Risk factors

It has been estimated that “25 to 30 percent of ambulatory clients in general medical practices have a diagnosable psychiatric condition, and a further 10 to 15 percent of people suffering from major psychiatric illnesses such as affective disorder, schizophrenia, and alcoholism will end their lives by suicide” (Blumenthal 1988, p. 937). Suicide rates are particularly high among persons with the following mental disorders (Blumenthal 1988, pp. 944–946):

• Bipolar disorder, particularly at the time of the switch from depression to mania or vice versa (as high as 20 percent)
• Schizophrenia—15 percent end life by suicide
• Antisocial personality disorder—5 percent die by suicide and as many as 46 percent attempt it
• Borderline personality disorder—5 to 10 percent eventually commit suicide, though they may also engage in self-destructive behavior without lethal intent
• Major depression—6 percent
• Substance-induced depression—7 percent

Suicide is also more likely among those with the personality traits of impulsivity, hopelessness, or cognitive rigidity (Blumenthal 1988).

Substance use disorders alone increase suicidality (Inskip et al. 1998), and rates of suicide among persons with the above mental disorders are even higher (roughly doubled) if co-occurring substance use disorders are present. In particular, there is a heightened risk of suicide when relapse occurs after a substantial period of abstinence—especially if there is concurrent financial or psychosocial loss.

Suicidality and chronic medical illness

The presence of a chronic medical illness also is a major risk factor, possibly by causing depression or by producing an organic disorder. Individuals at particular risk include people with epilepsy (who have a suicide rate of four times that of the population as a whole), people with cancer, people with peptic ulcers (probably because of the association of alcoholism with the formation of these ulcers), clients undergoing renal dialysis, people with Huntington’s chorea (their suicide rate is six times greater), and people with AIDS. It appears that “severe or incapacitating medical status when associated with depression, alcoholism, organicity, and neurological impairment are important contributing factors leading to diminished judgment and increased impulsivity in medically ill clients” (Blumenthal 1988, p. 951).

Suicidality and family history

A family history of suicide is a significant risk factor, and there is some evidence that biological factors, such as reduced serotonergic function, contribute to a likelihood of violence against oneself or others (Blumenthal 1988).

Engagement

It is possible, though uncommon, for people with suicidality as their primary complaint to present to substance abuse treatment professionals; it is more likely for them to go to mental health agencies or ERs. Nonetheless, substance abuse treatment counselors should be prepared to detect suicidality. During the course of substance abuse assessment, the suicidal client may appear withdrawn, depressed, or even angry or agitated. It is important to inquire about these symptoms as they appear. For example

• “You know, you seem to be pretty down. How depressed are you?”
• The issue may arise in response to general questions: “Crack? No, I don’t use that much any more…. I get really down when I’m coming off it.” The counselor might then ask, “How down have you gotten? Were you ever suicidal? How are you doing now?”

At issue is the principle that the suicidal client is more likely to engage with the counselor and reveal his or her suicidality if the counselor responds to clues given by the client and inquires sensitively about them. To say to an agitated client, “You seem pretty nervous and uncomfortable—is there something I can do to help?” opens a door to further assessment.

Screening and assessment

Crisis stabilization

The first steps in suicide intervention, and thus crisis stabilization, are contained in the process of a good engagement and evaluation. Asking suicide-related questions, exploring the context of those impulses, evaluating support systems, considering the lethality of means, and assessing the client’s motivation to seek help are in themselves an intervention. Such an interview will often elicit the client’s own insight and problem solving and may result in a decrease in suicidal impulses.

If, however, the client experiences little or no relief after this process, then it is clear that psychiatric intervention is required. This is especially true if it emerges that the client has a co-occurring mental disorder or medical disorder in which the risk of suicide is elevated (see “Risk Factors” above) or if the client has a history of suicide attempts. If either or both is true, arrangements should be made for transfer to a facility that is capable of more intensive psychiatric evaluation and treatment. Emergency procedures should be in place so the counselor can accomplish this transfer even when a psychiatrist or clinical supervisor/director are not available. Once the client is stabilized and is safe to return to a less restrictive setting, he or she should return to the program.

Short-term care and treatment

Treatment for the client who is suicidal should include supportive care aimed at helping the client vent feelings, discover alternatives, improve relationships, change negative thinking, and focus on the future (Blumenthal 1988). The clinician should be caring and supportive. The seriously suicidal client should have someone to contact 24 hours a day, and frequent telephone contact between the client and the contact person usually is indicated.

Management of a client who is suicidal “usually requires the assistance of a psychiatric consultant and is clearly indicated for all clients who have a serious plan for suicide or who have made an attempt” (Blumenthal 1988, p. 958). At a minimum, “consultation with a psychiatric colleague who has specialty training in the diagnosis of mental illness is often indicated and may be particularly helpful in the assessment and management of acutely suicidal persons” (Blumenthal 1988, p. 959). The client should be evaluated by a psychiatrist onsite immediately, or a case manager or counselor should escort the client to emergency psychiatric services. Where available, mobile crisis service, which includes a psychiatrist, is another quick response resource for the management of the client who is suicidal.

Longer term care

Suicidality is not in itself a disease; rather, it is a short-term, acute, and potentially lethal behavior or set of behaviors. Longer term treatment issues for a client who has been suicidal focus on long-term treatment strategies for COD or on other risk factors that have culminated in a suicidal event. In this case, treatment becomes long-term prevention. Some persons who are chronically suicidal need special programs that can handle this chronic behavior (American Society of Addiction Medicine 2001).

Among clients with dependence on alcohol, “suicide frequently occurs late in the disease, often in relation to rejection or some interpersonal loss as well as to the onset of medical complications of the illness” (Blumenthal 1988, p. 945). Particular attention should be given to people with long-term dependence on alcohol who are developing medical symptoms, who are experiencing a personal loss or crisis, or who have had a relapse. It is wise to check for suicidal ideation regularly as it can recur. Since relapse is far and away the most dangerous suicide risk in long-term substance abuse treatment clients, the consensus panel recommends a solid long-term recovery plan as the best approach to suicide prevention. In persons with serious and persistent mental disorders, such as bipolar disorder, long-term medication compliance is a key element in preventing suicide. Just as essential as medication and medication compliance, however, is the need to rebuild a sense of hope in the future and engender the belief that recovery from co-occurring disorders is possible and that one has a sense of purpose, value, empowerment, and role in one’s own recovery.

Figure D-2. DSM-IV Criteria for Nicotine Withdrawal

Timing of the quit attempt

A major clinical issue is the timing of the quit attempt. Should an individual try to quit all substances at the same time? Clinicians tend to endorse this strategy for all substances but tobacco. Although there is debate about the best time for tobacco treatment for people in substance abuse treatment, studies suggest that tobacco treatment does not jeopardize recovery from other substances and might improve the outcomes for the other substance use disorder.

Should nicotine dependence treatment be timed to a specific stage of recovery from a mental disorder? There are very limited data to guide this decision other than clinical judgment. Clinical experience suggests that treating tobacco dependence during outpatient treatment when mental disorder symptoms are somewhat stable appears to be an excellent time to target interventions. Of note, managing tobacco dependence through forced abstinence because of environmental tobacco smoke concerns is necessary, and addressing this issue with appropriate dosages of NRT is warranted.

Effect of tobacco abstinence on psychiatric medication blood levels

Tobacco (not nicotine) is metabolized in the liver by the P450/1a2 isoenzyme, and tobacco’s metabolism actually increases the metabolism rate of certain psychiatric medications such as haloperidol, fluphenazine, olanzapine, and clozapine. When an individual stops smoking tobacco, the liver enzymes P450/1a2 become less active and metabolize the psychiatric medications at a slower rate. Therefore there will be an increase in the blood levels of those medications, potentially causing an increase in the medication’s side effects or other adverse events, including noncompliance with the medication due to the side effects (APA 1996; Ziedonis and Fiester 2003).

Effect of tobacco abstinence on mental disorders

Some clinicians are concerned about whether tobacco abstinence will worsen mental illness or jeopardize recovery from other substances. This is an important area that needs more research; however, research and clinical experience support the ability of people to quit and not induce relapses or severe worsening of their mental illness. The studies to date report that nicotine dependence treatment for this population is safe and usually well tolerated. However, there have been reports of some increases in psychiatric symptoms during the acute detoxification phase (APA 1996; Ziedonis and Williams 2003b ).

Effect of trying to quit smoking on recovery from other addictions

Until recently, substance abuse treatment clinicians generally have not addressed the issue of tobacco dependence or provided treatment largely because of the belief that the added stress of quitting smoking would jeopardize the recovery from alcohol or other substances. Research has not confirmed this belief. One study evaluated the progress of residents in an alcoholism treatment facility who were concurrently undergoing a standard smoking cessation program (i.e., experimental group) (Hurt et al. 1994). A comparison group of people with alcohol use disorders who smoked participated in the same program but without undergoing the smoking cessation program. One year after treatment, results indicated that the smoking cessation program had no effect on abstinence from alcohol or other drugs. In addition, 12 percent of the subjects in the experimental group, but none of the subjects in the comparison group, had stopped smoking. Some data suggest that addiction recovery may facilitate nicotine abstinence. In one study, clients participating in concurrent treatment for nicotine addiction during residential treatment for alcohol and other drug abuse achieved at least a temporary reduction in smoking and an increased motivation to quit smoking (Joseph et al. 1990).

Following the lead of other health facilities, many substance abuse treatment facilities are becoming smoke free, providing a “natural experiment” on the effectiveness of dual recovery programs. Initial evaluations suggest that no-smoking policies are feasible in this setting (Martin et al. 1997). However, no outcome studies have been performed, and additional research is needed.

Effect of tobacco use on craving and other drugs

Researchers have found that craving for tobacco appears to increase craving for illicit drugs among people with substance use disorders who also smoke tobacco. This relationship suggests that people who smoke and are in drug treatment programs may be less successful in staying off drugs than people who do not smoke. Recent research has found that cues that elicited craving for tobacco also elicited craving for the person’s drug of choice. This suggests that situations that produce tobacco craving also may result in craving for drugs of abuse (Taylor et al. 2000). The findings suggest that substance abuse treatment efforts will benefit from a more complete understanding of the interrelationships between tobacco and drug craving (Taylor et al. 2000). In a study among patients on methadone maintenance, tobacco craving and heavy smoking appeared to contribute to increased use of cocaine and heroin (Frosch et al. 2000). In a study of people with alcohol use disorders, researchers at Purdue University concluded that alcohol alone can prompt people who smoke to crave a cigarette. In a study of rats, Canadian scientists found evidence that the nicotine in cigarettes can induce a craving for alcohol (Le et al. 2000) among rats trained to drink alcohol. Alcohol consumption increased 20 percent after nicotine exposure and consumption decreased 30 percent after mecamylamine exposure. The researchers hypothesized that nicotine receptors are involved in alcohol consumption and/or self-administration (Le et al. 2000).

Motivation to quit among individuals with substance use or mental disorders

Many people in mental disorder and substance abuse treatment settings are interested in quitting tobacco, even if the interest is not immediate. In one study 75 percent of substance abuse treatment inpatients accepted the offer of smoking cessation treatment (Seidner et al. 1996). In another study, 53 percent of outpatients reported moderate interest in quitting Kozlowski et al. 1989). Further, one study of methadone maintenance patients found that 61 percent planned to quit within 6 months, 57 percent were very interested in an on-site cessation program, and 80 percent were interested in nicotine replacement products (Clemmey et al. 1997). Still another study found that 72 to 94 percent of outpatients were not yet ready to quit (Abrams et al. 1996). In conclusion, there often is interest in quitting tobacco, but there is variability in the interest level and there is a need to provide encouragement and support to those who are considering quitting smoking.

Realistic expectations: Tobacco dependence is like other addictions

Nicotine dependence, like other substance use disorders, can be thought of as a chronic, relapsing illness with a course of intermittent episodes alternating with periods of remission for most people who smoke. Only about 3 percent of quit attempts without formal treatment are successful, and in recent years about 30 percent of people who smoke and who want to quit are seeking treatment. Outcomes for nicotine dependence treatment vary by the type of treatment and the intensity of treatment, with specific reports of 1-year abstinence rates following treatment ranging from about 15 to 45 percent. Cessation attempts result in high relapse rates, with the relapse curve for smoking cessation paralleling that for opioids. Most individuals relapse during the first 3 days of withdrawal and most others will relapse within the first 3 months (APA 1996; Ziedonis and Fiester 2003). Like any other substance, individuals can relapse to tobacco in any stage of recovery.

Engagement

People entering treatment for substance use or mental disorders rarely intend to receive treatment for nicotine dependence. They may be surprised or even annoyed by questions about their smoking. It is important to initially integrate assessment questions about nicotine dependence into an overall assessment and treatment plan, and to be prepared to revisit the topic throughout the course of treatment. This should be done in an empathic and nonjudgmental manner, emphasizing the clinician’s concern for the client’s general health and well-being. Initial interventions should be tailored to the client’s stage of change (Prochaska et al. 1992), with a focus in the earlier stages on providing information, exploring ambivalence, eliciting client concerns, and beginning to envision the possibility of quitting.

