional healing practices have been highlighted as successful components of SUD programs created for indigenous populations in North America.1182 Talking or healing circles have been noted as a mechanism to receive support from others that is compatible with traditional spiritual practices for many Native Americans.1183
For individuals with trauma, the “circle process” creates a safe space for individuals with similar experiences to come together to support healing. Healing circles and similar peer counseling interventions are a useful, accessible, and cost-efficient complementary approach for individuals who want peer support in addition to counseling support.1184
Counselors can select from several evidence-based psychosocial interventions and frameworks to help their clients achieve and sustain recovery from problematic substance use, regardless of their chosen recovery pathway. CBT, MI, and CM can be effectively combined to improve outcomes by addressing both extrinsic and intrinsic motivation underlying behavior change. Mindfulness and acceptance-based approaches have been less rigorously studied but have been effectively used with individuals in recovery.
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