Appendix D: Specific Mental Disorders – Additional guidance for the Counselor

While substance abuse treatment counselors do not always have the advantage of an accurate diagnosis of every disorder for each of their clients with co-occurring disorders (COD), the consensus panel believes it is useful to have a working knowledge of the most common disorders seen in substance abuse treatment settings. In cases in which a diagnosis has not been made, the counselor may be able to detect a pattern of behavior that suggests further assessment is needed. For clients currently receiving care, the counselor’s appreciation of the features and issues associated with each known disorder may improve coordination and mutual understanding between substance abuse treatment services and the mental health providers. Moreover, some knowledge of the disorder also will help the counselor understand the role of addiction within the framework of the client’s experience and to see how the client’s disorders are interrelated. This understanding may be helpful in relapse prevention. In addition, a general appreciation of the features of the disorder will help the counselor adapt the treatment strategy in meaningful ways that are more likely to be effective for the particular client. The consensus panel also acknowledges that people with COD may have multiple combinations of the various mental disorders presented in this appendix (e.g., a person with a substance use disorder, schizophrenia, and a pathological gambling problem). However, for purposes of clarity and brevity the panel chose to focus the discussion on the main disorders and not explore the multitude of possible combinations.

Known diagnoses should be documented. Such records will help the treatment agency gain a better understanding of this aspect of client demographics. If the substance abuse treatment agency seeks supplemental funding for its work with clients who have COD, it will be helpful, if not essential, to report the number and profile of such clients. Chapter 8 cites the diagnostic criteria used to identify many mental disorders by the standard diagnostic tool for professionals, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (). These criteria are not duplicated in this appendix.

The disorders in this chapter are discussed mainly within the following framework of topics:

  • Description of the disorder
  • Differential Diagnosis for the disorder, including how to distinguish this mental disorder from substance-related disorders or medical conditions that present in a similar way
  • Prevalence
  • Substance Use Among People With This Disorder
  • Key Issues and Concerns that arise in working with clients who have this disorder
  • Strategies, Tools, and Techniques, including those relevant to engagement, assessment, crisis stabilization, short-term care and treatment, and longer term care

Case studies are presented when illustrative information is useful to the counselor. See appendix F for medications commonly used to treat various disorders and observations on appropriate management of pharmacology with clients who have substance use disorders. Readers should also consult the introduction to chapter 8 for an overview of the aims and limitations of both chapter 8 and this appendix.




Differential Diagnosis


Substance Use Among Suicidal Persons

Key Issues and Concerns

Strategies, Tools, and Techniques

Nicotine Dependency

Differential Diagnosis


Tobacco Dependence Among Individuals With Another Substance Use Disorder

Tobacco Dependence Among Individuals With Mental Illness

Key Issues and Concerns

Strategies, Tools, and Techniques

Treatment Planning

How To Treat Tobacco Dependence

Personality Disorders (Overview)


Differential Diagnosis


Substance Use Among People With Personality Disorders

Key Issues and Concerns

Borderline Personality Disorder


Substance Use Among People With BPD

Key Issues and Concerns

Strategies, Tools, and Techniques

Antisocial Personality Disorder


Substance Use Among People With APD

Key Issues and Concerns

Strategies, Tools, and Techniques

Mood and Anxiety Disorders


Differential Diagnosis


Substance Use Among People with Mood or Anxiety Disorders

Key Issues and Concerns

Strategies, Tools, and Techniques

Schizophrenia and Other Psychotic Disorders


Differential Diagnosis


Substance Use Among People With Bipolar Disorder or Schizophrenia

Key Issues and Concerns

Strategies, Tools, and Techniques

Attention Deficit/Hyperactivity Disorder (AD/HD)


Differential Diagnosis


Substance Use and Dependence Among Adults With AD/HD

Key Issues and Concerns

Strategies, Tools, and Techniques

Posttraumatic Stress Disorder



Substance Use and Dependence Among People With PTSD

Key Issues and Concerns

Strategies, Tools, and Techniques

Eating Disorders



Substance Use Among Individuals With Eating Disorders

Key Issues and Concerns

Strategies, Tools, and Techniques

Pathological Gambling



Key Issues and Concerns

Strategies, Tools, and Techniques



Though not a DSM-IV diagnosed mental disorder, per se, suicidality is a high-risk behavior associated with COD, especially serious mood disorders. Suicide is a complex behavior usually caused by a combination of factors. Research shows that most people who kill themselves have a diagnosable mental or substance use disorder, or both, and that the majority of them have depressive illness. Studies indicate that the most promising way to prevent suicide and suicidal behavior is through the early recognition and treatment of substance abuse and mental illnesses, especially depression (). A wide range of self-harm and severely negative feelings and beliefs about the self can be induced or exacerbated by substance use. As a result, suicidal ideations, intentions, and behaviors can be potentially lethal complications of substance use disorders, especially for clients with co-occurring mental disorders.

Self-harm, often called parasuicide, can be expressed in a less extreme form than suicide, such as self-cutting, self-burning, and other self-mutilation behaviors. include “victim-precipitated homicide” as a form of suicidal behavior and recognize that drug and alcohol abuse often play a part in such tragic events. Researchers found that self-cutting acts were not accompanied by frank suicidal ideation in 18 percent of 100 male clients with alcoholism hospitalized for detoxification.

Differential Diagnosis

Suicide or suicide attempts can be the result of any substance use or mental disorder; however, suicide is more common in some disorders and more likely to be lethal with particular disorders. Acute suicidal planning or behavior requires immediate intervention; sorting out the differential diagnosis can occur later, once the client is safe. Note that being suicidal does not, in itself, mean that the person has an independent mental disorder.


A recent report from the Centers for Disease Control and Prevention’s National Center for Health Statistics indicates that in 2002, suicide was the eleventh leading cause of death for all Americans and the third leading cause of death for people ages 15 to 24 (Kochanek and Smith 2004). Males are four times more likely to die of suicide than are females; however, females are more likely to attempt suicide than are males (). There are an estimated 16 attempted suicides for each completed suicide. The ratio is lower in women and youth and higher in men and the elderly. Women and youth try more often and with less success than men; men and the elderly succeed more frequently. In recent years, rates for young adults have soared. Significantly, 50 percent of people who commit suicide have alcohol in their blood ().

Suicide rates increase with age and are highest among Caucasian males aged 65 and older. Older suicide victims are likely to have lived alone, have been widowed, and have had a physical illness (). Other population groups also have elevated rates of suicide. Many communities of American Indians and Alaska Natives have elevated suicide rates. Between 1980 and 1996, the rate of suicide among African-American males ages 15–19 increased 105 percent ().

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” (, p. 937). Suicide rates are particularly high among persons with the following mental disorders (, 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 ().

Substance use disorders alone increase suicidality (), 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” (, 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 ().

Substance Use Among Suicidal Persons

Alcohol and other drug abuse is a major risk factor in suicide, both for those with co-occurring mental disorders and for the general population. Alcohol abuse is associated with 25 to 50 percent of suicides; between 5 and 27 percent of all deaths of people with substance use disorders are caused by suicide, with the lifetime risk for suicide estimated to be 15 percent (). There is a particularly strong relationship between substance abuse and suicide among young people. One study found that as many as 70 percent of adolescent suicide victims had alcohol or substance abuse problems. For people with substance use disorders, the incidence of suicide is 20 times greater than the general population ().

Comorbidity of alcoholism and depression increases suicide risk (), perhaps because these agents exacerbate personality and cognitive problems, and add to environmental stressors. Alcohol also can impair cognitive functioning (). Using alcohol in attempts to relieve depression, anxiety, and fear often creates more depression and psychological distress, an effect labeled alcohol myopia (). Alcohol myopia involves narrowing or impaired perception that interferes with inferential thought and makes one “the captive of an impoverished version of reality in which the breadth, depth, and time line of our understanding is constrained” (, p. 923).

Thus, the link between alcohol use and suicide goes beyond the pharmacological and interpersonal effects. The association also may be a function of the capacity of alcohol to restrict attention to immediate situations, inhibit the ability to solve current problems, and limit hope for the future (). “Alcohol and substance use and abuse exacerbate other environmental problems and lessen the ability to cope” (, p. 453).

Key Issues and Concerns

The following are key elements of effective suicide prevention.

  • All substance abuse treatment clients should receive at least a basic screening for suicidality. All substance abuse treatment professionals should know how to conduct at least basic screening and triage.
  • The counselor should know his or her own skills and limitations in engaging, screening, assessing, and intervening with suicidal clients. Work out these issues before an emergency.
  • Providers are advised to develop clear answers to the following questions: Do you or your agency have the knowledge, tools, skills, and personnel for crisis stabilization and/or ongoing work with suicidal clients? How suicidal can clients be and still be retained in your practice or agency? What about suicidality that emerges later in treatment or in conjunction with a relapse?
  • The counselor should know what immediate onsite and offsite resources are available to help with someone identified as suicidal.
  • Establish standardized protocols and staff training around suicide screening, assessment, intervention, and/or triage: (1) Who asks? (2) What is asked? (3) When is this done? (4) Where does this take place? (5) How are findings documented? (6) What is done with the results?
  • Suicide “contracts” are written statements in which the person who is suicidal states that he will not kill himself, but rather call for help, go to an emergency room (ER), etc., if he becomes suicidal. These contracts are not effective as the sole intervention for a client who is suicidal. While such contracts often help to make the client and therapist less anxious about a suicidal condition, studies have never shown these contracts to be effective at preventing suicide. What good contracts really do is help to focus on the key elements that are most likely to keep clients safe, such as agreeing to remove the means a client is most likely to use to commit suicide.