For people who smoke who are not yet ready to quit, the clinician can do effective motivational interventions that will keep the client thinking about quitting at some time in the future. Discussing reasons for the person to consider quitting—for example, carbon monoxide (CO) monitor readings, costs, short- and long-term health consequences of smoking, benefits of quitting specific to the individual, and the factors that may have prevented an attempt—is important. Written materials about tobacco dependence and treatment options with brief advice to quit is one method of providing such information and increasing motivation. Another is to follow the “5 Rs” as outlined in the Surgeon General’s guidelines (U.S. Public Health Service, Office of the Surgeon General 2004):

• Relevance: Encourage the client to indicate why quitting could be personally relevant, being as specific as possible.
• Risks: Motivational information has the greatest impact if it is relevant to a client’s disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important client characteristics (e.g., prior quitting experience, personal barriers to cessation).
• Rewards: Elicit from clients possible benefits of quitting, with a particular focus on identifying short-term benefits that they will notice immediately.
• Roadblocks: Help the client to identify barriers or impediments to quitting. Typical barriers might include withdrawal symptoms, fear of failure, weight gain, lack of support, depression, or enjoyment of tobacco.
• Repetition: The motivational intervention should be repeated every time an unmotivated client visits the clinical setting. People who use tobacco and who have failed in previous quit attempts should be informed that most people make repeated quit attempts before they are successful.

Preparation for quitting may include self-monitoring or keeping a diary of smoking, planning rewards for successful abstinence, seeking additional information about treatment, purchasing the medication to aid in quitting, attempting to not smoke in certain situations or locations (such as the car, in the house) to enhance perceived self-control over smoking, and making a list of reasons for and potential benefits of quitting. Sources of social support should also be identified.

Screening and assessment

All clients should be screened for tobacco use beginning with an assessment of current and past patterns of tobacco use (number of cigarettes smoked per day, times during the day, location, and circumstances). For individuals who currently smoke, a more comprehensive assessment should be completed (see text box below).

Assessing Nicotine Use and Nicotine Dependence

• Current and past patterns of tobacco use (include multiple sources of nicotine)

• Severity of tobacco dependence (e.g., Fagerstrom Scale)

• Current motivation to quit

• Breath CO level or cotinine level (saliva, blood, urine)

• Assess prior quit attempts (number of attempts and what happened in the more recent attempts), why the client quit, how long the client was abstinent, why the client relapsed, what treatment did the client use (how was it used and for how long)

• Assess withdrawal symptoms

• Psychiatric and substance use histories

• Medical conditions

• Common triggers (car, people, moods, home, phone calls, meals, etc.)

• Perceived barriers against quitting and supports for treatment success

• Preference for treatment strategy

Source: Ziedonis and Fiester 2003.

In addition to self-reported amount of tobacco use, the amount of tobacco usage can be assessed more objectively through cotinine or CO levels. Cotinine levels can be obtained from the urine, blood, or saliva to assess the amount of nicotine ingested. Cotinine is a primary metabolite of nicotine and remains in the body for several weeks. The expired-air test for a CO level is inexpensive and can be obtained within a minute by any clinician with a CO meter. The CO meter is useful at intake and to monitor for relapse. Higher cotinine and CO levels are associated with a higher number of cigarettes per day and also severity of nicotine withdrawal. Despite the usefulness of these biochemical measures, they are frequently unavailable in clinical settings.

Assessment of tobacco withdrawal symptoms in the past and during the early abstinence period can be helpful. Clients can be educated that these symptoms will reduce substantially after 2 weeks (see Figure D-2).

The severity of nicotine dependence can be assessed with the Fagerstrom Test for Nicotine Dependence (FTND) (see Figure D-3), a six-item, self-report measure that has been shown to predict withdrawal symptom and craving severity (Payne et al. 1994). Two questions from the FTND that assess the number of cigarettes per day and time elapsed before the first cigarette have been shown to perform about as well as the full scale (Hajek et al. 2001; Kozlowski et al. 2004). As a clinical guideline, those who smoke at least 10 cigarettes per day have moderate nicotine dependence, while those who smoke more than 20 cigarettes per day have high nicotine dependence. Similarly, those who smoke within 60 minutes of waking can be considered to have moderate dependence, and those who smoke within 30 minutes of waking can be considered to have high dependence. Because of the unique social circumstances of people with schizophrenia, the FTND may not be an ideal measure of nicotine dependence for this population. For example, items intended to assess the need to smoke in response to overnight abstinence may elicit artificially low scores among people who smoke who are not permitted to smoke first thing in the morning by group home staff, day treatment staff, or family members with whom they live (Steinberg et al. 2004a ).

Assessment of a client’s prior tobacco treatment and cessation attempts should include the nature of the prior treatments, length of abstinence, timing of relapse, and factors specifically related to relapse (e.g., environmental or interpersonal triggers). Assessing prior treatments includes assessing medications and psychosocial treatments. Important information about medications includes asking about the dose level of medications and for how long they were taken; any side effects that developed; and how the client actually took the medication. Psychosocial treatments might include group or individual treatment, American Lung Association and other community support groups, hypnosis, acupuncture, or attendance at Nicotine Anonymous meetings. A history of specific withdrawal symptoms and their severity and duration is critical, as is an assessment of the person’s social and environmental contexts; for example, whether other household members smoke and the availability of family and social supports (Ziedonis and Fiester 2003).

An assessment should be made of the person’s reasons for quitting and his or her motivation, commitment, and self-efficacy (perceived ability to quit). The individual’s stage of readiness for stopping smoking is also important; that is, whether the person is not yet seriously considering stopping smoking (precontemplation), is considering attempting to quit but not for several months (contemplation), is seriously considering quitting in the next month and has begun to think about the necessary steps to stop smoking (preparation), or is actually attempting to stop smoking (action).

Patient motivation: Although 70 percent of people who smoke express an interest in quitting, only 8 percent are planning to make a quit attempt in the next month (Wewers et al. 2003). Stages of change can be assessed using the following simple algorithm:

• Client is not planning to quit in the next 6 months (precontemplation)
• Client is planning to quit in the next 6 months, but not the next month (contemplation)
• Client is planning to quit in the next month (preparation)

Client self-efficacy: Clients with little confidence in their ability to quit are less likely to make a quit attempt and less likely to succeed if they do.

Environmental factors and social support: People who smoke find it harder to quit when they live and work alongside other people who smoke, have a high current stress level, or have a history of mental disorders. This is particularly true in mental disorder treatment settings or communal living arrangements where clients are commonly exposed to staff and other clients who smoke.

Client beliefs about smoking and quitting: For example, older adults who smoke may believe that they are less likely to be able to quit, or that they will experience few health benefits if they do so. In fact, most studies find the opposite—that older adults who smoke, (i.e., who have smoked the longest) have a higher probability of success on any given quit attempt (Stapleton et al. 1995). Similarly, some clients and clinicians believe that nicotine causes cancer and that NRTs are dangerous. This is clearly not the case, and addressing this common misconception can help to increase motivation to quit.

Interventions

The U.S. Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence (Fiore et al. 2000a ) advises clinicians to use the “5 A’s” (Ask, Advise, Assess, Assist, Arrange Followup) with every person who uses tobacco who shows a willingness to quit (see chapter 8 for more information). The 5A’s are a brief and simple tobacco intervention that has been shown to increase the quit rates in primary care settings (Katz et al. 2002). Unfortunately, they are rarely implemented by clinicians treating clients in behavioral healthcare settings. This may be because clinicians are unsure how to implement them in daily practice, or because the guideline gives little information on the assessment of tobacco use in these complex clients.

Figure D-4. Brief Strategies for Smoking Cessation

Medications for nicotine dependence treatment

Six medications have received Food and Drug Administration (FDA) approval for nicotine dependence treatment, and the practice guidelines recognize these medications as first-line treatments (Fiore et al. 2000a ). These treatments are effective for about 25 to 30 percent of people in the general population who smoke on any one attempt, and this rate increases with combined psychosocial treatment. These medications have similar success rates but have side effect differences.

The five types of NRTs are administered in a variety of ways: nicotine polacrilex (gum), nicotine transdermal patch, nicotine inhaler, nicotine nasal spray, and the nicotine lozenge. These medications are similar in how they reduce nicotine withdrawal and urge to smoke, and improve abstinence rates and client satisfaction. The only FDA-approved nonnicotine treatment is bupropion SR (marketed as Zyban SR) for tobacco addiction and Wellbutrin SR for treatment of depression. Bupropion’s effect on tobacco dependence, however, is independent of depression status. Bupropion SR has proven effectiveness in clients with or without past depression medication treatment.

Most people who smoke and who have mental disorders smoke heavily. People who smoke heavily usually have higher CO and cotinine levels, higher Fagerstrom nicotine dependence scores, more nicotine withdrawal symptoms, and experience mood difficulties during withdrawal. There is some evidence to suggest titrating the dosage of NRT to the cotinine levels in the client. People who smoke heavily may have improved outcomes with higher NRT dosages (multiple NRTs simultaneously, multiple NRT patches), adding bupropion SR, and integrating behavioral therapies. There is one report that high-dose patch treatment resulted in 40 percent fewer withdrawal symptoms and 2.5 times greater reductions in craving in a pilot study of people with schizophrenia who smoked, and was well tolerated, although larger trials are needed.

Specific psychosocial treatments for tobacco dependence

Psychosocial treatments for nicotine dependence are among the first-line treatments in several practice guidelines (APA 1996; Fiore et al. 2000a ). Because behavioral health treatment providers (i.e., those treating substance use and/or mental disorders) possess many of the skills needed to provide tobacco dependence services, intensive interventions may be well suited to a mental or substance use disorder treatment setting. Data support the use of psychosocial interventions for tobacco dependence as provided by various counselor disciplines (e.g., physicians or nonphysicians), and via multiple treatment modalities (e.g., telephone, group, and individual counseling). Although there is a clear dose-response relationship between counseling intensity and success, even very brief counseling can increase quit rates (Fiore et al. 2000a ).

Despite the strong evidence that psychosocial treatments are effective for treating tobacco dependence, only 5 percent of people who smoke who make a 24-hour quit attempt receive counseling as part of their treatment (Zhu et al. 2000). Clients who are motivated to quit smoking should be taught general problemsolving skills, provided with social support as part of counseling, and assisted in gaining social support from family and friends for their quit attempt.

Psychosocial interventions have been successfully adapted for people with schizophrenia who smoke (Addington et al. 1998; George et al. 2000; Steinberg et al. 2004a ; Ziedonis and George 1997), depression (Hall et al. 1994, 1995, 1996, 1998, 1999), and substance use disorders (e.g., Burling et al. 2001; Patten et al. 1998, 2001). Successful adaptation involves blending traditional mental health services with tobacco dependence treatments while addressing the unique problems associated with the specific mental disorder. Integrating medications with these psychosocial treatments is also very important, since these groups are often highly dependent on tobacco.

While clinicians are often hesitant to help clients with serious mental illness who smoke to quit smoking, the Clinical Practice Guideline (Fiore et al. 2000a ) recommends that tobacco use be addressed in all clients who smoke. While many excuse smoking in this population, it should be recognized that smoking exacerbates many existing problems. When compared with people who do not smoke, those with schizophrenia who smoke exhibited more positive symptoms of schizophrenia (Goff et al. 1992; Ziedonis et al. 1994) and experienced more hospitalizations than their counterparts who did not smoke (Goff et al. 1992; Kelly and McCreadie 1999). People with schizophrenia who smoke often are prescribed more antipsychotic medication than people with schizophrenia who do not smoke, due to an increased metabolism of many psychiatric medications secondary to the “tar” or aromatic polynuclear hydrocarbons—not due to nicotine (Goff 1992; Hughes 1993; Ziedonis 1994). They also experience greater medication side effects such as tremor (Kelly and McCreadie 1999), rigidity (Ziedonis et al. 1994), and possibly tardive dyskinesia (Nilsson et al. 1997). Tobacco use also depletes their already scarce financial resources. Cigarettes may constitute up to 27 percent of the monthly budget for people with schizophrenia who smoke (Steinberg et al. 2004a ). A recent study indicated that a brief motivational interviewing intervention was effective in motivating people with schizophrenia who smoked to seek formal tobacco dependence treatment (Steinberg et al. 2004b ).

Relapse prevention also uses social skills training to teach drug refusal skills. Since seeing others smoke is a strong predictor for relapse, this approach is very important for those living in a group home or attending a substance abuse treatment or mental health services setting where smoking may be ubiquitous. Specialized treatments for this group should incorporate techniques for reducing the appeal of smoke breaks and learning to avoid “bumming” cigarettes or accepting an offered cigarette. Interactive teaching through role playing can enhance this type of learning and allow for real-world practicing. Raising awareness of the stigma related to these drug-seeking and drug-use behaviors can also help to change behavior. Creating a relapse analysis is helpful to understand the role of “seemingly irrelevant decisions” in the path toward a relapse. An example of a “seemingly irrelevant decision” might be a relapse to smoking after dining in the smoking section of a restaurant rather than sitting in the nonsmoking section.