Strategies, Tools, and Techniques


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


All substance abuse treatment clients should receive at least a brief screening for suicide, such as: “In the past, have you ever been suicidal or made a suicide attempt? Do you have any of those feelings now?” All substance abuse treatment staff should be able to screen for suicidality and basic mental disorders. It is expected that those at the intermediate or advanced levels of COD competence will have additional knowledge and skills.

Risk assessment

No generally accepted and standardized suicide assessment has been shown to be reliable and valid, but most established suicide assessments contain similar elements. A particularly easy-to-use method has been developed by the QPR Institute for Suicide Prevention. Further information and training is available at their Web site (

The QPR Institute’s risk assessment interview is designed to elicit information about the individual’s current risk of suicide, which then can be used to match the level of care with the level of risk (). The authors note that “client answers to an initial seven questions provide the database for clinical decision making, while the client’s level of commitment to a safety/treatment management plan determines the level of care, e.g., outpatient, inpatient, evaluation for involuntary admission.” See Figure D-1.

Figure D-1. Key Questions in a Suicide Risk Review

What is wrong?
• Personal narrative about how bad things are and the nature of the problem(s)
• Personal construction of reasons for suicide
• Personal measure of psychological pain and suffering
Why now?
• Elements of the current crisis
• History of real or imagined losses or rejections
• Sudden and unacceptable changes in life circumstances; for example, the client just received a serious or terminal diagnosis, relapse, onset of possible symptoms (e.g., sleeplessness)
With what?
• The means of suicide under consideration
• Access to the means selected
Where and when?
• Possible location and timing of a suicide attempt
• Degree of planning
• Possible anniversary phenomena
When and with what in the past?
• Past history of suicidal behavior
• Past history of intense suicidal ideation and/or planning
• Whether rescue was avoided
• Timing of past attempts
• Social response to past attempts
• Potential protective factors (reasons for living)
• Comparison of current method versus old method
Who’s involved?
• Others who may know or be involved
• Persons who may or may not be helpful in managing the client
• Names of potentially helpful third parties
• Possible presence of a suicide pact or murder-suicide plan
Why not now?
• One or more protective factors (reasons for living)
• Spiritual or religious prohibitions
• Duties to others or pets
• Residual tasks to be completed before the attempt; for example, making out a will

While the entire protocol includes 13 questions, the seven questions in Figure D-1 provide rich data that provide a basis for making clinical decisions.

Instead of the common “no-suicide” contracts (e.g., “I will go to the ER before taking an overdose”), this protocol recommends a more complete informed consent, safety, and risk management process that requires the client’s consent to six key elements. These are

  • To remain clean and sober
  • To follow medical advice
  • To see to the removal of the means of suicide
  • To commit to personal safety
  • To seek help in case of emergency
  • To follow through on referral and/or treatment ()

By using this evaluation format or other suicide evaluation tools, the clinician needs to determine whether the risk of imminent suicide is mild, moderate, or high. The clinician must also determine to what degree the client is willing and able to follow through with a set of interventions to keep safe.

Using many of the same indicators, counselors should also be prepared to probe the client’s likelihood of inflicting harm on another person. Specifically

  • On a scale of 0 to 10, with 0 meaning “not likely at all,” how likely are you to harm this person in the next week?
  • Do you have a plan for how you would do this?
  • Would you be willing to agree not to harm this person during the next week?
  • Would you be willing to agree to tell someone before you do this?
  • How confident are you that you can remain sober over the next week? What can you do to increase the chances you will remain sober? (e.g., use of 12-Step meetings, supports, or treatment).

Screening personnel should also assess whether suicidal feelings are transitory or reflect a chronic condition. Factors that may predispose a client toward suicide and should be considered in client evaluation can be seen in “Risk Factors” above.


In today’s managed care environment, intakes are often preprinted with yes/no or other check-off items. For example, some State versions of the Addiction Severity Index (ASI) may include only whether the client has ever had psychiatric care (yes/no) and whether the client is on psychiatric medications (yes/no) or some other abbreviated psychiatric inventory. As noted, it is the view of the consensus panel that because suicidality is common in the substance abuse treatment population, all substance abuse treatment clients should receive at least a brief screening for suicide. If the screen is positive, the client should receive a more thorough assessment as discussed previously. Further screening/assessment should be documented to protect both the client and the counselor. This means writing information on evaluation forms or making additional notes, even if suicide-related items are not included on the form used.

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 (). 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” (, 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” (, 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.

Case management

Interventions should seek to increase support available to the client from the family and community, and should provide immediate interventions, including medication to stabilize the client’s mental state, if needed.


Families and individuals often benefit from education about depression and suicidality, including warning signs, resources for help, and the importance of addressing this problem. Education often provides individuals with a sense of hope and realistic expectations. Many individuals will have passive suicidal ideation at one point in their lives. Some individuals will feel reassured to know their feelings are not uncommon and be more willing to share their feelings about their thoughts.

Adapting mental health/substance abuse treatment approaches to specific disorder subtypes

The co-occurrence of substance abuse and suicidal thoughts increases the risk of suicide and requires clinicians to be more active in their management of the problem. People with chronic substance use disorders may need to undergo detoxification and may have cognitive limitations secondary to chronic usage.

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 ().

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” (, 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.

Nicotine Dependence

Tobacco dependence is the most common substance use disorder in the United States, and cigarette smoking is the primary preventable cause of disease and deaths in the United States. Smoking causes approximately 450,000 premature deaths among people who use tobacco and an additional 50,000 deaths in nonsmokers from exposure to environmental tobacco smoke (; ).

Tobacco dependence is present in most clients in mental health and addiction treatment settings. Individuals with behavioral health disorders spend about $214 billion annually on tobacco, and account for 44 percent of all cigarettes smoked in the United States (). More people with alcohol use disorders die from smoking-related diseases than from alcohol-related diseases (). Smoking is also linked to depression and substance use disorders. Research repeatedly has shown that, compared with the general population, people who smoke are more likely to abuse substances, and people who abuse substances are more likely to smoke cigarettes. Those who abuse alcohol are two to three times more likely to smoke than the general population (; ), and up to seven times more likely to smoke heavily (). There is no simple reason why so many clients in mental health or substance abuse treatment smoke. As with other addictive disorders, it is likely a combination of complex biological and psychosocial factors ().

Nicotine dependence was first included as a substance use disorder in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980. The diagnostic criteria for dependence are the same as other substance use disorders. Of note, unlike all other substances, the DSM only recognizes nicotine dependence (there is no diagnosis of nicotine abuse) because most individuals transition quickly and directly from use to dependence and meet criteria of tolerance and withdrawal. The nicotine withdrawal syndrome develops after abrupt cessation of or a reduction in the use of nicotine products and is accompanied by four of the following signs and symptoms: (1) dysphoria or depressed mood; (2) insomnia; (3) irritability, frustration, or anger; (4) anxiety; (5) difficulty concentrating; (6) restlessness or impatience; (7) decreased heart rate; and (8) increased appetite or weight gain (, p. 266). The withdrawal symptoms also must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Although nicotine is thought to be the primary addictive component in tobacco, it is important to remember that not all forms of nicotine are equivalent. The pharmacology and potential for addiction to nicotine is dependent on its route of entry into the body. Smoking is an extremely efficient route of administration, and delivers the fastest and highest-spiking arterial dose of nicotine. Nicotine delivery from smoking produces levels of nicotine in the body that are many times higher than those achieved with use of nicotine replacement therapies (NRT). Therefore, NRT products do not replicate the perceived effect of smoking.

NRT has been found to be safe in cardiovascular disease and safe in persons who use it while continuing to smoke. Several forms are available without prescription (patches, gum, lozenge), since nicotine is not a carcinogen and there is little abuse potential for nicotine when it is administered in forms other than smoking. Nicotine has a pH of 8, making oral absorption poor. NRT products rely on administration through the skin, or buccal (cheek) or nasal mucosa, and are buffered to increase alkalinity and absorption. Nicotine absorption in the mouth is markedly reduced when it is administered with acidic beverages like sodas, coffee, and juices. Simple instructions not to use the gum, lozenge, or inhaler in conjunction with these beverages can greatly increase the nicotine absorption.