Relapse prevention also distinguishes between a “lapse” and a “relapse” as a matter of degree and severity. There is a focus on trying to avoid letting a “lapse” become a “relapse” by quickly managing the situation and framing it as a learning opportunity in an effort to return to abstinence. This model allows for some mistakes as the client is working toward a goal of abstinence. Figure D-5 presents strategies for helping clients address situations that may lead to relapse.

Personality disorders grouped into clusters A, B, or C

The PDs include paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, and obsessive-compulsive. In the DSM-IV-TR (pp. 690–730), PDs are conceptualized as three distinct clusters, “A,” “B,” and “C”:

• Cluster A: Paranoid PD; Schizoid PD; and Schizotypal PD
• Cluster B: Antisocial PD; Borderline PD; Histrionic PD; and Narcissistic PD
• Cluster C: Avoidant PD; Dependent PD; and Obsessive-Compulsive PD

Engagement

Safety is an anchor for clients with BPD, for whom abandonment and fear of rejection often are core issues. Counselors should recognize that acting-out behavior common to people with BPD is a maladaptive survivor response that expresses a need for safety. Indeed, the client’s primary motivation for treatment may be a desire for safety. Therapists should discover what safety means to the client.

Soon after entering into a therapeutic alliance, the reliability of the counselor can have strong symbolic importance to the client and the strengthening of the relationship between client and counselor. Showing up on time, being there throughout the time period expected, and not allowing interruptions can have a strong and positive effect on the client and the client’s response to treatment. Alternatively, disruptions in the sense of the counselor’s reliability and trust can have negative fallout. Even what might seem to the counselor to be a minor event can be a blow to a client’s shaky emotional state and interfere with the client-counselor relationship. The therapist’s absence, even for brief periods, can prompt acting-out behavior.

Therapists can learn how clients create their own feelings of safety by asking them about safe spots, magic getaway places, closet-sitting, rocking or other repetitive movements, or other techniques the client may use to generate a sense of security. To help clients with BPD establish and maintain a sense of safety, counselors regularly should ask clients: “What do you need right now?” “What do you want right now?” Counselors can also help clients to develop a list of the conditions that they need to feel safe. Counselors might ask clients, “What would have been helpful (in a specific situation) to make you feel safe?” Through teaching cognitive skills to promote a client’s sense of safety, counselors can help clients with BPD assume personal responsibility for their own safety. (See TIP 36, chapter 4, for a complete discussion about counseling issues related to those clients with BPD and a history of childhood trauma [CSAT 2000d ].)

Written and verbal contracts can identify specific ways to help clients stay safe physically and emotionally and to prevent relapse. Contracts for safety should be developed during the assessment process with simple and clear behavioral responses regarding the management of unsafe feelings and behaviors. These contracts can be very simple and direct:

• “If I feel like I want to get drunk, I will call my sponsor.”
• “If I feel like getting high, I will go to the next NA meeting.”
• “If I feel like hurting myself, I will call a crisis hotline and go to my sister’s house.”
• “I will report self-harm thoughts and behaviors to the therapist at the next session.”

A discrepancy between the client and his or her clinical record or other source of information can reflect the client’s inclination to deny, minimize, or hide what the service provider is trying to diagnose. Similarly, few addicted individuals come into an assessment and treatment planning session prepared to make a full disclosure of their patterns of substance use and the harm that results from such use. Similarly, few individuals with BPD acknowledge their maladaptive and provocative behaviors. Both disorders are misrepresented by client self-report and involve the client’s insistence that the real problem lies elsewhere, usually in how they are being treated by others. Diagnosis and understanding of both disorders must come from observation, interpretation, extrapolation, information from objective instruments (e.g., assessment tools, urinalysis), and outside sources (e.g., family).

Screening and assessment

Gathering historical information affords an opportunity to examine a client’s strengths and weaknesses, which are especially important for clients with BPD. When things are going well, clients with BPD might have exceptional skills in various areas. Consequently, a discussion of what the client sees as weaknesses can be revealing. Any history of psychotic-like thinking that occurred under intense stress or that was drug-related should be noted. For example, a client may state, “I really believed the walls were bleeding.”

The assessment of clients with BPD should elicit any history of self-harm, which is common among these clients. It is important to explore when and how such episodes, if any, occurred. Specifically, determine what is remembered about the period of time before, during, and after any episodes of self-harm. A list of potential means available to clients to injure themselves in their own homes, such as a large supply of medication, warrants review for clients with BPD who have any history of self-harm.

Assessment also should establish any history or evidence of dissociative experiences, such as trance states, rocking, flashbacks, or nightmares. Anniversary reactions also are common to survivors of abuse, whose memories or feelings may be triggered by certain dates, events, or objects. For no apparent reason, the survivor may become sick or suicidal when faced with a situation similar to a past reminder of abuse. The history of fugue states and losing time may also be significant. For example, clients with BPD might start watching a movie and suddenly reorient later in the middle of another movie, with no clear memory of the elapsed time.

Crisis stabilization

Safety issues are at the core of crisis stabilization. To ensure the client’s safety or to detoxify a client, a brief psychiatric hospitalization may be necessary. Issues to be addressed during crisis stabilization might include an unwillingness or inability to contract for safety. A written release of medical information is important to coordinate care with physicians and substance abuse treatment counselors.

At this stage, counselors should avoid psychodynamic confrontations with clients and should not engage clients in further therapy for abuse or trauma. The treatment focus should be on addressing the client’s need for safety, which is especially important with clients who have BPD. More complicated and emotionally charged material should be deferred until the client has better skills to manage emotional pain.

It may be helpful to describe out-of-control crisis behavior as a survivor response. Counselors and clients should avoid rigid black-or-white thinking. For example, describing events or issues as being more or less helpful may circumvent the inflexibility of seeing life’s challenges and problems only as good or bad, while ignoring the numerous gray areas of experience.

The family should take part in this process. It may be useful to encourage written and verbal contracts with family members. These contracts can dissuade family members from assuming dysfunctional roles such as the victim, the persecutor, and the rescuer. The family should learn how to set boundaries with the client and avoid playing certain roles, especially that of rescuer.

Short-term care and treatment

Theorists and clinicians with expertise in PDs agree that BPD requires long-term, comprehensive, integrated treatment. Recommendations for the early stages of treatment include developing “skills for managing negative emotions and memories, such as deep breathing, using time-outs, and centering through the senses” (Sullivan and Evans 1994, p. 374), focusing on emotional regulation, enhancing motivation, discussing what interferes with treatment (Dimeff et al. 1998), and carefully considering all medication issues (including the possible genuine need for assistance with pain control through medication or other techniques).

Longer term care

Individual counseling, continuing group therapy, 12-Step participation, and continuum of care components are the major forms of intervention for comprehensive treatment of clients with BPD. Dimeff et al. (1998) recommend that individual and group counseling concentrate on the development of new skills, balancing toleration of distress with how to change life circumstances (what they see as a “dialectical” interplay of the opposites of an emphasis on change and an emphasis on acceptance of things as they are), and targeting specific areas where control is lacking, such as impulsivity or suicidality.

People with BPD may benefit from skills development in anger management (Reilly et al. 1994). Linehan and colleagues’ (1999) dialectical behavior therapy (DBT) solidly intertwines group counseling with the unique DBT terminology and therapeutic strategies. Linehan and her colleagues offer 2-day workshops that train counselors to use their skills training techniques in leading group counseling for clients with BPD and substance use disorders.

Individual counseling

Issues stemming both from BPD and substance use may emerge in individual therapy. Issues related to unsafe behavior or substance use will continue to be important. Longer term care is a stage in which teaching the client skills such as assertiveness and boundary setting can be useful.

There is no pressing need for the discussion of early memories; rather the focus of therapy should be on behavior (Sullivan and Evans 1994). Complications at this stage can include a variety of compulsive and impulsive behaviors, such as eating disorders (obesity, anorexia, bulimia), compulsive spending and money mismanagement, relationship problems, inappropriate sexual behaviors, and unprotected sex (in regard to sexually transmitted diseases and pregnancy). Other maladaptive behaviors include sexual impulsiveness, which can cause confusion about sexual identity dramatized in experimental sexual relationships, adding to the crisis and drama to which people with BPD often seem drawn.

Counselors may want to avoid educational material about adult children of alcoholics or general self-help books for clients with BPD, as reading such material may be detrimental to some clients’ recovery. For some clients, self-labeling can become counterproductive and in worst-case scenarios, it can lead to self-fulfilling prophecies. For example, books suggesting that some people self-mutilate in order to relieve pain may teach clients with BPD to self-mutilate. Some books offering “inner-child work” lead the client through age-regressive exercises that can cause an overwhelming flood of feelings the abused client may not yet be ready to manage.

Counselors should remember that progress in treating clients with BPD and substance abuse problems may be slow and may have many setbacks. Rather than looking for enormous changes in personality or behavior, counselors should look for small, observable signs of improvement.

In addition, counselors may want to consider the following in treating clients with BPD:

• Use mini-contracts for each session to encourage the client to stay focused.
• Immediately ask clients about any crises that have occurred and review the entire week, not just a particular day.
• State the purpose of each session.
• Run through a checklist that might include homework, failing tests, arguments with others, interactions with the criminal justice system, problems in school or work life, family relationships and friends, relapses, thoughts of self-harm, nightmares, flashbacks, painful situations, and bad memories. Questions should be specific.
• Keep and date all correspondence and notes from telephone conversations. Documenting conversations can help remind the client of earlier agreements and conversations.

Countertransference and transference

In working with clients with APD, countertransference issues might be of equal or greater concern than transference issues. That is, although it is usually of more clinical concern how the client reacts to, interprets, and misinterprets the counselor, when working with clients with APD, it is also important how the counselor reacts to, interprets, or misinterprets the client. Some clients with APD can be frightening to work with; some engage in behaviors that counselors may reject as criminal and antisocial; a few have histories of acts that counselors may abhor. Counselors should be wary of those clients with APD who can be charming and underhanded. The reactions of counselors to working with clients with APD in general, and each specific client with APD in particular, requires regular self-examination and supervision. (Again, the reader is referred to chapter 4 of TIP 36 [CSAT 2000d ].)

Counselor well-being

Counselor well-being is critical for counselors serving individuals with substance use disorders and APD; counselors who are not provided with an environment that supports a sense of well-being are subject to burnout. A sense of well-being can be fostered by the availability of supervision, the coordination of duties in a team structure, and a clear understanding of roles and responsibilities for standard and crisis situations.

Carlson and Baker (1998) report briefly on efforts at the Portland Veterans Affairs Medical Center to establish a system to assist staff and improve care when managing clients who are dangerous, difficult, demanding, or drug-seeking. They describe a coordinated and focused approach with multidisciplinary meetings of administrators, clinicians, and others that serve to support consistent and systemwide methods of handling these types of situations. In examining 36 consecutive cases under the system, they noted that the 36 individuals committed 47 incidents of violence during the year prior to the implementation of their program, whereas the number of incidents dropped to 4 in the year following implementation. Moreover, their evaluations documented increased staff morale and confidence. Although not specifically targeting clients with substance use disorders and APD, their coordinated, top-to-bottom system for team-handling such stressful client-staff interactions is applicable to these clients.

Resistance

Clients with APD are often said to “act out” tension or conflict. Behaviors that interfere with treatment, which might even result in a client being sent immediately to jail, are seen by therapists as a form of resistance to whatever happens to be the focus of therapy at the time. Substance abuse treatment counselors working with clients with APD often sense resistance to substance abuse treatment and its goals. The counselor should not buy into this negative or pessimistic outlook. Instead, counselors can focus on how much better the client’s life will be with successful treatment, and explain to the client that treatment can succeed without the client’s complete commitment at the beginning.

It can be hard for a counselor not to blame the client for failing to seek a better life and better behavior. Counselors who fall into this countertransference reaction expect that the client simply has a choice he fails to make. Interestingly, some research (Raine et al. 2000) shows lower prefrontal gray matter volumes in clients with APD (compared to healthy controls, individuals with substance dependence, and other mental disorders). Thus, the extent of actual control clients with APD have over their responses and resistance might well be less than others due to this physiological deficit.

Contracting

Contracting is essential in working with clients with APD. Without contracts and clear expectations of what is to be done, when, how, and the consequences of failing to comply, the therapeutic relationship can become a constant argument about why something was not done and why it is unfair to be punished for an infraction or omission. As a general rule, when working with individuals with substance use disorders and APD, it is advised to put everything into writing.

Engagement

In engaging the client with APD, it is useful to remain neutral toward the client’s world view, which may include a need for control and a sense of entitlement. In this context, entitlement refers to people who believe their needs are more important than the needs of others. Entitlement may include rationalization of negative behavior (such as robbery or lying). People with APD may evidence little empathy for their victims. If incarcerated, they may believe they should be released immediately. In a substance abuse treatment program, they may describe themselves as being unique and requiring special treatment.

The primary motivation of the client with APD is to be right and to be successful. It is useful to work with this motivation, not against it. Although this motivation may not reflect socially acceptable reasons for changing behavior, it does offer a point from which to begin treatment. Wanting to be clean and sober, to keep a job, to avoid jail, and to become the chair of an Alcoholics Anonymous (AA) meeting are reasonable goals, despite a self-serving appearance. Counselors can help clients with APD by working with clients’ world views, rather than by trying to change their value systems to match those of the therapist or of society. Of course, in therapeutic communities the expectation of eventually having a change in values and in self is part and parcel of the structure of the community, but early in a client’s treatment those aspects of the program might well be kept on the “back burner.”

Contracting is another effective strategy. Contracts establish rules for conduct during treatment and clarify the clients’ role in the therapeutic process. The contract should state explicitly all expectations and rules of conduct and should be honored by all parties. Such an approach can be useful with people with APD, who often view relationships as unfair contracts in which one person attempts to take advantage of the other. Counselors may find that once a level of interpersonal respect has been established, working with antisocial clients can lead to important gains for the client.

Screening and assessment

In addition to an objective psychosocial and criminal history, the following steps may be useful in assessing the antisocial client:

• Taking a thorough family history.
• Finding out whether the client set fires as a child, abused animals, or was a bed-wetter.
• Taking a thorough sexual history that includes questions about animals and objects. Asking about any unusual or out-of-the-ordinary sexual experiences may serve as a lead-in and as a means to gauge how the client responds to questions about such personal areas.
• Taking a history of the client’s ability to bond with others. Counselors can ask, “Who was your first best friend?” “When was the last time you saw him or her?” “Do you know how he or she is?” “Is there any authority figure who has ever been helpful to you?”
• Asking questions to find out about possible parasitic relationships and taking a history of exploitation of self and others. In this context, parasitic refers to a relationship in which one person uses and manipulates another until the first has gotten everything he or she wants, then abandons the relationship.
• Taking a history of head injuries, fighting, and being hit. It may be useful to refer for neuropsychological testing.
• Testing urine for recent substance use.
• HIV testing.

The assessment should consider criminal thinking patterns, such as rationalization and justification for maladaptive behaviors. There is a special need to establish collateral contacts and to assess for criminal history and the relationship of substance use to behavior. Useful assessment instruments include

• The Minnesota Multiphasic Personality Inventory – 2 (MMPI-2)
• The Millon Clinical Multiaxial Inventory (MCMI), and Nadeau et al. 1999
• The PCL-R (Hare Psychopathy Checklist-Revised), and the forthcoming TIP Substance Abuse Treatment for Adults in the Criminal Justice System (CSAT in development e)

Crisis stabilization

People with APD may enter treatment profoundly depressed, feeling that all systems have failed them. Often, their scams and lofty ideas have failed. They feel exposed and have no ego strength. They are at risk for suicide, especially during intoxication or acute withdrawal, and may require psychiatric hospitalization and detoxification. Containment in the form of a brief hospitalization may be indicated for clients experiencing acute paranoid reactions to avoid acting out against others. When paranoid reactions are less acute, counselors should avoid cornering clients, disengage from any power struggle, offer lower stimulus levels, and explore options, especially those suggested by the client. During this phase, clarification without harsh confrontation is recommended.

Counselors should be especially cautious when working with APD clients in crisis. These clients may engage in dangerous physical behavior to avoid unpleasant situations or activities. Counselors are advised avoid angry confrontations.

Short-term care and treatment

O’Connell (1998, pp. 123–124), acknowledging the historical contributions of Doren (1987) and Barley (1986), advises counselors to be prepared to be “amused by these clients, outraged by their lack of conscience, intrigued with the glamour of their high-risk lifestyle, or flattered by their praise of the therapist’s skills and knowledge … excessively fascinated by the course of therapy.” He recommends developing strategies to (1) get reliable information from others to counter misrepresentation of facts, (2) avoid being manipulated or having any intense interest in any of the client’s escapades or old war stories, and (3) confront intimidation, criticism, and flattery through supervision and/or a team approach. Confronting antisocial behavior and its relationship to substance use is, of course, an ever-present part of treating clients with substance use disorders and APD.

Longer term care

Mood episodes

A mood episode is a cluster of symptoms that occur together for a discrete period of time, including

• Changes in appetite or weight, sleep, and psychomotor activity. The individual may report loss of interest in eating or may crave foods such as sweets or carbohydrates; the person may seem agitated or action may seem slowed down—for example, slowed speech and body movements. Frequently, the person has difficulty sleeping or sleeps too much. Waking up 90 minutes to 2 hours before usual and being unable to go back to sleep (“early morning awakening”) and difficulty falling asleep are common manifestations of sleep problems.
• Decreased energy. Sometimes the person also reports decreased efficiency in performing tasks.
• Feelings of worthlessness or guilt. The individual may be preoccupied with past feelings and dwell on personal defects, often with cognitive distortion such as strong feelings of not living up to her or his potential even though the person has been very productive and others think well of her or his work.
• Difficulty thinking, concentrating, or especially making decisions. Sometimes people are easily distracted, have difficulty with memory, or perform normally but feel that it requires increased effort to do so.
• Recurrent thoughts of death, suicidal ideations, and/or suicidal plans or attempts.

Mood disorders

Dysthymia and generalized anxiety disorder (GAD)

GAD and dysthymia are, respectively, prevalent anxiety and mood disorders. Both are persistent disorders. GAD is characterized by at least 6 months of persistent and excessive anxiety and worry (APA 2000). Dysthymic disorder “is characterized by a depressed mood for most of the day, for more days than not, for at least 2 years” (APA 2000, p. 380). Dysthymic symptoms can include feelings of inadequacy, loss of interest and social withdrawal, irritability, excessive anger, and lethargy. At some time in their lives 5 percent of people will have GAD and 6 percent will have dysthymic disorder (APA 2000). Consequently, substance abuse counselors need to be alert to GAD or dysthymic disorder in their clients. The term anxiety refers to the sensations of nervousness, tension, apprehension, and fear. In GAD there is no specific focus to the anxiety—it is said to be “free-floating.” Other common anxiety disorders are panic disorder, specific phobia, and social phobia; obsessive-compulsive disorder; and PTSD and acute stress disorder.

Anxiety disorders

Diagnostic process

Diagnoses of mental disorders should be provisional and reevaluated constantly. Many apparent mental disorders are really substance-induced disorders that are caused by substance use. Treatment of the substance use disorder and an abstinent period of weeks or months may be required for a definitive diagnosis of an independent, co-occurring mental disorder. As described in chapter 4 on assessment, substance abuse treatment programs and clinical staff can concentrate on screening for mental disorders and determining the severity and acuity of symptoms, along with an understanding of the client’s support network and overall life situation.

Anxiety and mood disturbance in other disorders

Anxiety and mood disturbance, often a regular part of the life of people with substance use disorders, are common, ubiquitous components of almost all mental disorders. People with schizophrenia or PDs, for example, typically experience ups and downs in anxiety, as well as waxing and waning of mood disturbance. Therefore, not only is it difficult to tell when someone enters substance abuse treatment whether the person has a co-occurring mood or anxiety disorder that is separate from the substance use disorder, it is also hard to determine whether the symptoms of mood or anxiety disorders are part of the manifestations of another mental disorder or constitute a separate disorder.

Many psychiatric conditions can mimic mood disorders. Disorders that can complicate diagnosis include schizophrenia, brief reactive psychosis, and anxiety disorders. Clients with PDs, especially of the borderline, narcissistic, and antisocial types, frequently manifest symptoms of mood disorders. These symptoms often are fluid and may not meet the diagnostic criterion of persistence over time. In addition, all of the mental disorders noted here can coexist with substance use and mood disorders.

To make the initial evaluative situation even more challenging, discriminating between an acute anxiety disorder and an acute mood disorder can be difficult. Of course, where severe and acute symptoms exist, treatment personnel move ahead with treatment for all the presenting problems while awaiting the ultimate resolution over time of the diagnostic specifics. As noted in chapter 4, this is a major reason to repeat screening and assessment periodically as recovery proceeds.

Anxiety and mood disturbances versus substance use

Symptoms that look like anxiety or mood disturbances may appear either during use or withdrawal. Withdrawal from depressants, opioids, and stimulants invariably includes potent anxiety symptoms (see Figure D-10). During the first months of abstinence, many people with substance use disorders may exhibit symptoms of depression that fade over time and are related to acute withdrawal. Since depressive symptoms during withdrawal and early recovery may result from substance use disorders and not an underlying depression, a period of time should elapse before depression is diagnosed. Overall, the process of addiction per se can result in biopsychosocial disintegration, leading to chronic dysthymia or depression often lasting from months to years.

Acute manic symptoms may be induced or mimicked by intoxication with stimulants, steroids, hallucinogens, or polydrug combinations. They may also be caused by withdrawal from depressants such as alcohol. Individuals experiencing acute mania with its accompanying hyperactivity, psychosis, and often aggressive and impulsive behavior should be referred to emergency mental health professionals. This is true whatever the causes may appear to be.

Substance-induced mood alterations can result from acute and chronic drug use as well as from drug withdrawal. Substance-induced mood disorders, most notably acute depression lasting from hours to days, can result from sedative-hypnotic intoxication. Similarly, prolonged or subacute withdrawal, lasting from weeks to months, can cause episodes of depression, and sometimes is accompanied by suicidal ideation or attempts. Figure D-10 provides an overview of drugs that precipitate or mimic mood disorders.

Mood and anxiety disorders versus medical conditions and medication-induced symptoms

Medical problems and medications can produce symptoms of anxiety and mood disorders. For example, acute cardiac disorders can produce symptoms that suggest generalized anxiety or panic disorders. Similarly, both prescribed and over-the-counter medications can precipitate depression. Diet pills and other over-the-counter medications can lead to mania. It is important to distinguish between the symptoms of a mental disorder and those accompanying a medical disorder or those associated with an over-the-counter or prescription medication. The counselor should be aware of these possibilities and seek information that helps make an accurate determination.

Engagement

As observed in the section above on “Differential Diagnosis,” a client who shows severe and acute levels of anxiety and mood disturbance may have another psychological disorder, such as psychosis, PTSD, or a PD. The client may also have a history of suicidality or may be suicidal currently. When this is the case, see the pertinent portions of the “Differential Diagnosis” section and the “Suicidality” section.

In general, counselors can engage clients with mood or anxiety difficulties by gathering enough information to empathize with the clients’ experience and acknowledge the legitimacy of the client’s feelings. Worried clients tend to know they are overly concerned compared to other people, and depressed clients often feel that they should not be depressed. Depressed clients may view depression as a personal shortcoming and imagine that they are bringing others down with them.

A model of engagement that can be instructive is the sympathetic physician who has seen it all before and is calm in the face of what she or he knows others find upsetting. That is, a substance abuse treatment counselor can attend to the symptoms and their effects on the client, while remaining an observant distance from the worry itself or the depressed mood. For example, the counselor could tell a client that he or she recognizes how painful and nerve-racking it is for the client to be so concerned about the possible loss of employment, while avoiding getting into the details of either the worst possible outcomes or the worries. Such a strategy can help with engagement.

Cognitive-behavioral therapy might help a client see how he or she has developed a way of viewing mainly the worst possible outcomes of events, or how he or she tends to emphasize the most negative aspect of a situation. However, the client’s ability to recognize these patterns of behavior may be a long-term goal that can only be accomplished through time and trust. Trying too soon to address such entrenched habits of perception is not likely to be an effective engagement strategy. “Start low, go slow” is a cliché physicians use to describe beginning with a small amount of a medication to gauge side effects, then slowly increasing the medication to a therapeutically effective dose. A similar approach can help with the engagement phase of working with clients who have mood and anxiety concerns.

Screening and assessment

Crisis stabilization

When a mood and anxiety disturbance is at mild or moderate levels, crisis stabilization should not be needed. Substance abuse counselors should use their clinical skills and be responsive to signs of an impending serious crisis, such as a moderately depressed client who has given away his or her belongings or who has begun to talk about wills or contacting old friends.

In terms of anxiety disorders, an immediate episode of panic (and to some degree a dissociative state) can represent a crisis. In some cases, the counselor may have to make arrangements for a client to get home. Two of the acute anxiety conditions most commonly encountered in emergency room settings are panic attacks and dissociative states that may resemble psychosis. However, some anxious clients misinterpret their symptoms of chronic anxiety as symptoms of an acute anxiety episode. Their misinterpretation may predispose the therapist to make the same misinterpretation.

Interventions for acute anxiety conditions include calming reassurance, reality orientations, breathing management, and when needed, sedative medications such as benzodiazepines. These interventions are nearly identical to those used for the two most common substance-related anxiety emergencies: withdrawal from sedative-hypnotics (including alcohol) and intoxication from stimulants (including cocaine). While the use of benzodiazepines generally is not problematic during acute withdrawal, their use may become a problem for abstinent, recovering people. Such people may have abused benzodiazepines before they became abstinent, and the use of benzodiazepines to calm the anxiety disorder may lead to relapse of the addictive behavior. Interventions for acute anxiety conditions should include behavioral, cognitive, and relaxation therapies, often in combination with long-term serotonergic and depressant medications.

During an acute panic attack, people often believe that they are having a heart attack, feel dizzy, and are unable to catch their breath. Enforced regular breathing through the use of a paper bag helps to regulate breathing and diminish excess release of carbon dioxide. Such breathing exercises, education about symptoms, and reassurance will diminish panic symptoms for many clients. These clients also should be examined by a medical professional such as a nurse to identify any person who may be having an actual heart attack.