Research has demonstrated that the vast majority of harm associated with cigarettes is attributable to the byproducts of smoking rather than to the effects of nicotine (Slade 1999). In addition to nicotine, unprocessed tobacco smoke includes more than 2,500 compounds, and when manufactured additives and other compounds are taken into account, about 4,000 compounds are present (U.S. Department of Health and Human Services 1988). Smoking is the cause of 90 percent of all lung cancers and nearly all cases of chronic obstructive pulmonary disease, and is associated with a two times greater risk of death from stroke and coronary heart disease. It is also associated with an increased incidence of cancer at a number of other sites, including the larynx, oral cavity, esophagus, cervix, bladder, pancreas, and kidney, and is associated with complications of pregnancy and negative effects on the fetus, including low birth weight (; ). Why do individuals with mental illness or addiction die? Most die of smoking-caused diseases, including cardiac and pulmonary problems, infections, and cancer. Among people who are addicted to narcotics who are in substance abuse treatment, the death rate of smokers is four times that of nonsmokers (Hser et al. 1994). Among people who are in recovery for alcohol abuse who die, 51 percent of mortality is attributed to smoking-related illness, and at 20-year followup the cumulative mortality was 48 percent versus 19 percent expected if a person never smoked ().

Differential Diagnosis

Unsuccessful quit attempts, difficulty controlling use, and previous withdrawal symptoms during abstinence are criteria for nicotine dependence in both the DSM-IV () and the ICD-10 (). These sources provide useful descriptions of clinically observed phenomena, and clinicians are advised to familiarize themselves with diagnostic criteria and withdrawal symptoms (see Figure D-2). However, unlike other mental disorders, tobacco dependence diagnostic criteria are rarely used in clinical or research settings. Instead, tobacco dependence is usually conceptualized dimensionally rather than categorically. It should be noted that categorical diagnostic schemes based on DSM criteria are not highly correlated with dimensional assessments, such as the Fagerstrom Test for Nicotine Dependence ().

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

A. Daily use of nicotine for at least several weeks.
B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by four (or more) of the following:
(1) dysphoric or depressed mood
(2) insomnia
(3) irritability, frustration, or anger
(4) anxiety
(5) difficulty concentrating
(6) restlessness
(7) decreased heart rate
(8) increased appetite or weight gain
C. The symptoms in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
Associated features:
• Craving for nicotine
• Desire for sweets
• Impaired performance on tasks requiring vigilance
• EEG slowing
• Decrease in catecholamine and cortisol levels
• Decreased metabolism of medications and other substances

Source: , p. 266. Reprinted with permission.

Differential diagnosis is a less pressing clinical issue with tobacco dependence than with other substance use and mental disorders. Approximately 80 percent of all people who smoke, and virtually all people who smoke daily, are nicotine dependent. DSM-IV diagnostic criteria are identical to those for other substance use disorders, although DSM does not recognize Nicotine Abuse as a diagnostic category.


Although tobacco dependence is the most common substance use disorder, there are subgroups of individuals with particularly high rates of tobacco dependence. Individuals with mental illness and other substance use disorders are the most common subgroup; however, other important subgroups are known. The prevalence of cigarette smoking is higher at lower socioeconomic levels. Slightly more males than females smoke, although more males than females are successful in stopping smoking. There is evidence that the number of cigarettes smoked per person is increasing, leaving a more hard core and, potentially, more dependent group of people who smoke. There has also been a recent increase in the rate of smoking among adolescents, particularly in the number of teenage girls smoking. This increased smoking rate among adolescents is particularly alarming, as people who smoke typically start smoking at an early age, with more than 60 percent beginning by age 14, and nearly all by age 18 ().

Tobacco Dependence Among Individuals With Another Substance Use Disorder

Rates of smoking in people with substance use disorders consistently have been shown to be three to four times higher than in the general population (Berger 1972; ; ), with heavier smoking linked to increased drug or alcohol severity (; ). More than two thirds of people who abuse drugs smoke tobacco regularly, a rate double that of the rest of the population ().

An 80 to 90 percent rate of smoking has been found in persons with active alcoholism (). Similar results have been found in people who use illicit drugs, with recent studies finding smoking rates as high as 90 percent among outpatient substance abuse clients (Clarke et al. 2001; Clemney et al. 1997; ). Heavy smoking is particularly linked with drinking, with 72 percent of people in treatment for alcohol use disorders smoking heavily, versus 9 percent of the general population (). Smoking also has been shown to be a predictor of greater problem severity and poorer treatment response ().

People who smoke and have a history of an alcohol problem find nicotine more reinforcing, and meet more nicotine dependence criteria and withdrawal symptoms (; 2002). This may make consideration of pharmacological approaches crucial, although some clients in recovery from another addiction prefer to quit without medications. There is growing evidence to suggest that many people in substance abuse treatment are interested in smoking cessation treatment simultaneously (; ), although there is still some debate as to the best time for tobacco treatment during substance abuse treatment. A recent study by Joseph and colleagues (2003), comparing the timing of tobacco dependence treatment, showed no difference in number of quit attempts, smoking abstinence, or use of NRT between those who received tobacco treatment concurrent with substance abuse treatment, and tobacco treatment that was delayed for 6 months after initiating intensive substance abuse treatment. The overall quit rates were comparable to the general population, with about 18 percent achieving abstinence at 1 year.

Surveys have reported that prevalence rates of smoking in clients in methadone maintenance programs are between 85 and 98 percent (Berger 1972; ). Smoking status is predictive of illicit substance use in methadone programs and increases in a stepwise fashion from people who do not smoke, to people who smoke but are nondependent, to people who smoke heavily (). There is a significant positive relationship during treatment between rates of change in heroin use and rates of change in tobacco use.

Tobacco Dependence Among Individuals With Mental Illness

The prevalence of smoking is high among people with all types of mental illnesses, including schizophrenia (70 to 90 percent), affective disorders (42 to 70 percent), and anxiety disorders, especially agoraphobia and panic disorder. Conversely, there is also evidence that affective, anxiety, and substance use disorders may be more common in individuals who smoke than in those who do not or in those who have never smoked. The presence of depressive symptoms during withdrawal is also associated with failed cessation attempts (APA 1996; ).

Smokers with schizophrenia are more likely to be current smokers (58 to 88 percent versus 23 percent) (Centers for Disease Control and Prevention 2001; ), to smoke more (), and to have ever smoked daily (). They also smoke more “efficiently” by inhaling more deeply and smoking more of each cigarette (). People with schizophrenia are less successful in quitting smoking, both in naturalistic settings () and in tobacco-dependence treatment trials (). Although smoking rates are elevated among all people with mental disorders, individuals with schizophrenia are more likely to smoke than those with other mental disorder diagnoses (). In addition, smokers with schizophrenia are more likely to experience smoking-related morbidity and mortality than the general population of smokers (; ). The effect of tobacco is that medications are metabolized faster and are cleared from the body more efficiently, causing smokers with schizophrenia to be prescribed higher medication doses. As a result, these people also experience greater medication side effects such as tremor (), rigidity (Gideon et al. 1994), and possibly tardive dyskinesia ().

Key Issues and Concerns

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; ).

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; ).

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) (). 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 ().

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 (). 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 (). The findings suggest that substance abuse treatment efforts will benefit from a more complete understanding of the interrelationships between tobacco and drug craving (). In a study among patients on methadone maintenance, tobacco craving and heavy smoking appeared to contribute to increased use of cocaine and heroin (). 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 () 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 ().

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; ). Like any other substance, individuals can relapse to tobacco in any stage of recovery.

Strategies, Tools, and Techniques


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 (), 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 ():

  • 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

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 (). 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 (; 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 ().

Figure D-3. The Fagerstrom Test For Nicotine Dependence

Question Answer Score
How soon after you wake up do you smoke your first cigarette? Within 5 minutes 3
6–30 minutes 2
31–60 minutes 1
> 60 minutes 0
Do you find it difficult to refrain from smoking in places where it is forbidden? Yes 1
No 0
Which cigarette would you hate to give up the most? The first one in the morning 1
Others 0
How many cigarettes per day do you smoke? < 10 0
11–20 1
21–30 2
> 31 3
Do you smoke more frequently during the first hours after waking than during the rest of the day? Yes 1
No 0
Do you smoke if you are so ill that you are in bed most of the day? Yes 1
No 0

Scores are totaled to yield a single value, with scores of 6 or more indicating high nicotine dependence.

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 ().

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 (). 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 (). 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.


The U.S. Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence () 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 (). 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.

Treatment Planning

All clients who smoke should have tobacco dependence as a problem listed in their treatment plans and motivation-based treatment plans written to match their motivation to address tobacco. Those with less motivation can receive written information and motivational interventions. For clients interested in tobacco dependence treatment a “quit date” should be selected. After cessation, close monitoring should occur during the early period of abstinence. Before the quit date, the person should be encouraged to explore and organize social support for the self-attempt. Plans to minimize cues associated with smoking (e.g., avoiding circumstances likely to contribute to relapse) are important, as is considering alternative coping behaviors for situations with a higher potential for relapse. A telephone or face-to-face followup during the first few days after cessation is critical because this is the time that withdrawal symptoms are most severe, and 65 percent of patients relapse within 1 week. A followup face-to-face meeting within 1 to 2 weeks allows a discussion of problems that have occurred (e.g., difficulties managing craving) and serves as an opportunity to provide reinforcement for ongoing abstinence. Even after the early period of abstinence, periodic telephone or face-to-face contacts can provide continued encouragement to maintain abstinence, allow problems with maintaining abstinence to be addressed, and provide feedback regarding the health benefits of abstinence. Figure D-4 provides several strategies for counselors to use in helping clients stop smoking.