Short-term care and treatment

The acronym MASST, defined in the text box below, is a reminder for counselors of the areas of substance abuse recovery that need to be continually assessed.

MASST Areas of Recovery for Assessment

M: Meetings (12-Step or other recovery-oriented self-help)

A: Abstinence goals S: Sponsor and other helping people

S: Social support systems

T: Treatment efforts

In terms of mood and anxiety problems, MASST can be used to incorporate specific strategies within the client’s overall recovery efforts. Though there are many interventions for anxiety and mood disorders other than medications, medications often are a significant part of such treatment efforts. For clients with more than mild levels of disturbance, medications can be essential.

For many clients in early recovery from substance abuse, treatment of anxiety disorders can be postponed unless a certain or verifiable history shows that the anxiety preceded the addiction or is incapacitating. If symptoms are mild and do not interfere with functioning, including participation in treatment, it is judicious to wait to see if the symptoms resolve as the substance abuse treatment progresses. Antecedent traumas, as well as dysfunctional family situations that have been identified during the assessments, should be addressed in a supportive and calming manner. However, affect-liberating therapies probably should be deferred until the client is stable with respect to substance abuse and acute anxiety has been established. Issues of importance to the client and raised by the client should not be ignored, but exploration of underlying trauma should not be encouraged until the client is stabilized.

Supportive, cognitive, behavioral, and dynamic therapies all can be used, but in early recovery, clients need significant support and will have limited tolerance for anxiety and depression. The emphasis should be on supporting recovery, attending 12-Step meetings, and participating in other self-help and group therapies. Insight-oriented treatments must be measured carefully and limited early on by their potential to increase anxiety and trigger relapse. When psychotherapy is immediately essential, clients should be referred to recovery-oriented psychotherapists who will integrate psychotherapy with mutual self-help approaches.

Clients may overuse medications or relapse to illicit drugs. Certain medications that do not produce physical dependence or withdrawal and have much lower potential for abuse have been found to be effective for treating anxiety disorders. Many are as effective as the benzodiazepines but without the abuse liability. The antidepressants fluoxetine (Prozac) and sertraline (Zoloft) and the antianxiety medication buspirone (BuSpar) are medications that can be used to treat symptoms of anxiety disorders, have good safety profiles, are not euphorigenic (producing euphoria), and have few drug interaction cautions. They can be used in the management of subacute withdrawal states. When these drugs do not produce the desired results, the tricyclic and monoamine oxidase inhibitor antidepressants may be used. (See appendix F for a discussion of psychiatric medications.)

Medications should be used in combination with nondrug treatment approaches. Although studies are still underway, acupuncture, aerobic exercise, stress reduction techniques, and visualization techniques may be useful components of treatment and recovery. These tools can be valuable adjuncts for the reduction of stress. Clients should be taught that efforts to improve their general health, such as eating more healthful foods and exercising regularly, can lead to better mental health.

It is beyond the scope of this TIP to provide comprehensive review on the use of psychotherapeutic treatment. However, there are numerous resources regarding counseling and psychotherapy for depression and anxiety (e.g., Barlow 2002).

Longer term care

Always first in longer term COD treatment are the issues of diagnosis and re-diagnosis. Once a patient has engaged in treatment and has been abstinent for over a month, most of the substance-induced depression/anxiety symptoms caused by either the substance or its withdrawal should have abated. This allows for the diagnosis of ongoing symptoms to be more certain. It should be recognized that just because psychiatric symptoms abate with abstinence and addiction treatment alone doesn’t mean that such symptoms may not re-occur later and need specific mental health services, such as medications. It does, however, make this much less likely. If a patient is diagnosed with COD, is in active addiction treatment, but has been started on a psychiatric medication for depression, anxiety, or both by an outside prescriber (either a psychiatrist or primary care physician), then the substance abuse counselor should refer to chapter 5 of this TIP (the section titled “Monitor Psychiatric Symptoms”) to identify strategies for monitoring symptoms and supporting medications.

While medications are useful for anxiety disorders, they are not a substitute for substance abuse treatment or other activities related to recovery. Cognitive and behavioral techniques used in substance abuse treatment often are as effective as medications in treatment of anxiety disorders, though they generally take longer to achieve an equivalent response for the mental illness component of the disorder.

It should also be noted that certain depressions may become so severe that they can cause symptoms of mental disorders, such as delusions (e.g., “I’m so evil that I was responsible for starting World War II”) or hallucinations (e.g., “When I’m alone I hear my name being called and the voices tell me that I am bad”). These types of depression need immediate psychiatric consultation and medication treatment. Patients who are significantly anxious or depressed should always be evaluated for suicide: Counselors are referred to chapter 5, the subsection “Potential for harm to self or others” within the section titled “Monitor Psychiatric Symptoms,” as well as to the suicidality sections in chapter 8 and this appendix, for details on evaluation and management.

The consumption of foods containing stimulants should not be overlooked. People who consume significant amounts of caffeine and sugar may have a higher risk for episodes of anxiety and depressive symptoms. Chocolate, large quantities of refined carbohydrates, and any diets that cause significant variations in blood sugar levels should be avoided, since this condition will tend to aggravate or induce both mood and anxiety states. It is important to be sure that eating habits do not imitate the rushes and crashes of substance abuse.

Schizophrenia

Schizophrenia is best understood as a group of disorders that can be divided into subtypes: (1) paranoid type, in which delusions or hallucinations predominate; (2) disorganized type, in which speech and behavior peculiarities predominate; (3) catatonic type, in which catalepsy or stupor, extreme agitation, extreme negativism or mutism, peculiarities of voluntary movement or stereotyped movements predominate; (4) undifferentiated type, in which no single clinical presentation predominates; and (5) residual type, in which prominent psychotic symptoms no longer predominate.

Symptoms of schizophrenia include delusions, hallucinations, disorganized speech (e.g., frequent derailment or incoherence), grossly disorganized or catatonic behavior, and deficits in certain areas of functioning—for example, the inability to initiate and persist in goal-directed activities. These symptoms regularly develop before the first episode of a schizophrenic breakdown, sometimes stretching back years and often intensifying prior to reactivations of an active, acutely psychotic state.

Relatively subtle indicators may exist. For example, a clinician may notice a client’s tendency toward loose associations, a symptom that is exhibited when ideas expressed appear to be disconnected or only very loosely connected. A similar disturbance, called tangentiality or tangential thinking, occurs when a client gets lost in telling a story and cannot get to the point. As with many of the behaviors discussed, isolated occurrences of these phenomena are unremarkable, but their repetition can be a cause for concern.

Clinicians generally divide the symptoms of schizophrenia into two types: positive and negative symptoms. Acute course schizophrenia is characterized by positive symptoms, such as hallucinations, delusions, excitement, and disorganized speech; motor manifestations such as agitated behavior or catatonia; relatively minor thought disturbances; and a positive response to neuroleptic medication. Chronic course schizophrenia is characterized by negative symptoms, such as lack of any enjoyments (“anhedonia”), apathy, very little emotional expressiveness (“flat affect”), and social isolation. Some clients will live their entire lives exhibiting only a single psychotic episode; others may have repeated episodes separated by varying durations of time.

Brief reactive psychosis describes a condition in which an individual develops psychotic symptoms after being confronted by overwhelming stress.

Bipolar disorder

Bipolar disorder, formerly termed “manic-depressive illness,” is meant to characterize the fluctuations in mood from one end or “pole” to the other—severe depression to mania. Unlike schizophrenia, bipolar illness might have little effect on the client’s ability to think; that is, it does not necessarily include the symptoms of a “thought disorder,” whereas schizophrenia at some point always shows disturbances of thought (such as delusions, bizarre beliefs, or loose associations).

Depressive phases in bipolar clients are similar to those in clients who are severely depressed—that is, the person feels sad; might feel life is not worthwhile; gets little or no enjoyment from anything, even from involvement with children or family/friends; and has altered appetite and sleep needs, for example, waking up early in the morning almost 2 hours before normal or oversleeping. Similarly, the client may overeat or have little or no appetite. The person might experience lethargy; fatigue easily; have feelings of guilt or worthlessness (sometimes for seemingly trivial things) or show strong feelings disproportional to the acts or thoughts involved; and experience recurrent thoughts of death, illness, or manifest suicidal thoughts, plans, or attempts.

Manic episodes for someone with bipolar disorder also vary in intensity. Full-blown, intense mania (during which a client might, for example, take off all his or her clothes and run to a church to declare that the secrets of the universe have been revealed) is relatively rare and, especially with medication, usually short-lived. An evolving manic episode might be hard to detect, especially in someone who is drinking and/or using drugs; some people with mania can get by on a day-to-day basis, partying and barely sleeping, telling tall tales others might ignore, and even being intact enough to persuade others that their delusion of vast wealth is true. People in a manic state have been known to get yachts to take to sea for a trial run or to run up thousands in bills at expensive hotels before anyone recognizes that the individual has not changed clothes in 6 days and cannot carry on a conversation without stating outlandish impossibilities (such as owning Nebraska or being married to the queen of England).

In between the extremes of elation and depression, some clients with bipolar disorder are likely to struggle almost all the time with mild-to-moderate depression and, on occasion, with “hypomanic” (mildly elevated) states that can carry deterioration in judgment, leading to legal trouble, financial loss, or relapse to abusing substances. For the 20 to 30 percent of people with bipolar illness who are not fully functional between episodes of mania and/or depression, the residual phase is usually characterized by mood instability, interpersonal problems, and/or occupational difficulties (APA 2000). However, clients with bipolar disorder who are successfully treated frequently return to positive and productive lives without any future disruption.

Psychosis versus substance-induced psychotic disorder

Differential diagnosis among psychotic disorders can be challenging, even for experienced clinicians and diagnosticians, especially when drugs and alcohol are involved. When a client presents in a psychotic state, any immediate or recent substance use is difficult to determine, and it may be impossible to discern whether the hallucinations or delusions are caused by alcohol or other drug use. If the hallucinations or delusions can be attributed to substance use, but are prominent and beyond what one might expect from intoxication alone, the episode would be described as a “substance-induced psychotic disorder.” Hallucinations that the person knows are solely the result of substance use are not considered indicative of a psychotic episode; instead, they are considered part of what DSM-IV-TR calls Substance Intoxication.

Psychedelic, hallucinogenic, and stimulant drugs can produce reactions with psychotic features, especially in clients with co-occurring schizophrenia and bipolar disorders. People who use phencyclidine (PCP) and who experience one psychotic episode are “more likely to develop another with repeated use” (Goldsmith and Ries 1998, p. 971). In addition, withdrawal from some substances, especially alcohol, can produce states that can mimic psychosis. Consider the following descriptions by Goldsmith and Ries (1998, p. 970) of the known concomitants of withdrawal:

• Sedatives: “A protracted withdrawal syndrome has been reported to include anxiety, depression, paresthesias [a tingling, prickling, or burning sensation on the skin], perceptual distortions…headache, derealization and depersonalization, and impaired concentration.”
• Amphetamines: Many people who abuse stimulants report a state of hopelessness, discomfort, and unhappiness that includes little or no pleasure. This state may persist for weeks. “Some stimulant addicts report hallucinatory symptoms that are visual (e.g., coke snow) and tactile (e.g., coke bugs). Sleep disturbances are prominent in the intoxicated and withdrawal states, as is sexual dysfunction.”
• Opioids: “There are reports of an atypical opiate withdrawal syndrome consisting of delirium following the abrupt discontinuation of methadone.”
• Alcohol: “A few chronic heavy drinkers experience hallucinations, delusions, and anxiety during acute withdrawal, and some have grand mal seizures. Brain damage of several types is associated with alcohol-induced dementias and deliriums.”

Some clinicians have developed clues to differentially discriminate one type of disorder from another. For example, DSM-IV (APA 2000, p. 300) advises that “certain types of auditory hallucinations (i.e., two or more voices conversing with one another or voices maintaining a running commentary on the person’s thoughts or behavior) have been considered to be particularly characteristic of schizophrenia….” Mendoza and Miller (1992) suggest that people who abuse cocaine and become paranoid maintain their abstract thinking and basic clear thinking; they have delusions that are poorly developed and of a non-bizarre nature (Goldsmith and Ries 1998). Fortunately, both the substance abuse treatment clinician and the physician responsible for the management of a client with psychotic-like symptoms can attend directly to the symptoms presented and begin by treating those symptoms without requiring an exact diagnosis beforehand.

Physical illnesses and reactions to medication

Any number of physical illnesses or medication reactions, from brain tumors to steroid side effects, can cause a psychotic episode or psychotic behavior. These are situations when the thorough diagnostician, one who follows a client until the details of the disorder and the correct differential diagnosis are clear, earns his or her keep.

Schizophrenia versus bipolar disorder

Detailed and complex strategies for conducting a differential diagnosis take into consideration the typical “natural” histories of both substance use disorders and schizophrenia or bipolar disorder and the pattern of presenting symptoms (see, e.g., Rosenthal and Miner 1997). Often, continued input from the substance abuse counselor and treatment team staff will help clarify the diagnosis or lead a psychiatrist to change a diagnosis from schizophrenia to bipolar disorder. This may also lead the psychiatrist to switch a client’s medication from one of the “antipsychotic” medications to a “mood stabilizer” such as lithium.

Collateral information can be important in making an accurate diagnosis. For example, Sloan and colleagues (2000) found that a self-report of having been hospitalized with a diagnosis of bipolar disorder and/or a report of a prior positive therapeutic response to a mood stabilizer were better measures of bipolar disorder than questions about symptoms. Some types of delusions brought on by drinking (often delusions of jealousy) or by methamphetamine use can be recognized easily with input from collateral sources that clarify the situation. Without such information, staff can be misled into believing the delusion is true.

Schizophrenia

The lifetime prevalence rate for adults with schizophrenia is between 0.5 and 1.5 percent (APA 2000). The Epidemiologic Catchment Area (ECA) studies reported that among clients with schizophrenia, 47 percent met criteria for some form of a substance use disorder (Regier et al. 1990). Fifteen years earlier, McLellan and Druley (1977) also found that about half of male inpatients with schizophrenia could be expected to have a co-occurring addiction to amphetamines, alcohol, or hallucinogens. Research by Fowler et al. (1998) reviewed prior studies and assessed 194 Australian outpatients with schizophrenia, finding similar results with more than 59 percent of the group having lifetime alcohol abuse/dependence. In an almost all-male study of the medical records of 1,027 veterans treated for some form of schizophrenia, Bailey and colleagues (1997) found that 50.8 percent of the clients had received a diagnosis of a substance use disorder.

Bipolar disorder

The lifetime prevalence of bipolar disorder also is roughly 1 percent of the general U.S. population (APA 2000), so both schizophrenia and bipolar disorder are relatively rare compared to major depressive illness, which has lifetime incidences in the general population of 10 to 25 percent for women and 5 to 12 percent for men (APA 2000). People with bipolar disorder also are subject to high rates of co-occurring substance abuse and dependence, with even higher rates in specific populations. In the ECA study, nearly 90 percent of those with bipolar disorder in a prison population had a co-occurring substance use disorder (Regier et al. 1990).

Engagement

For clients with psychosis, as for others with co-occurring disorders, it is essential to build a relationship. Actively helping them to secure basic needs such as medical assistance and housing helps with the engagement process, and also helps create the level of stability needed for treatment to proceed successfully (see Figure D-11). It also is helpful to increase client motivation for treatment through involvement of the client’s family.

Screening and assessment

Clinicians experience a common difficulty in determining whether psychotic symptoms represent a primary mental disorder or are secondary to substance use. In the early phase of assessment, the goal is to stabilize the crisis rather than to establish a diagnosis, which is often best determined during a multiple-contact, longitudinal assessment process. The best assessments include direct client interviews, collateral data, observations of the client, and a review of available documented history. Especially with clients who have bipolar or schizophrenic disorders, the counselor will profit from always actively inquiring how they are feeling and how things have been going. These clients might sometimes inexplicably fail to describe the most significant events or changes spontaneously, even though they are forthright and open about such matters when asked.

Crisis stabilization

The most important initial step in treatment is to identify high-risk conditions that require immediate attention. Within the area of acute management it is useful to differentiate between acute management of crises and the resolution of subacute problems that may be severe but not life threatening.

Short-term care and treatment

Following the resolution of the acute crisis, subacute conditions must be addressed before long-term management can occur. (Subacute conditions can also occur as a precursor to acute relapse of psychiatric symptomatology or substance use.) Examples of specific management issues that may arise in regard to subacute conditions include resuming or adjusting psychotropic medication, clients’ comfort with the medication, medication compliance, addressing acute psychiatric symptoms, establishing early substance abuse treatment intervention, and establishing or sustaining clients’ connection with support systems and services for obtaining housing and meeting basic needs.

The subacute phase offers an opportunity to reassess the diagnosis and overall treatment needs. The ultimate goal should be to establish a long-term treatment plan, avert imminent decompensation or relapse, and plan to address long-term needs. Both short-term and long-term plans should be developed with the client and should be subject to periodic review and revision.

Longer term care

The overall goal of long-term management should involve: (1) providing comprehensive and integrated services for both the mental and substance use disorders, and (2) doing so with a long-term focus that addresses biopsychosocial issues in accord with a treatment plan with goals specific to a client’s situation. The following cases exemplify some of the diverse issues that may arise in treatment planning.

Case Studies: The Importance of a Dual Recovery Approach for Two Clients With Psychosis

Louisa F.

Married for more than 15 years, Louisa F. was responsible for most of the duties related to raising four children and maintaining the home. In the past, she had been treated for an episode of postpartum psychosis, but until recently she had not required any psychiatric medications or mental health services.

Her husband, a successful businessman, was the family’s only source of financial support and was emotionally distant. While Louisa F. believed that her husband was frequently out of town on business trips, he was actually nearby having an affair with a woman whom Louisa F. had known for many years. One day, he abruptly informed Louisa F. of the affair and moved out of the house.

During the next 3 days, Louisa F. was intensely depressed and agitated. Her normally infrequent and low-dose alcohol use escalated as she attempted to diminish her agitation and insomnia. During this time, she ate and slept very little. She began to feel extremely guilty for even the smallest problem experienced by her four children. She felt burdened by what she called her “transgressions, faults, and sins.” She expressed fears about being doomed to “eternal damnation.” Loudly and inconsolably, she declared that she “had lost her soul” and would have to repent for the rest of her life. While being taken to a nearby clinic for evaluation, she passionately described a conspiracy by members of the Catholic Church to steal her soul.

James T.

In his inner-city neighborhood, James T. was well known by the local medical clinic, the substance abuse treatment program, and the community mental health program. During the day he spent much of his time walking around the neighborhood, frequently talking to himself or arguing with an unseen individual. He spent most of his evenings in the park in a wooded area away from other people, except in the winter when he slept in community-run shelters.

James T. has a prominent scar in the center of his forehead. When asked about it, he described in great detail his “third eye,” and how he could see into the future through the eye. When asked about his stated reluctance to live in an apartment, he described an aversion to “electromagnetic fields” that drain his “life force” and make it difficult for him to “think about good things.” For extended periods lasting several months, James T. appeared disheveled and agitated, and he could be seen drinking heavily or using whatever drugs were available. During other periods, he did not use drugs and alcohol heavily and appeared well-groomed.

In general, James T. was pleasant and well-liked, although he was known to become hostile and potentially violent when he used substances.

Figure D-13. AD/HD Symptom Cluster: Inattention

Figure D-14. AD/HD Symptom Cluster: Hyperactivity-Impulsivity

Engagement

During engagement, a problem can emerge if the client divulges a previous AD/HD diagnosis to a counselor who does not believe the problem exists. Another problem can occur if the client has the hyperactive version of AD/HD, which makes interaction difficult, and poses many of the same challenges as hypomanic clients. Such clients have trouble staying focused and maintaining a dialogue. Eliciting information and keeping the client on task for the duration of the intake interview is difficult. These clients may have a “short fuse” and become irritable when the counselor has to bring them back to the intake process repeatedly. During group, this type of behavior and habitual side conversations can lead to intragroup conflict.

These engagement problems are in fact the beginning stages of differential diagnosis and assessment. Adult AD/HD has not been widely recognized or accepted in either the substance abuse or mental health treatment communities, but occupies a position similar to that of PTSD in the last decade—clients with complaints, a small amount of research, and often active resistance by therapists to acknowledging that AD/HD is a real disorder. Substance abuse treatment counselors who hear clients say, “I was just self-medicating my AD/HD with cocaine,” as a convenient rationalization for substance abuse may be even more suspicious, but about one in six of these “rationalizers” may have real attention deficit problems that undermine their treatment and abstinence. At this stage, the best engagement strategy for such clients is to keep an open mind to the possibility the client does have AD/HD and develop services or referrals for clients who are legitimately affected by AD/HD.

Screening and assessment

Strictly speaking, it is not possible to diagnose an adult as having AD/HD unless there is a childhood history of the disorder. Basic screening for this possibility can be as simple as asking, “When you were in grade school, before you used drugs or alcohol, did you have learning or behavior problems? Were you ever diagnosed with AD/HD? Did you ever take medications for this? How much did the medications help?”

The clinician is advised to “focus on the primary symptoms of inattention, impulsivity, and hyperactivity because secondary symptoms such as procrastination, disorganization, forgetfulness, chronic lateness, or underachievement do not necessarily indicate that the client suffers from AD/HD” (Waid et al. 1998, p. 406).

Since people with substance use disorders are not always good historians, whenever possible it is useful to interview others who knew them well as children. Evidence should also be sought “via review of records, reports from parents or significant others, and use of behavioral checklists and questionnaires” (Waid et al. 1998, p. 412). Scales and checklists currently available for use in assessing behavioral symptoms of AD/HD include the Hyperkinesis-Minimal Brain Dysfunction Childhood Symptom Checklist, the Wender Utah Rating Scale (Ward et al. 1993), the Client Behavior Checklist, and the Conners Abbreviated Symptom Questionnaire. When using these instruments, the clinician should be aware that they have not been validated for use in substance-abusing populations.

There is no “definitive test battery” to assess the neuropsychological impairments associated with AD/HD, but much can be learned by observing clients’ behavior in testing situations. Frequent false starts, off-task behavior, and concentration problems are suggestive (Waid et al. 1998), and continuous performance tests—the Gordon Diagnostic System (GDS), the Test of Variables of Attention (TOVA), and the Conners Continuous Performance Test—can be used to measure distractibility.

The most common attention problems in people with substance use disorders occur as a result of short-term toxic effects of substances. Such difficulties should improve with each month of abstinence. With this in mind, Waid and colleagues suggest that “frequent reassessments as abstinence is maintained may result in the detection or disappearance of other psychiatric and cognitive disorders, including learning disabilities” (Waid et al. 1998, p. 415). If attention symptoms do not improve over time, the client should be referred for further assessment.

Crisis stabilization

Adult AD/HD is not an emergency condition. Rather, it usually is chronic, subtle, and difficult to separate from the client’s substance use or its consequences. The most likely crisis that might emerge is from the significant abuse of prescription stimulants obtained illegally or from a doctor outside the client’s established healthcare providers. For example, a client might arrive at a group intoxicated, on stimulants, hyperactive, and evasive. The client might have a positive urine test, but refuse to accept the incident as serious because “the medication was prescribed.” The second part of the crisis would then require consultation with the outside prescribing doctor; the client must sign a consent form for the release of information held by this doctor.

If the client is found to be taking psychoactive and abusable prescription medications such as amphetamines, Ritalin, and pemoline outside of the substance abuse treatment agency treatment plan, an immediate treatment conference is needed to determine and discuss

• Client safety: Does the client need hospitalization or detoxification?
• If not, is the client willing to discontinue the outside medications and continue substance abuse treatment?

Preferably, medical personnel at the substance abuse treatment agency will obtain the appropriate consent from the client, contact the outside doctor, discuss the case, and make the best clinical decisions around the welfare of the client. This typically includes consideration of other, nonabusable AD/HD medications such as bupropion or desipramine, preferably prescribed by internal agency substance abuse treatment staff (if available).

Short-term care and treatment

Unless the client already has been diagnosed with valid AD/HD, which is possible but rare, AD/HD cognitive and behavioral problems begin to become apparent during this initial phase of treatment. Poor attention and impulsive behavior are most likely due to continued substance use or withdrawal; however, if the client is found to be clean and has no history of a mental disorder, then AD/HD should be considered, and the client should be referred to an expert diagnostician. Since AD/HD expert diagnosticians are rare, especially as available to substance abuse treatment agencies, the field faces a serious challenge. Individual clinicians need to do the best they can with their limited resources.

Factors leading to underdiagnosis of AD/HD at this stage include

• Reluctance on the part of staff or the client to considering or accepting the diagnosis, or lack of familiarity with the disorder.
• Difficulties stemming from the client’s lack of recall or having no family to help with the diagnosis of a childhood AD/HD condition, whether or not the diagnosis was made officially.
• The client’s life habits have compensated partially for AD/HD symptoms, though AD/HD was present in childhood and symptoms may emerge in the treatment process.

Factors leading to overdiagnosis include

• Attributing cognitive or behavioral abnormalities prematurely to AD/HD, rather than considering the most usual causes (continued substance use, withdrawal, or other disorders noted above).
• Using results of standardized screens such as the AD/HD Behavior Checklist for Adults without considering that many positive responses can be caused by substance use or other mental disorders.

Assuming that the AD/HD diagnosis is reasonably and accurately made, sensible treatment for adults with co-occurring substance dependence and AD/HD include the following:

• Abstinence from substances of abuse or dependence.
• A psychosocial treatment plan that takes into account the client’s AD/HD profile—for example, an increased use of visual aids (Dansereau et al. 1995; Dees et al. 1994).
• The use of medications to increase attention.