Figure D-4. Brief Strategies for Smoking Cessation

Action Strategies for Implementation
Help the client with a quit plan. A client’s preparations for quitting
• S et a quit date—ideally, the quit date should be within 2 weeks.
• T ell family, friends, and coworkers about quitting and request understanding and support.
• Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms.
• R emove tobacco products from your environment. Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., work, home, car).
Provide practical counseling (problem solving/skills training). Abstinence—Total abstinence is essential. “Not even a single puff after the quit date.”
Past quit experience—Identify what helped and what hurt in previous quit attempts.
Anticipate triggers or challenges in upcoming attempt—Discuss challenges/triggers and how client will successfully overcome them.
Alcohol—Since alcohol can cause relapse, the client should consider abstaining from alcohol while quitting.
Other smokers in the household—Quitting is more difficult when there is another smoker in the household. Clients should encourage housemates to quit with them or not smoke in their presence.
Provide intra-treatment social support. Provide a supportive clinical environment while encouraging the client in his or her quit attempt. “My office staff and I are available to assist you.”
Help client obtain extra-treatment social support. Help client develop social support for his or her quit attempt in his or her environments outside of treatment. Have the client ask his or her spouse/partner, friends, and coworkers to support the client in the quit attempt.
Recommend the use of approved pharmacotherapy, except in special circumstances. Recommend the use of pharmacotherapies found to be effective in this guideline. Explain how these medications increase smoking cessation success and reduce withdrawal symptoms. The first-line pharmacotherapy medications include bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch.
Provide supplementary materials. Sources—Federal agencies, nonprofit agencies, or local/State health departments.
Type—Culturally/racially/educationally/age appropriate for the client.
Location—Readily available at every clinician’s workstation.

How To Treat Tobacco Dependence

Before making a quit attempt, clients should know the psychopharmacological options (i.e., NRT and bupropion) and what to expect while trying to quit. This knowledge may inoculate people who smoke from the frustration they might otherwise experience with the discomfort of quitting. Clients should know about the withdrawal symptoms they may experience, the fact that many people quit several times before quitting successfully, and the potential for minor weight gain. Clinicians should also discuss the timing of the quit attempt to maximize the chances for success. In contrast to other drugs of abuse, it is recommended that people who smoke take 2 to 4 weeks to prepare for the quit date. Clients with few mental health problems may be ready in 2 weeks, while people with more serious mental illnesses should take longer to prepare. Once a quit date is set, a decision must be made regarding making an abrupt or gradual change. Making a gradual change has the disadvantage of making each cigarette more enjoyable as the number of cigarettes decreases, with the result that the last few cigarettes may be very difficult to give up.

Other preparatory strategies include using “behavioral disconnects,” publicizing the planned quit attempt, and creating a detailed coping plan for dealing with cravings after the quit date. Behavioral disconnects involve using the preparation time to practice not smoking in the client’s usual contexts. For example, if the client is accustomed to smoking while speaking on the telephone, he or she can practice speaking on the phone without smoking cigarettes. This strategy has the dual benefit of increasing self-efficacy if done successfully and of decreasing psychological cravings in the presence of the client’s usual smoking cues.

By publicizing the planned quit attempt, the client is likely to feel more committed to following through on the quit day. It is helpful to tell as many significant others as possible, including all friends, family, coworkers, and so on. Telling other treatment staff is also important, as supportive treatment staff can play a key role in encouraging the change. The client should also be informed of the potential effects of smoking on psychotropic medications, as aromatic hydrocarbons (tar) in the tobacco smoke increases the metabolism of many of the medications the client may be taking. Upon quitting smoking, the medications may need to be adjusted accordingly.

Publicizing the planned quit attempt will also help in gathering the social support needed to be successful. Significant others who do not smoke are likely to be supportive, and those who do smoke can be put on notice that they should not offer cigarettes or sabotage the quit attempt. The detailed coping plan should include having a reference sheet with several individualized reasons for quitting, names and phone numbers of supportive others to call, and a list of distracting activities, preferably those that are inconsistent with smoking (e.g., exercising, playing with children).

As the quit date approaches, stimulus control techniques should be implemented, such as removing all tobacco product cues (e.g., cigarettes, lighters, ashtrays) from the client’s environment. The client should also make sure others do not smoke in the home, be prepared to sit in non-smoking areas, and avoid smoking cues that can be avoided.

Avoiding smoking cues is often difficult for people who smoke and have other substance use or mental disorders. Clients with other substance use disorders may be faced with smoke-filled 12-Step program meetings, sponsors who smoke, or even sponsors who discourage them from quitting. Clients with mental disorders may be faced with group home housemates who smoke and day treatment programs populated by people who smoke. It is helpful to have other supportive treatment staff to intervene in these circumstances to facilitate the quit attempt. Regardless of the co-occurring disorder, it is important to take into account the specific deficits or circumstances secondary to the disorder.

An in-person or telephone followup contact should occur within 2 days of the quit date. Clinicians and clients should have an action plan for managing a lapse or relapse, and this plan should be activated if the client slips and has a cigarette. After the client has quit, relapse prevention strategies should be used. Popularized by , relapse prevention is a well-established, empirically based approach using cognitive-behavioral therapy techniques to teach people to avoid and/or cope with triggers to use addictive substances. Since cravings or urges to use addictive substances are common issues for clients seeking treatment for substance use disorders (including nicotine dependence), clients are taught how to manage and cope with these feelings and avoid smoking cues whenever possible. Common cues for smoking include the people, places, and things associated with tobacco use as well as negative mood states like anger or sadness. These cues can trigger smoking behavior and can be lessened through psychosocial interventions.

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 (). 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; ). 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 ().

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 (). 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 (; ; ; ), depression (, , , , ), and substance use disorders (e.g., Burling et al. 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 () 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 (; ) and experienced more hospitalizations than their counterparts who did not smoke (; ). 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 (), rigidity (), and possibly tardive dyskinesia (). 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 (). 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 ().

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.

Figure D-5. Brief Strategies 2. Components of Prescriptive Relapse Prevention

Problems Responses
During prescriptive relapse prevention, a client might identify a problem that threatens his or her abstinence. Specific problems likely to be reported by clients and potential responses follow:
Lack of support for cessation Schedule followup visits or telephone calls with the client.
Help the client identify sources of support within his or her environment.
Refer the client to an appropriate organization that offers cessation counseling or support.
Negative mood or depression If significant, provide counseling, prescribe appropriate medications, or refer the client to a specialist.
Strong or prolonged withdrawal symptoms If the client reports prolonged craving or other withdrawal symptoms, consider extending the use of an approved pharmacotherapy or adding/combining pharmacological medications to reduce strong withdrawal symptoms.
Weight gain Recommend starting or increasing physical activity; discourage strict dieting.
Reassure the client that some weight gain after quitting is common and appears to be self-limiting.
Emphasize the importance of a healthy diet.
Maintain the client on pharmacotherapy known to delay weight gain (e.g., bupropion SR and NRTs, particularly nicotine gum).
Refer the client to a specialist or program.
Flagging motivation/feeling deprived Reassure the client that these feelings are common.
Recommend rewarding activities.
Probe to ensure that the client is not engaged in periodic tobacco use.
Emphasize that beginning to smoke (even a puff) will increase urges and make quitting more difficult.

Source: , .

Personality Disorders (Overview)


Personality disorders (PD) are rigid, inflexible, and maladaptive behavior patterns of sufficient severity to cause significant impairment in functioning or internal distress. Personality disorders are enduring and persistent styles of behavior and thought, rather than rare or unusual events in someone’s life. Furthermore, as opposed to a response to a particular set of circumstances or particular stressors, people with personality disorders carry with them these destructive patterns of thinking, feeling, and behaving as their way of being and interacting with the world and others.

Though sudden stressful circumstances might worsen the response of a client with a PD, such a client experiences the disorder regularly and often pervasively. Clients with PDs frequently are unaware of the impact of the disorder on their personality, behaviors, and interactions with others. Sometimes clients with PDs blame others or the world for misery that they clearly bring upon themselves.

The course and severity of PDs can be worsened by the presence of other mental disorders such as mood, anxiety, and psychotic disorders. Furthermore, of the roughly 10 different types of PDs that can be described, people with any one of the disorders are at an increased likelihood of having another—that is, though the different PDs can be discussed as if they were separate entities, in clinical practice, clients often have more than one PD and might well have features of many.

“Mixed personality disorder,” the mental health equivalent of “polysubstance abuse,” describes individuals who meet the diagnostic criteria for more than one PD. This TIP provides details about two of the PDs—borderline personality disorders (BPDs) and antisocial personality disorders (APDs). Before exploring BPD and APD in detail, a brief overview of the other PDs follows. However, the reader should keep in mind that the diagnostic approach to personality disorders is slated for significant change and refinement, as there have been numerous concerns expressed about the meaningfulness and utility of the current system for diagnosing personality disorders (see footnote[1] for more information).