Though substance-dependent AD/HD clients may be able to take abusable stimulants in highly monitored clinics, much as opioid-dependent clients can take methadone in highly controlled clinics, this approach should not be attempted by other substance abuse treatment clinics. Rather, when medication is indicated, bupropion, tricyclics such as desipramine, or other antidepressants should be used. These medications have been found to be about as effective as stimulants, but are not abusable and have little if any street value. The substance abuse treatment counselor helps to monitor compliance, asks about side effects, and communicates any clinical responses to the prescriber.

Longer term care

Even if response to medications and structure occurs, the effects may be subtle and slow to develop—it is primarily in longer term care that the real benefit of integrated AD/HD care emerges. The client will be more likely to stay sober and in treatment within the framework of longer term care. Gradually, the impulsiveness and inattention should lessen. Coaching about how to handle taking medications while attending 12-Step or other mutual self-help programs also may be advisable.

Figure D-15. Grounding: A Coping Skill for Clients With Emotional Pain

Screening and assessment

It is important to emphasize that, in obtaining a preliminary diagnosis of PTSD, it can be damaging to ask the client to describe traumatic events in detail. When screening it is important to limit questioning to very brief and general questions, such as “Have you ever experienced childhood physical abuse? Sexual abuse? A natural disaster such as a hurricane or tornado? A serious accident? Violence or the threat of it? Seeing a dead body?” Once a brief and general identification of such traumas has occurred, the substance counselor should not seek to obtain detailed description of such events, which can be extremely destabilizing for the client and is unnecessary for screening purposes. Indeed, it has been found that having the client complete a written questionnaire leads to higher reporting of traumas and may be less upsetting for clients (Najavits et al. 1998).

Assuming the client has a trauma, the Modified PTSD Symptom Scale (Falsetti et al. 1993) is a good screening instrument. The scale asks about each of the DSM-IV symptoms for PTSD and is useful for monitoring and tracking PTSD over time. Although it is relatively rare for clients to become upset when answering a written questionnaire about trauma, if such a questionnaire is used, the client should know how to locate clinical staff for help if the process becomes too upsetting. Both childhood and adult traumas should be identified; for example, a rape experience within the last year and early childhood incest both could lead to the development of anxiety disorders. Because people living in violent situations, such as prostitutes who have been raped, can manifest anxiety symptoms, it is a mistake to ignore proximal violence and look solely at early traumas. Abuse of males as well as females must be considered, as the issue of physical and sexual abuse of males historically has been overlooked.

Crisis stabilization

Danger to self is a particular risk for clients with PTSD and substance abuse; the self-harm may include suicidality, which is common in this population, as well as self-injurious behavior such as cutting or burning. People in dissociated states may put themselves in danger to which they remain unaware, thus may require involuntary commitment. Finally, the potential for harm to others needs to be considered, particularly in clients with PTSD who show high levels of aggression and poor impulse control. The clinician should establish a written plan that details what the client will do if he feels the impulse to act out any self-harm behavior; this plan should include who to call after hours (for outpatient care), as well as strategies that may help the client reduce the impulse. The client and the clinician should each keep a copy of the plan.

Short-term care and treatment

Longer term care

For clients with a severe trauma history, treatment is likely to be long term. If possible, refer the client with PTSD to an individual therapist who can work with the client consistently over a long period. Individual therapy generally is needed (in addition to the standard group treatments typical of substance abuse treatment programs) to permit confidential discussion of, and adequate attention to, trauma.

Case Study: Counseling a Client with Polysubstance Abuse and PTSD

Carlos F. is a 34-year-old man who repeatedly has been admitted to detoxification and substance abuse treatment for polysubstance abuse. He appears aggressive and defensive and tends to isolate. Since childhood, he has a long history of starting fights, and does not like to talk about his past. He was not assessed for PTSD until the present admission, where a counselor found out that he was physically and sexually abused by his mother during childhood. Carlos F. had never heard of PTSD, but when presented with education about the symptoms he was able to recognize them in himself immediately. Carlos F. stated, “I always thought there was just something wrong with me—bad genes, or just a bad attitude. It is a relief to know there’s a reason why I feel and act the way I do.”

Discussion: Counselors often are more likely to diagnose PTSD in women, with the single exception being soldiers or survivors of kidnapping or torture. It is important to screen for PTSD for all clients—men and women—and for all types of trauma. For more information on PTSD and trauma, see the forthcoming TIP Substance Abuse Treatment and Trauma (CSAT in development d).

Anorexia nervosa

Anorexia nervosa, the most visible eating disorder, is marked by a refusal to maintain body weight above the minimally normal weight for age and height (currently operationalized as 85 percent of expected weight for height). Anorexia nervosa (“nervous loss of appetite”) is a misnomer. Only in extreme stages of inanition (i.e., exhaustion as a result of lack of nutrients in the blood) is appetite actually lost.

Individuals with anorexia nervosa have a dogged determination to lose weight and can achieve this in several ways. Individuals with the classic restricting subtype of anorexia nervosa achieve this weight loss solely through severe food restriction, exercise, and fasting. Others augment their dieting with vomiting, laxative use, diuretic use, diet pills, and other methods of purging. In addition to these purging behaviors, women with the bulimic subtype also exhibit binge eating.

Individuals with anorexia nervosa have an intense fear of gaining weight even when emaciated, place undue importance on weight and shape in terms of self-evaluation, deny the seriousness of their illness, and may experience a distortion of the manner in which they perceive their own body size (i.e., they may see themselves as fat even when emaciated). In women, the cessation of menstrual periods for 3 or more months officially is required to diagnose anorexia nervosa; however, this criterion should be viewed with caution because there is great variation in the reproductive system’s response to starvation.

The age of onset of anorexia nervosa usually is during the teenage years (Lucas et al. 1991). However, it can occur earlier and may emerge at any time.

Bulimia nervosa

The core symptoms of bulimia nervosa are bingeing and purging. A binge is regarded as the rapid consumption of an unusually large amount of food by comparison with social “norms” in a discrete period of time. Integral to the notion of a binge is feeling out of control. An individual with bulimia may state that he or she is unable to postpone the binge or stop eating willfully once the binge has begun. The binge may only end when she is interrupted, out of food, exhausted, or physically unable to consume more. Although the current DSM-IV diagnostic criteria require the presence of binge eating at least twice per week for at least 3 months (see chapter 8), bingeing and purging clearly are unhealthy behaviors and should not be ignored when present at lesser frequencies.

The second feature of bulimia nervosa is purging. There are many different ways that individuals with bulimia nervosa compensate for overeating. Between 81 and 88 percent of women with bulimia self-induce vomiting (Hoek and van Hoeken 2003; Johnson et al. 1982; Mitchell et al. 1985; Rome 2003; Sigman 2003). Other methods of purgation include the abuse of laxatives, diuretics and emetics, saunas, excessive exercise, fasting, and other idiosyncratic methods that people believe will lead to weight loss. Many of these auxiliary methods are dangerous and ineffective as they promote loss of water and valuable electrolytes (see the section on crisis stabilization below). Finally, individuals with bulimia nervosa place undue emphasis on shape and weight in their sense of identity.

The age of onset of bulimia nervosa is generally somewhat later than for anorexia nervosa; however, many women have bulimia for up to 5 years prior to seeking treatment.

Other eating disorders

There are several alternative and subthreshold presentations of disordered eating. Among these are individuals who purge in the absence of binge eating, as well as individuals who meet some but not all formal diagnostic criteria for anorexia or bulimia nervosa. Binge-Eating Disorder (BED) is being scrutinized as a potential third discrete eating disorder. BED is associated with binge eating in the absence of compensatory behaviors and commonly is associated with obesity.

Substance abuse and dependence among people with eating disorders

Estimates of the prevalence of co-occurring substance abuse and/or dependence in clinical samples of women with bulimia nervosa have varied widely. The prevalence of comorbid substance abuse ranges between 3 percent and 49 percent. A review of 25 studies of the prevalence of substance abuse in women with bulimia nervosa in clinical samples calculated a median prevalence of 23 percent (Corcos et al. 2001; Holderness et al. 1994; Specker and Westermeyer 2000; Westermeyer and Specker 1999). Parameters affecting the estimates differ according to the nature of the clinical service (inpatient versus outpatient), the definition of the disorder, assessment procedures for both eating disorders and substance dependence, whether current or lifetime diagnoses are assessed, the distorting effects of any exclusion criteria for clinical trials, and the age of clients seen.

Overall, the majority of studies have observed an elevated prevalence of substance abuse in clinical samples of women with bulimia nervosa. Most studies have observed comorbidity that exceeds that expected in the general population of women of similar age, as well as higher rates than in women with major depression. Population-based studies also have observed elevated substance abuse in women with bulimia nervosa (although not as extreme as in clinical samples), suggesting that the observed co-occurrence is not merely the result of focusing studies on treatment-seeking populations.

The frequently observed co-occurrence of substance abuse in women with bulimia nervosa warrants routine screening for the presence of substance abuse when women with bulimia nervosa are assessed. The screening ideally would address both current and lifetime presence of alcohol and other substance use disorders and would seek to develop an indepth understanding of the relation between the eating disorder and substance use.

Substance abuse appears to be much less frequent in women with the restricting subtype of anorexia nervosa than in other subtypes of eating disorders (Corcos et al. 2001; Specker and Westermeyer 2000; Westermeyer and Specker 1999). In most studies, the prevalence of substance abuse in women with anorexia nervosa was less than in women with bulimia nervosa and not significantly different from women in the general population. Substance use disorders are observed primarily in women with the bulimic subtype of anorexia. Across studies, the prevalence of substance-related disorders in anorectic women with bulimic features appear to be comparable to or exceed those of women with normal weight bulimia nervosa (Corcos et al. 2001; Specker and Westermeyer 2000; Westermeyer and Specker 1999).

In summarizing the data regarding the prevalence of substance abuse in clinical samples of women with eating disorders, several issues must be considered. First, although the prevalence of comorbid substance abuse is high, it is not the most frequently diagnosed comorbid condition. Most studies have reported more frequent lifetime comorbid affective and anxiety disorders. Thus, comorbidity of a range of disorders, not just substance abuse, commonly is observed in women with bulimia nervosa.

In addition, with some exceptions, most studies have been cross-sectional and have determined the eating disorder diagnosis based on current clinical presentation. This approach is conceptually problematic as the boundary between anorexia and bulimia nervosa often is fluid. Although a percentage of women with the restricting subtype of anorexia never binge or purge, between 37 and 48 percent of clinical samples of women with anorexia nervosa display features of bulimia nervosa at some point during their illness. The distinction between current anorexia nervosa with or without current bulimic symptoms has been codified in the DSM-IV into “restricting” and “binge-eating/purging” types. It is difficult, if not impossible, to predict accurately which women are likely to recover, maintain a chronic course of restricting anorexia, or develop bulimia nervosa. Therefore, when examining the prevalence of substance abuse in women with eating disorders, counselors must be mindful that the clinical features on which groups are defined are multifaceted, and that a cross-sectional examination of the same sample at a later date may yield different groupings, and therefore, different estimates of the prevalence of comorbidity.

Eating disorders among individuals with substance use disorders

To what extent are eating disorders a problem in individuals with primary substance use disorders? Studies examining prevalence of eating disorders in substance-dependent treatment samples have used both questionnaires and interview designs. With some exceptions, the prevalence of bulimia nervosa is elevated in women presenting for treatment of substance dependence (Corcos et al. 2001; Specker and Westermeyer 2000; Westermeyer and Specker 1999). The characteristics of people with substance use disorders and bulimia included younger age at presentation, onset of problem drinking at an earlier age, higher self-report scores on eating pathology, decreased chance of a family history of alcoholism, and heavier weight.

A study of callers to a national cocaine hotline (122 men and 137 women) via a structured telephone interview found that 22 percent of callers met DSM-III criteria for bulimia, 7 percent for anorexia and bulimia, 2 percent anorexia nervosa, and 9 percent met criteria for bulimia plus vomiting. Among female callers, 23 percent met criteria for bulimia and 13 percent met criteria for bulimia with purging (Jonas et al. 1987).

Studies of individuals in inpatient substance abuse treatment centers suggest that approximately 15 percent of women and 1 percent of men had a DSM-III-R eating disorder (primarily bulimia nervosa) in their lifetime as assessed via questionnaire (Hudson et al. 1992). Individuals with eating disorders were significantly more likely to use stimulants and significantly less likely to use opioids than individuals undergoing substance abuse treatment without comorbid eating disorders.

In summary, eating disorders and disordered eating appear to be overrepresented in clinical samples of women presenting for treatment of substance abuse. Further studies are required to assess how the presence of an eating disorder affects treatment for substance abuse and how best to integrate treatment for those with both conditions.

Figure D-16. How Are Eating Disorders and Substance Use Disorders Related?

Engagement

No controlled trials have yet been conducted to determine the optimal intervention strategy for women with co-occurring eating disorders and substance use disorders, although a variety of treatments have been described (Bergh et al. 2003; McElroy et al. 2003; Trotzky 2002; Weiner 1998). Few specialist services exist that are designed to treat eating disorders and substance abuse concurrently. In the absence of such services, staff on specialty services for substance use or eating disorders should have specific training in working with individuals with this particular pattern of comorbidity. Even less is known about men with eating disorders, and almost nothing has been written recently about their treatment (Mangweth et al. 2004).