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
Cluster A

Cluster A PDs describe clients who may be seen as “odd-eccentric.”

People with paranoid personality disorder are pervasively distrustful and suspicious to a degree that routinely interferes with their forming a correct perception of the motives and beliefs of others, and with their successfully forming positive relationships with others. They may interpret other people as trying to threaten, demean, or intimidate them, even when such behavior is not exhibited.

Schizoid personality disorder is descriptive of a person whom others often see as a “loner” and who commonly exhibits an indifference to the views and feelings of others. People with a schizoid personality disorder have a restricted range of emotional experience and expression.

People with a schizotypal personality disorder often behave in ways others see as weird, with possible peculiarities of speech, dress, and/or beliefs. These strange or markedly unusual characteristics often produce avoidance or wariness in others, and the resulting difficulties in interpersonal relations may lead to anxieties and depression.

Cluster B

Cluster B PDs include histrionic PDs and narcissistic PDs, in addition to the borderline and antisocial PDs (which are discussed in detail in following sections). The general characterization of the Cluster B dimensions is “dramatic-emotional.”

Histrionic personality disorder is expressed in excessive emotionality and attention seeking, often including inappropriate sexually seductive behaviors.

Clients with narcissistic personality disorder exhibit a “pervasive pattern of grandiosity, need for admiration, and lack of empathy” (, p. 714). While a certain self-centeredness and falsity are common with addictive disease, a client with a true narcissistic disorder displays a grandiosity, over-inflates the value of his or her own abilities, and displays a superiority that is so distorted as to impair his or her judgment. People with narcissistic PD and substance use disorders will exhibit these features even after achieving and maintaining abstinence.

Antisocial personality disorder involves a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood (though the diagnosis cannot be made officially unless a person is at least 18 years old). The disorder is manifested by a pattern of irresponsible and antisocial behavior indicated by illegal activities, recklessness, impulsive behavior, academic failure, and poor job performance. Other features often include dysphoria, an inability to tolerate boredom, feeling victimized, and a diminished capacity for intimacy.

Borderline personality disorder is characterized by unstable mood and self-image, and unstable and intense interpersonal relationships. These people often display extremes of overidealization and devaluation, marked shifts from baseline to an extreme mood or anxiety state, and impulsiveness.

Though people with APD are more likely to be male and those with BPD female, APD and BPD have a number of features in common. Both disorders tend to diminish in intensity with age, and sometimes even remit after a client reaches age 40 or so. People with APD or BPD are likely to show features of other PDs. Both APD and BPD are commonly associated with a co-occurring substance use disorder as well as with other significant (Axis I) mental health complaints. Characteristics of people with APD and BPD are presented in Figure D-6.

Figure D-6. Characteristics of People With Antisocial and Borderline Personality Disorders

Characteristic Antisocial Borderline
Affect Angry intimidation Angry self-harm
World view If you don’t do what I want, you’ll be sorry. I’ve got to get you before you get me.
I deserve it all. I don’t deserve to exist.
They’re the ones with the problem. Help me, help me, but you can’t.
Presenting problem Legal difficulties, polysubstance abuse and dependence, parasitic relationships Self-harm, impulsive behavior, episodic polysubstance abuse, hot-and-cold relationships
Social functioning Episodic achievement Gross dysfunctioning
Motivation Self-esteem Safety
Defenses Rationalization, projection Splitting, projection
Cluster C

Cluster C PDs include avoidant PD, dependent PD, and obsessive-compulsive PD and describe clients who are “anxious-fearful.”

People with avoidant personality disorder show extreme hypersensitivity to others, social discomfort, and timidity, often with accompanying depression, anxiety, and anger for failing to develop social relations.

People with obsessive-compulsive personality disorder display a preoccupation with orderliness, perfectionism, and control, and they may appear excessively conscientious, moralistic, scrupulous, and judgmental. Symptoms may include distress associated with indecisiveness and difficulty in expressing tender feelings, feelings of depression, and anger about feeling controlled by others.

Clients with dependent personality disorder live with a pervasive and excessive need to have others take care of them. Individuals with a dependent PD typically have severely low self-esteem, and their behavior often is submissive and clinging. Such individuals are at risk of forming abusive relationship and even of failing to protect their children from abuse.

Differential Diagnosis

The clinical situation often is challenging when working with clients who have both a PD and a substance use disorder. PDs should not be diagnosed during substance use or withdrawal as misdiagnosis can easily occur if the current and historical roles of substance use are not properly assessed. A period of abstinence is often required before the co-occurrence of a PD with a substance use disorder can be determined. If a PD coexists with substance use, the PD will remain during abstinence. When a bona fide co-occurring PD exists, during abstinence and recovery the PD symptoms can get worse and the functioning level of the client might even deteriorate, though over time improvement and greater stability are possible for the client with co-occurring personality disorder and substance use disorder who receives effective care for both.

Some criteria that describe PDs (e.g., dependency or insensitivity) are also characteristic of other Axis I disorders. Three PDs—paranoid, schizoid, and schizotypal—may be distinguished from psychotic disorders by being observed when the client is clearly not experiencing a psychotic episode ().

Counselors are cautioned to take into account the individual’s ethnic, cultural, and social background when judgments are made about personality functions. To make a sound judgment when working with a client who has an unfamiliar cultural background, it is a good idea to consult with someone who is familiar with that culture to gain a sense of norms and alternative, culturally consonant explanations of observed behaviors.


contends that the prevalence of PDs is at least 50 percent in substance-abusing populations. found that 35 percent of the 716 consecutive admissions to a methadone maintenance program had a personality disorder, while in the large Drug Abuse Treatment Outcome Study of over 7,400 clients with substance dependence found antisocial personality disorder in 34.7 percent for alcohol-only clients, 27 percent for heroin only, 30.4 percent for cocaine only, percentages in the mid-40 percent range for clients dependent on two of these three drugs, and 59.8 percent for clients dependent on all three drugs. As noted, however, no diagnosis should be made during the acute phase of detoxification. The early phases of treatment involve addressing behaviors that may appear to be symptoms of PDs, especially BPD. Thus, counselors should exercise care not to rush to conclude that a patient or client has BPD.

Among Cluster A disorders (“odd-eccentric”), paranoid PD has been reported to be 0.5 to 2.5 percent in the general population, as high as 10 to 30 percent among those in inpatient mental health settings, and 2 to 10 percent among those in outpatient mental health clinics (). One study found 44 percent of persons in treatment for alcoholism to have this disorder (). Another study () found through semi-structured interviews that 13.2 percent of a group of 370 patients in treatment for substance abuse warranted a diagnosis of a paranoid personality disorder. Schizoid PD is believed to be uncommon in clinical settings (). Similarly, although up to 3 percent of the general population may be affected by schizotypal PD (, p. 699), the prevalence rate even in substance abuse treatment programs that treat clients with COD appears to be quite low.

Among Cluster B disorders (“dramatic/emotional”), about 1 percent of females and 3 percent of males in the general population are believed to have antisocial PD. In clinical settings, the prevalence is estimated to be anywhere from 3 percent to as high as 30 percent, with especially high prevalence in substance abuse treatment and prison settings (). Among the male prison population, 20 percent or more may have antisocial PD. Borderline PD also is relatively common in mental health settings. Although only about 2 percent of the general population has this disorder, its incidence is about 10 percent of mental health clinic outpatients and 20 percent of mental health inpatients. From 30 to 60 percent of other clinical populations may have this disorder. One study of 370 clients in substance abuse treatment () found that more had Cluster B diagnoses (27 percent antisocial PD and 18.4 percent borderline PD) than either Cluster A (13.2 percent) and Cluster C (18.4 percent avoidant).

The DSM-IV suggests prevalence rates of 2 to 3 percent for histrionic PD in the general population and 10 to 15 percent in mental health settings; there is reason to believe the 10 to 15 percent estimate would also be true of substance abuse treatment settings (). Prevalence rates for narcissistic PD are estimated to be roughly similar to those for histrionic PD—from 2 to 16 percent in the clinical population () and about 10 to 15 percent in the clinical practice of a substance abuse counselor.

Among Cluster C disorders (“anxious/fearful”), avoidant PD and obsessive-compulsive PD probably each make up at most 10 percent of clients at mental health clinics. With a rate in the general population of less than 1 percent for each, substance abuse counselors seldom see pure forms of these types of PDs in clinical practice. On the other hand, persons with dependent PD are “among the most frequently… encountered in mental health clinics” ().

Again, the reader is cautioned that the utility and meaningfulness of the Cluster groupings and/or the distinctiveness of the 10 separate “personality disorders” is in doubt. Bohn and Meyer (1999) report that frequencies of antisocial PD “in samples of alcoholic patients have ranged from 16 to 49 percent. Somewhat higher rates have been detected among opioid- and other drug-abusing populations. The frequency of occurrence of ASPD [antisocial PD] varies depending on the type of sample and the diagnostic criteria used [emphasis added] (Hesselbrock et al. 1985; Rounsaville et al. 1983). The higher reported prevalence rates of ASPD among substance-dependent patients since 1980 … are likely a function of the broad diagnostic criteria applied to this disorder by DSM-III, DMS-III-R, and DSM-IV, rather than of a real change in the patient population” (Bohn and Meyer 1999, p. 99). In fact, North and colleagues found that antisocial PD appeared to change little over 20 years within the homeless populations with 10 to 20 percent of homeless women and 20 to 25 of homeless men receiving diagnoses of antisocial PD (see ).

Substance Use Among People With Personality Disorders

Substance use may trigger or worsen personality disordered behaviors. No single pattern of substance use or abuse can be identified for any one PD; the drug or drugs of abuse depend on many factors beyond the presence of a specific PD. For example, individuals with paranoid PD may prefer stimulants to augment their need to be vigilant or they may seek opioids to reduce the severe tension generated by their fear and distrust.

Plans to place the diagnosis of PDs on a solid research foundation (including the ever-growing body of neurobiological knowledge) that will yield diagnoses useful for clinical practice (Kupfer et al. 2002) envision significant changes to the DSM-IV-TR presentation of PDs. In brief, it seems that a more complex and psychometrically based set of categories and measurement dimensions will be utilized instead of 3 clusters and 10 PDs. The meaningful and useful relationships among the behaviors and treatment considerations relevant for people with personality disorders may well match up with categories and dimensions that are not clearly enough represented by the current schema to yield treatment decisionmaking information. Perhaps the future understanding of people with personality disorders and DSM-V will be useful to enhance the treatment responses of these individuals, as the one thing that is already clear from the available research is that these individuals can change and profit from treatment.

Key Issues and Concerns

Clients with PDs tend to have difficulty forming a genuinely positive therapeutic alliance. They tend to frame reality in terms of their own needs and perceptions and to be unable to understand the perspectives of others. Also, most clients with PDs are limited in terms of their ability to receive, accept, or benefit from corrective feedback. A further difficulty is the strong countertransference clinicians can have in working with these clients, who are adept at “pulling others’ chains” in a variety of ways. Specific concerns will, however, vary according to the PD and other individual circumstances. In general, group therapies, therapeutic communities, and more rationally oriented, directive, behavioral forms of treatment have been thought to be particularly appropriate for people with PDs.

Borderline Personality Disorder


One of the most prominent features of people with BPD is instability. Their relationships with others are likely to be unstable, with reports of how wonderful an individual is one day and expressions of intense anger, disapproval, condemnation, and even hate toward that same individual a week later. Then a month later the person with BPD is once again singing the praises of the same person. These reactions can be unsettling for a counselor, especially if it is the counselor who is being held in high esteem one minute and accused of every form of deceit the next. The severe instability experienced by the person with BPD includes fluctuating views and feelings about him- or herself. Those with BPD often feel quite good about themselves and their progress and optimistic about their future for a few days or weeks, only to have a seemingly minor experience turn their world upside-down with concomitant plunging self-esteem and depressing hopelessness.

Basic instability extends to work and school, where it sometimes seems that people with BPD “snatch failure out of the jaws of success.” Individuals with BPD might well be engaging and attempt to please initially, then become demanding, hostile, and exhausting. When experiencing emotional states they cannot handle, clients with BPD can be at risk of suicidal, self-mutilating, and/or brief psychotic states.

Since people with BPD typically seek mental health or substance abuse treatment based on their current life conditions and emotional state, it is likely that the person with BPD who seeks mental health treatment is acutely emotionally distraught, needing some relief from how she or he feels. Similarly, the client with BPD who chooses (or is directed to choose) a substance abuse treatment program probably is experiencing the substance use disorder as the immediate target for treatment. Consequently, the average admission of a person with BPD to a mental health environment might, in general, be considerably different from the average admission of a person with BPD to a substance abuse treatment setting.

Evidence is accumulating that BPD, posttraumatic stress disorder (PTSD), and a history of childhood abuse occur with regularity among women in substance abuse treatment (; ). Women with BPD are more likely to have eating disorders or PTSD, while men are more likely to have co-occurring substance use disorders, along with PTSD and other personality disorders ().

Substance Use Among People With BPD

Individuals with BPD are often skilled in seeking multiple sources of medication that they favor, such as benzodiazepines. Once this medication has been prescribed in a mental health system, they may demand that it be continued. Confrontation or pressure to engage in detoxification or outpatient withdrawal can precipitate intense rage and various levels of client crises.

Individuals with BPD may well associate drugs with social interaction and use the same drugs of choice, route of administration, and frequency as the individuals with whom they are interacting. On the other hand, they often use substances in chaotic and unpredictable patterns. Polydrug use is common and may involve alcohol and other sedative-hypnotics taken for self-medication.

People with BPD usually have big appetites; they experience powerful, emotion-driven needs for something outside of themselves. If they do give up alcohol and other drugs, perhaps because they are experiencing a positive relationship to a service provider or a group, they are extraordinarily vulnerable to meeting their needs through other compulsive behaviors. Newly abstinent individuals with BPD must be monitored for compulsive sexual behavior, compulsive gambling, compulsive spending/shopping, or other out-of-control behaviors that result in negative or even dangerous consequences.

At the beginning of a crisis episode, a client with BPD might take a drink or a different drug in an attempt to quell the growing sense of tension or loss of control. What the client needs to learn is twofold: (1) that a drink/drug at that point increases the harm and real loss of control, and (2) that at the point where a drug/drink is desired some other, positive coping strategy needs to be put into play immediately.

Key Issues and Concerns

Progress with clients who have BPD can be slow. Therapists should be realistic in their expectations and know that clients will try to test them. To respond to such tests, therapists should maintain a matter-of-fact, businesslike attitude, and remember that people with PDs often display maladaptive behaviors that have helped them to survive in difficult situations, sometimes called “survivor behaviors.” (See TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues [].)

It is important to educate clients about their substance use and mental disorders. Clients should learn that treatment for and recovery from their substance use disorder may progress at a different rate than their treatment for and recovery from BPD. In addition, while many clients appear to fully recover from their substance use disorders, the degree of long-term recovery from BPD is less understood and characterized. Written and oral contracts that are simple, clear, direct, and time-limited can be a useful part of the treatment plan. Contracts can help clients create safe environments for themselves, prevent relapse, or promote appropriate behavior in therapy sessions and in self-help meetings.

Treatment of people with BPD requires attention to several issues, such as violence to self or others, transference and countertransference, boundaries, treatment resistance, symptom substitution, and somatic complaints.

Key Issues and Concerns in the Treatment of Borderline Personality Disorders

• Slow progress in therapy
• Suicidal behavior
• Self-injury or harming behavior
• Client contracting
• Transference and countertransference
• Clear boundaries
• Resistance
• Subacute withdrawal
• Symptom substitution
• Somatic complaints
• Therapist well-being

Strategies, Tools, and Techniques


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 [].)

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” (, p. 374), focusing on emotional regulation, enhancing motivation, discussing what interferes with treatment (), and carefully considering all medication issues (including the possible genuine need for assistance with pain control through medication or other techniques).

Group therapy

There are particular issues of concern when working with people with BPD in group therapy. Since group counseling regularly begins early in treatment, counselors should consider the following group-related issues in both short- and long-term treatment:

  • Making contracts for all members to stay in the room.
  • Making contracts for group rules that promote safe behavior.
  • Discussing thoughts and feelings about other group members as they arise.
  • Mentioning the time limits at the start of each session.
  • Making mini-contracts for those who have issues to work on in each session.
  • Having group members sign contracts for abstinence and reporting self-harm and substance use to the group.
  • Making contracts for confidentiality.
  • Disallowing participants to form intimate or exclusive relationships with one another. Supportive activities, such as calling one another during crises or attending 12-Step meetings together, are acceptable and should be encouraged.
  • Evaluating safety issues in screening people with BPD for group therapy. Clients should be safe from the predatory, manipulative behavior of others, and should not engage in such behaviors themselves.
  • Promoting same-sex groups.

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. 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 (). 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 (). 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.
Mutual self-help group participation

Although mutual self-help groups can be important for clients with BPD, some may not be able to attend them right away. Some individuals with BPD may find it helpful to participate in self-help group practice sessions. For example, for clients planning to attend a 12-Step meeting, they should be helped to organize their thoughts, to practice saying their name or “pass” for their first few 12-Step meetings. Counselors may want to use the step work handout (see Figure D-7) as a treatment tool for working with people with BPD (see chapter 7 on the use of 12-Step programs and the use of other mutual support meetings). Other mutual self-help groups would require their own types of preparation.