Screening and assessment

Even though a client may not have an eating disorder currently, the past presence of bulimia or anorexia could become a factor in the successful treatment of her substance abuse, or vice versa. To detect this possibility, clinical interviews may be supplemented with structured eating disorders interviews such as the Eating Disorders Examination. A number of medical investigations might be warranted, depending on the findings on physical examination and based on the nature and severity of the substance-related disorder.

Figure D-17 suggests general and specific screening questions that may be used to probe the possibility that the client has an eating disorder. The general questions simply explore the individual’s attitudes toward shape, weight, and dieting. Sometimes it is best to start with such questions rather than begin immediately with questions focused specifically on the behavior patterns associated with anorexia and bulimia because clients may feel shame about these behaviors. Easing into the topic sometimes is the best approach.

Once the co-occurrence of eating and substance use disorders has been established, then a complete behavioral analysis can be informative, if consistent with the philosophy and approach of the treatment service. The critical questions to be addressed in this portion of the assessment include foods and substances of choice, high-risk times and situations for engaging in disordered eating and substance abuse behaviors, and the nature, pattern, and relationship of disordered eating and substance use. Examples of appropriate areas of inquiry are

• What sorts of situations could prompt the client to diet/binge/drink?
• What times of the day are high-risk times for each behavior?
• What are the cues that prompt disordered eating behavior/substance use?

In addition, counselors must address how dieting and bingeing are related to substance abuse. For example, does the client drink or use drugs to curb appetite when dieting? What is the effect of drinking on eating behavior? Does alcohol use lead to unrestrained eating? From the client’s perspective, do bingeing and drinking serve similar or different “functions?”

Crisis stabilization

Crisis situations differ somewhat between women with anorexia and bulimia nervosa. In both cases, the presence of substance abuse intensifies the crisis. Presenting symptoms include dehydration, electrolyte abnormalities, cardiac or gastrointestinal complications, secondary to extreme inanition, and suicidality. Women with bulimia nervosa may present in crisis with dehydration, electrolyte abnormalities, gastrointestinal crises secondary to purging (e.g., esophageal ruptures or instruments used for purging lodged in the throat), or suicidality.

In the case of both disorders, medical stabilization is of primary importance. Anorexia nervosa, in particular, is the most lethal of all mental disorders, with a mortality rate of approximately 6 percent per decade (Sullivan 1995). Deaths associated with anorexia nervosa are most commonly complications of starvation followed closely by suicide. Hospital admission with vigilant monitoring for disordered eating behaviors (e.g. bingeing, purging, excessive exercising) is critical. In their terror of weight gain, clients might attempt to engage in disordered eating behaviors in the hospital and sneak substances such as laxatives and diuretics into treatment facilities.

Short-term care and treatment

Once a diagnosis has been established and the behavioral parameters identified, three potential approaches have been outlined for the treatment of the individual with eating disorders and substance abuse. First, both disorders can be treated concomitantly on a unit specializing in this particular pattern of COD. Second, detoxification and treatment for substance abuse can be completed first, followed by specialized treatment for the eating disorder. Third, specialized treatment for the eating disorder can be followed by specialized treatment for the substance abuse.

There are several factors that can dictate which of these approaches is followed; however, no empirical data exist to inform the decision. Specialty services for clients with COD are scarce and hence the opportunity for concurrent treatment is limited. In the absence of such a service, counselors must attempt to determine which disorder currently is most troublesome and requires the most immediate attention. Perhaps the most important treatment goal is to encourage the client to complete treatment for both disorders, although detoxification is an essential first step for some individuals. Completion should be emphasized throughout the treatment process.

Whichever treatment approach is chosen, the other disorder cannot be compartmentalized and ignored. It is critical to address the presence of the eating problem, even if the substance-related problem is the initial target of treatment. Failure to integrate treatment leads to the “ping-pong” phenomenon where clients bounce back and forth between eating and substance abuse treatment services, never addressing the relation between the two disorders. The re-emergence of binge eating following detoxification from opioids and alcohol has been observed. It has also been noted clinically that the frequent behavioral pairing between disordered eating behaviors and substance abuse can lead to a situation in which relapse in one domain fuels relapse in the other. Thus, an integrated relapse prevention plan that acknowledges the similarities and differences in relapse risk for each behavior is essential.

Individuals with eating disorders who are being treated in substance abuse treatment facilities should participate fully in the substance abuse treatment program. Their treatment may be augmented with nutritional consultation, the setting of a weight range goal, and observations at and between meal times for disordered eating behaviors. If a treatment program has sufficient numbers of clients who have eating disorders or disordered eating behavior, special eating disorders psychoeducation or basic cognitive-behavioral strategy groups can be used to augment the substance abuse treatment plan.

The available literature supports the inclusion of clients with past or current mild or moderate substance-related disorders in eating disorders treatment programs. Cognitive-behavioral techniques targeted toward bulimic symptoms such as psychoeducation, identification of automatic thoughts, thought restructuring, chaining, and relapse prevention, often generalize to substance-related problems.

Treatment of individuals with severe substance-related disorders and eating disorders poses a more significant clinical challenge. In addition to traditional cognitive-behavioral approaches, many individuals find 12-Step approaches beneficial in controlling their drinking or drug use and disordered eating behavior. Traditionally, the 12-Step approach of Overeaters Anonymous focuses on abstinence from high-risk foods (i.e., sugar, wheat), which are believed to have the ability to trigger a binge. In direct contrast, the cognitive-behavioral approach emphasizes empowerment over food and minimizes avoidance.

Although it is possible to abstain from alcohol and drugs, it is virtually impossible to abstain from foods, given their obvious relationship to survival and the frequency with which high-risk foods are encountered in daily life. In an integrated model that tries to merge cognitive-behavioral techniques with the beneficial 12-Step approach, one can encourage clients to abstain from high-risk behaviors (i.e., dieting or bingeing) rather than high-risk foods. Empirical data are required to substantiate the efficacy of this approach; however, it holds intuitive appeal for those individuals who find a 12-Step approach beneficial and who see similarities between their disordered eating and substance-related problems.

Pharmacological approaches to treatment also may be considered. The SSRI fluoxetine has been shown to be of some efficacy in the treatment of bulimia nervosa (Fluoxetine Bulimia Nervosa Collaborative Study Group 1992), although its specific efficacy in individuals with comorbid substance use disorders has not been documented. The opioid antagonist naltrexone appears to decrease the reinforcing efficacy of alcohol and has been approved by the Food and Drug Administration for the treatment of alcohol dependence because of its efficacy in reducing alcoholic relapse. Preliminary data suggest that naltrexone may decrease the frequency of bingeing and purging and the preoccupation with food in women with bulimia (Jonas and Gold 1988). The possible utility of naltrexone in the treatment of individuals with comorbid bulimia nervosa and alcohol dependence is an empirical question worthy of further investigation.

No clinical trials exist that identify the optimal approach to the treatment of comorbid eating disorders and substance-related disorders. Such trials clearly are needed to determine the most effective approach to individuals who present with severe co-occurring eating and substance-related disorders.

Longer term care and treatment

Relapse is a major concern in eating disorders. Anorexia nervosa is particularly difficult to treat, with the average duration of treatment being 5 years. Even women who have recovered from anorexia nervosa continue to maintain relatively low body weight and retain cognitive features of the disorder.

Although relatively successful treatments for bulimia nervosa have been developed (primarily cognitive-behavioral therapy), which lead to abstinence in between half and two thirds of clients, relapse is common within the first year following therapy. Thus, concrete relapse prevention strategies are critical both to prevent the re-emergence of disordered eating symptoms as well as to prevent the ping-pong effect in symptom expression. Techniques that can be incorporated into a successful relapse prevention program include

• Booster therapy sessions
• Participation in both 12-Step groups and more unstructured support groups for eating disorders and for substance abuse
• Use of self-help manuals and programs when slips occur and regularly throughout the recovery intervals
• Development of strategies that enhance self-awareness of imminent slips and relapses

Figure D-18. Diagnostic Criteria for Pathological Gambling Compared to Substance Dependence Criteria

Figure D-19. Comparison of Action and Escape Pathological Gamblers

Engagement

In an initial contact with a pathological gambler, it is important to begin developing rapport quickly. Counselors should remember that when a pathological gambler makes an initial phone call to access treatment or comes in for an initial evaluation, he or she is likely to be feeling a great deal of shame, guilt, anxiety, or anger. To acknowledge gambling problems is to admit to being a “loser,” an extremely difficult admission for most gamblers. The gambler whose family and friends have failed to acknowledge that he or she has a legitimate disorder also is likely to be sensitive about being judged, criticized, and condemned. Consequently, the clinician must demonstrate knowledge of the signs, symptoms, and course of pathological gambling; present a nonjudgmental attitude and empathy regarding the emotional, financial, social, and legal consequences of gambling; and convey hope regarding the potential for recovery.

It is also important for the clinician to understand how and when to probe for greater detail regarding the severity of the gambling disorder and its consequences, since as with substance abuse, the gambling client is likely to minimize the negative impact of gambling. Clients with COD are likely to minimize or deny the disorder for which help is not being sought.

Screening and assessment

There are several valid and reliable instruments that have been developed for the screening and assessment of pathological gambling.

Crisis stabilization

Pathological gamblers frequently come into treatment in a state of panic and crisis. The attempted suicide rate among gamblers in treatment is high (20 percent) (NRC 1999), which makes a careful evaluation of suicide potential essential. A common suicide plan for PG clients is to have an automobile accident so that family can collect life insurance to pay off gambling debts. Concurrent substance use adds to the risk potential for self-harm, so it is important that the gambler who is at risk for suicide contracts not to use any mind-altering substances in addition to not endangering him/herself or others. (However, as noted in the discussion of suicide, counselors should not rely solely on such contracts.) Placement in a structured environment, inpatient, or residential setting may be necessary in some cases.

Short-term care and treatment

This section will first discuss specific treatments that have been used in the treatment of pathological gambling, then explore how this knowledge can be applied to the pathological gambler with a substance use disorder. Although a broad range of treatment modalities have been applied to the treatment of pathological gamblers, to date there has been little research to support one type of treatment over another.

Longer term treatment

PG, like substance use disorders, may be conceptualized as a chronic, recurring disorder. Potential for lapses and relapses must be recognized for both disorders—and perhaps particularly for people with both disorders. It is important to educate clients about this possibility, if not likelihood, and to develop a plan for re-engaging in treatment if a lapse or a relapse occurs. Professionally facilitated continuing-care groups that focus on recovery maintenance skills can be effective, particularly in combination with mutual self-help groups.

Continuing-care groups often can be facilitated by peer counselors or treatment program alumni with several years of abstinence. Such continuing-care groups particularly may be useful for clients with COD to maintain contact with therapy resources, to help “catch” a relapse in the making, and to supplement limited availability of GA in many communities. Development of a treatment alumni network also can be a useful strategy to maintain contact with clients over longer periods of time and to increase the likelihood of using supportive resources in times of stress, vulnerability, or crisis.

Since Gam-anon groups are even less prevalent than GA groups, continuing-care groups for family members or for family members and PG clients jointly particularly can be useful to provide support for coping with financial issues that may persist for many years despite gambling abstinence.

Resolving financial problems and accomplishing debt repayment also can be a relapse trigger for pathological gamblers, so often it is important to schedule a “check up” visit around the anticipated time when gambling debts may be paid off. In general, it may be advisable to attempt to maintain therapeutic contact beyond the gambler’s 1-year anniversary of abstinence, since often this seems to be a time of vulnerability, overconfidence, and complacency regarding recovery.

Case Study: Counseling the Client With Pathological Gambling and Substance Use Disorders

Jan T. is a 32-year-old divorced, single parent with a history of cocaine and marijuana dependence, alcohol abuse, and two prior treatments for her substance use disorders. She entered treatment following a bout of heavy drinking resulting in a citation for Driving Under the Influence (DUI). During assessment, she screened positive on the SOGS for probable pathological gambling. She had been going to casinos several evenings per week, losing on average $200 to $500 per week playing video poker. Her rent and utilities were past due, and she feared losing her job due to tardiness and inefficiency because often she would go to work after staying up all night gambling. She had begun drinking while gambling after a 2-year abstinence from substances, and her drinking had increased as her gambling problems progressed.

Jan T.’s DUI occurred while driving home from an all-night gambling episode. Her gambling had begun to increase following her first substance abuse treatment and she acknowledged that her alcohol relapse after her first treatment was related to her gambling, as was her current relapse. She reported having increased her gambling due to feelings of stress and loneliness. As her gambling increased, she discontinued going to continuing care and AA and Cocaine Anonymous meetings. However, in her second substance abuse treatment, no one had asked her about her gambling and she did not recognize it as a problem at the time.

Current treatment emphasized her gambling problems as well as substance abuse. She attended gambling-specific education and therapy groups as well as AA, Cocaine Anonymous, and GA meetings. Due to serious, continuing financial problems and debt, Jan T. moved in with an older sister who had a 12-year history of abstinence from alcohol and attended AA meetings regularly. This sister also agreed to be her money manager.