Figure D-7. Step Work Handout for Clients With BPD

Step One: “We admitted we were powerless over alcohol, that our lives had become unmanageable.”
• Describe five situations where you suffered negative consequences as a result of drinking or using other drugs.
• List at least five “rules” that you have developed to try to control your use of alcohol or other drugs. (Example: “I never drink alone.”)
• Give one example describing how and when you broke each rule.
• Check the following that apply to you:
□ I sometimes drink or use drugs more than I plan.
□ I sometimes lie about my use of alcohol or drugs.
□ I have hidden or stashed away alcohol or drugs so I could use them alone or at a later time.
□ I have had memory losses when drinking or using drugs.
□ I have tried to hurt myself when drinking or using drugs.
□ I can drink or use more than I used to, without feeling drunk or high.
□ My personality changes when I drink or use drugs.
□ I have school or work problems related to using alcohol or drugs.
□ I have family problems related to my use of alcohol or drugs.
□ I have legal problems related to my use of alcohol or drugs.
• Give two examples for each item that you checked.
Step Two: “We came to believe that a Power greater than ourselves could restore us to sanity.”
• Give three examples of how your drinking or use of drugs was “insane.” (One definition of insanity is to keep repeating the same mistake and expecting a different outcome.)
• Check which of the following mistakes or thinking errors that you use:
□ Blaming
□ Lying
□ Manipulating
□ Excuse making
□ Beating up yourself with “I should have” statements
□ Self-mutilation (cutting on yourself when angry)
□ Negative self-talk
□ Using angry behavior to control others
□ Thinking “I’m unique”
• Explain how each thinking error you checked above is harmful to you and others.
• Give two examples of something that has happened since you stopped drinking or using drugs that shows you how your situation is improving.
• Who or what is your Higher Power?
• Why do you think your Higher Power can be helpful to you?
Step Three: “We made a decision to turn our will and our lives over to the care of God as we understood Him.”
• Explain how and why you decided to turn your will over to a Higher Power.
• Give two examples of things or situations you have “turned over” in the last week.
• List two current resentments you have, and explain why it is important for you to turn them over to your Higher Power.
• How do you go about “turning over” a resentment?
• What does it mean to turn your will and life over to your Higher Power?
• Explain how and why you have turned your will and life over to a Power greater than yourself.
Step Four: “We made a searching and fearless moral inventory of ourselves.”
• List five things you like about yourself.
• Give five examples of situations where you have been helpful to others.
• Give three examples of sexual behaviors related to your drinking or use of other drugs, which have occurred in the last 5 years, about which you feel bad.
• Describe how beating yourself up for old drinking and drug-using behaviors is not helpful to you now.
• List five current resentments you have, and explain how holding on to these resentments hurts your recovery.
• List all laws you have broken related to your drinking and use of other drugs.
• List three new behaviors you have learned that are helpful to your recovery.
• List all current fears you are experiencing, and discuss how working the first three Steps can help dissolve them.
• Give an example of a current situation you are handling poorly.
• Discuss how you plan to handle this situation differently the next time the situation arises.

• Source: Adapted with permission from .

Because of their problems with intimacy and trauma, and their own impulsiveness, clients with BPD should be encouraged to join same-sex mutual self-help groups when possible. People with BPD may find it helpful to use same-sex sponsors as guides to recovery. When possible, counselors should educate the sponsor about survivor behaviors. Since antidepressants or lithium may be an important part of the client’s recovery, the sponsor might attend a counseling session to learn why the client is taking medications. Explaining how medications are helpful can enable sponsors to help improve medication compliance.

Sponsors who have problems setting boundaries or become overly angry when doing so should not be paired with clients with BPD. If such pairing does occur, the sponsor needs to understand how important boundaries are to help clients with BPD feel safe. Understanding this may keep them from taking on those with BPD, who may be more than the sponsor can handle. Material in the step program should be limited to the here-and-now. As previously stated, clients with BPD should not be asked to address sexual abuse issues until they are ready.

Longer term care should include specialized 12-Step work. In using step one (“We admitted we were powerless over alcohol/our addiction, that our lives had become unmanageable”) with clients who have BPD, counselors should encourage clients to recognize that “powerlessness” does not mean “helplessness.” Instead, clients should focus on gaining personal control over the tools for recovery. Faith and hope concepts used in 12-Step work may also be difficult for this group to comprehend or integrate.

Figure D-7 shows a recovery model for treatment of BPD.

Antisocial Personality Disorder


The essential diagnostic feature of APD is the pervasive disregard for and violation of the rights of others. Since most clients who are actively using substances display behaviors at one time or another that show disregard for the rights of others, it is not surprising that the distinction between addictive diseases and APD has been a difficult one for both the mental health and the substance abuse treatment fields.

Individuals with APD exhibit signs of antisocial behavior from 15 to 18 years of age, such as unlawful behavior, deceitfulness, consistent irresponsibility, and lack of remorse. Often there is evidence of similar behaviors even before the person turns 15. When antisocial behavior occurs without any signs of it during adolescence, the DSM-IV diagnosis is Adult Antisocial Behavior to distinguish the person who engages in such behaviors after 18 years of age—perhaps because of an alcohol-induced state or the development of substance dependency—from someone with a genuine APD. It is now widely recognized that “…although many delinquent youth abuse alcohol as part of their antisocial behavior, and some become alcoholic, the majority of alcoholics are not sociopathic except as a result of their addiction” (, p. 88).

One stigmatizing aspect of having a co-occurring APD is that the history of the terms sociopathic, psychopathic, and antisocial carry extremely negative connotations that might well be accurate in only a small percentage of those people with substance use disorders and a current DSM-IV-TR diagnosis of APD. differentiates between more severe cases of APD by using the term psychopaths, or “predators who use charm, manipulation, intimidation, and violence to control others and to satisfy their own needs” (p. 104). Hare is careful to point out that probably only 1 percent of the general population can be classified as psychopaths according to his criteria and that most people with antisocial personality disorder are not psychopaths. Consequently, the number of individuals with both a co-occurring substance use disorder and psychopathy is quite small, and substance abuse treatment counselors are unlikely to see such clients outside of criminal justice settings (; ). (See also the forthcoming TIP Substance Abuse Treatment for Adults in the Criminal Justice System [CSAT in development e] for a full discussion of psychopathy and its relationship to APD.)

More men than women are diagnosed with APD, although some women with APD may be misdiagnosed as BPD. Determining the type and extent of antisocial symptoms for women is not easy (), but it is important because of the high prevalence of neglectful parenting in women with substance use disorders and APD ().

Substance Use Among People With APD

Many people with APD use substances in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. The illicit drug culture can correspond with their view of the world as fast-paced and dramatic, which supports their need for a heightened self-image. Consequently, they may be involved in crime and other sensation-seeking, high-risk behavior. Some may have extreme antisocial symptoms—for example, rapists with severe APD may use alcohol to justify conquest, and the small number of these individuals might warrant Hare’s designation as psychopaths.

APD appears to be a failure to attach. The people with this diagnosis appear deficient in their ability to experience shared or reciprocal emotions such as guilt or love. Individuals with APD disdain society’s rules; they know right from wrong but they do not care. They may be excited by the illicit drug culture and may have considerable pride in their ability to thrive in the face of the dangers of that culture. They are often in trouble with the law. If they are more effective, they may limit themselves to exploitive or manipulative behavior that does not make them so vulnerable to spending time in jail.

Key Issues and Concerns

As with co-occurring disorders in general, individuals with both a substance use disorder and APD have been perceived as exceptionally hard to treat, having poor prognoses, and warranting exclusion from treatment programs and/or group counseling.

These negative stereotypes do not hold up well on examination (). It is true that as a group substance abuse clients with APD do worse than substance abuse clients who do not have APD. Indeed, many articles begin by correctly describing clients with both disorders as having a “worse” response to treatment or a “poor prognosis.” Nonetheless, research suggests that clients with APD and substance use disorders can and do respond to treatment. note that clients with APD “progress reasonably satisfactorily in methadone maintenance” (p. 247), and found in his longitudinal study that after 10 to 15 years, 48 percent of men from an inner-city environment who had been classified as both alcoholic and sociopathic were abstinent. This is about the same percentage as an advantaged comparison group of college men without APD and a significantly higher percentage than the rate of 28 percent found in an inner-city group of men who abused alcohol but did not have APD.

The substance abuse treatment system encounters many individuals with substance abuse and APD and has developed effective treatment methods for clients with this mental disorder. Key issues and concerns in the treatment of people with APD include

  • Countertransference and transference
  • Counselor/therapist well-being
  • Resistance
  • Contracting

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 [].)

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.

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.


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 () 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 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.

Strategies, Tools, and Techniques


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
  • 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

, pp. 123–124), acknowledging the historical contributions of and , 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.

Group therapy

In group therapy, clients with APD can learn to identify errors not only in their own thinking but in the thinking of others, as well as thinking that makes them vulnerable to relapse. For example, when an individual begins to glamorize stories of substance use or criminal and acting-out behaviors, the group can help to limit that grandiosity. Counselors may also ask people with APD to discuss feelings associated with the behavior being glamorized.

Clients with APD may be asked to sign contracts that establish healthy and nonparasitic relationships with other group members. This means not becoming romantically involved with other members, not borrowing money from them, and not developing exploitive relationships. Role-play exercises can be useful tools in group counseling; however, counselors should be careful to prevent clients with APD from using newly learned skills to exploit or control other group members. In group therapy, clients with APD can be encouraged to model prosocial behaviors and to learn by practicing them. Role-play exercises can help these clients focus on their own shortcomings rather than on the faults of others.

describe anger, group cohesion, dependency/counterdependency, and overdeveloped/underdeveloped strategies as significant areas requiring the counselor’s attention when running outpatient groups for male clients with Cluster B personality disorders and chemical dependency. They emphasize the importance of interrupting anger and hostility early in group formation by encouraging the clients to “talk through the therapist” rather than directly to each other, and by having members learn to monitor triggers and understand why some behaviors elicit a hostile response. Group cohesion can be threatened unless clients with PD also have individual counseling that helps them manage their reactions to the group and group membership. For clients with APD, issues related to dependency and counterdependency are likely to be long-term group issues, and group work will focus on overdeveloped combativeness, exploitiveness, and predation and underdeveloped strategies of empathy, reciprocity, and social sensitivity. Many theorists and clinicians employ cognitive-behavioral and “reality therapy” orientations for clients with APD, both with and without substance use disorders. offers an outline of Group Leadership Actions for a 4-week, 15-session cognitive-behavioral therapy group for clients with substance use disorders and APD.

Longer term care

Individual counseling

It is helpful to view working with clients with APD as a process of adaptation of thinking, rather than the restructuring of a client into a person whose morals and values match those of the therapist or society. Counselors may benefit from modifying their own expectations of treatment outcomes, realizing that they may not be able to help certain clients develop empathic and loving personalities—it is enough to guide clients to lead lives that follow society’s rules. Figure D-8 offers tips for counseling clients with APD.

Figure D-8. Counseling Tips for Clients With APD

Corral: • Coordinate treatment.
• Communicate with other providers.
• Make contracts with clients.
Confront: • Be direct and firm.
• Identify antisocial thinking.
• Conduct random substance testing.
Consequences: • Make clients responsible for their behavior.
• Record violations of rules.
• Allow clients to experience consequences of their behavior.
• Designate positive consequences for prosocial behavior.

Individual counseling offers the counselor an opportunity to point out clients’ errors in thinking without causing them to feel humiliated in the presence of the group. Other issues for individual counseling may include continued relapse management and identity of empathy. Three key words summarize a strategy for working with people with APD: corral, confront, and consequences.

  1. Corral. Corralling with regard to clients with APD means coordinating treatment with other professionals, establishing a system of communications with other professionals and with clients, contracting clients to be responsible for their substance use in the recovery program, monitoring information about clients, and working toward specific treatment goals. Clients may benefit by signing agreements to comply with the treatment plan and by receiving written clarification of what is being done and why. Interventions and interactions should be linked to original treatment goals. One approach to treatment that adds to the notion of “corralling” is to “expand the system.” Spouses, family members, friends, and treatment professionals may be invited to participate in counseling sessions as a way to provide collateral data. This is sometimes called “network therapy.”
  2. Confront. In confronting clients who are antisocial, counselors can be direct and firm. They can be clear in pointing out antisocial thinking patterns. They can remark on contradictions between what clients say and what clients do. Random testing for substances is essential for monitoring clients with APD. Honest reporting of substance use should be an active part of treatment.
  3. Consequences. Clients should bear the responsibility for the consequences of their behavior. For instance, violation of probation or rules should be recorded. Clients who are offenders should be encouraged to report behavior that violates probation, thus taking responsibility for their own actions. Positive consequences that demonstrate to clients the benefits of appropriate behavior should also be designed and incorporated into the treatment plan.
Case management

Case management may involve coordinating care with a variety of other professionals and individuals, including those in the criminal justice system, mental health providers, and family members. Clients need to understand that the counselor must talk to other providers and to family members. It is helpful for clients to sign consents for the release of information for all people involved in their treatment.

Terminating counseling

The question of terminating counseling can be puzzling for counselors treating clients with APD. Clients with APD frequently express a desire to end treatment. This desire should be closely examined to determine whether it is a manifestation of client resistance or a valid request. Reasons for termination on the counselors’ part can include noncompliance with treatment, continued drug use without improvement, any aggressive behavior, parasitic relationship with other clients, or any unsafe behavior.

Breaking the rules

Clients with APD compulsively try to break rules. If a treatment plan is not devised to work with a person who wants to redefine rules, termination should be considered and transfer to more appropriate care arranged.

Continuum of care

A key to treating people with APD is to be flexible within an array of containment interventions. Counselors should have the ability to move a client quickly from a less controlled environment to a more controlled environment. Clients benefit from sanctions that match the degree of severity of behavior. Sanctions should not be “punishments” but responses to the need for containment and more intensive treatment. Clients with APD need a range of treatment and other services, from residential to outpatient treatment, from vocational education to participation in long-term relapse prevention support groups, and from jail to 12-Step programs.

Thinking-error work

Continued thinking-error work, as described in Figure D-9, may help clients identify various types of rationalizations that they may use regarding their behaviors. and developed a 24-week manual guided cognitive-behavioral approach for people with substance use and PDs; research with an opioid-dependent group is being supported by NIDA.

Figure D-9. Antisocial Thinking-Error Work

The group facilitator presents thinking errors and then asks each group member to identify two thinking-error examples that apply to him or her and to choose one to focus on with the group’s help.
1. Excuse making. Excuses can be made for anything and everything. Excuses are a way to justify behavior. For example: “I drink because my mother nags me,” “My family was poor,” “My family was rich.”
2. Blaming. Blaming is an excuse to avoid solving a problem and is used to excuse behavior and build up resentment toward someone else for “causing” whatever has happened. For example: “They forced me to drink it!”
3. Justifying. To justify an antisocial behavior is to find a reason to support it. For example: “If you can, I can,” “I deserve to get high, I’ve been clean for 30 days.”
4. Redefining. Redefining is shifting the focus on an issue to avoid solving a problem. Redefining is used as a power play to get the focus off the person in question. For example: “I didn’t violate my probation. The language is confusing and the order is full of typos.”
5. Superoptimism. “I think; therefore it is.” Example: “I don’t have to go to AA. I can stay sober on my own.”
6. Lying. There are three basic kinds of lies: (1) lies of commission, or making things up that are simply not true; (2) lies of omission, or saying partly what is true but leaving out major sections; and (3) lies of assent, or pretending to agree with other people or approving of their ideas despite disagreement or having no intention of supporting the idea.
7. “I’m unique.” Thinking one is special and that rules should not apply to oneself.
8. Ingratiating. Being nice to others, and going out of one’s way to act interested in other people, can be used to try to control situations or get the focus off a problem. Also known as “apple polishing.”
9. Fragmented personality. Some people may attend church on Sunday, get drunk or loaded on Tuesday, and then attend church again on Wednesday. They rarely consider the inconsistency between these behaviors. They may feel that they have the right to do whatever they want and that their behaviors are justified.
10. Minimizing. Minimizing behavior and action by talking about it in such a way that it seems insignificant. For example: “I only had one beer. Does that count as a relapse?”
11. Vagueness. This strategy is to be unclear and nonspecific to avoid being pinned down on any particular issue. Vague words or phrases such as: “I more or less think so,” “I guess,” “Probably,” “Maybe,” “I might,” “I’m not sure about this,” “It possibly was,” etc.
12. Power play. This strategy is to use power plays whenever one isn’t getting one’s way in a situation. Examples include walking out of a room during a disagreement, threatening to call an attorney or to report the group facilitator to higher-ups.
13. Victim playing. The victim player transacts with others to invite either criticism or rescue from those around him.
14. Grandiosity. Grandiosity is minimizing or maximizing the significance of an issue, and it justifies not solving the problem. For example: “I was too scared to do anything else but sit,” “I’m the best there is, so no one else can get in my way.”
15. Intellectualizing. Using an emotionally detached, data-gathering approach to avoid responsibility. For example, when faced with a positive urine drug screen the client states, “When was the last time the laboratory had its equipment calibrated?” or “What is the percentage of error in this testing procedure?”

Adapted with permission from .

Mood and Anxiety Disorders


Mood disturbance and anxiety are ever-present features of many people in treatment for substance use disorders. A substance-abusing lifestyle regularly brings with it great cause for worries and sadness. Often, in recovery, these negative feeling states are, in time, replaced with hopefulness, a sense of renewal, and a general level of well-being. Many substances also cause mood and anxiety disorders through biochemical changes that may be alleviated when the client is no longer using. Sometimes, however, clients have anxiety and/or mood disorders that require treatment, both for their resolution and to remove the threats to recovery associated with these disorders.

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

Bipolar I, bipolar II, and cyclothymia

While Bipolar I and II are classified in the DSM-IV as mood disorders, mania and bipolar disorders are addressed in the next section on schizophrenia and psychosis. The fundamental difference diagnostically between bipolar I and bipolar II disorders relates to whether the individual has experienced a manic episode. If a person has never experienced a manic episode, but has both periods of major depression and periods of at least 4 days of hypomanic states, the diagnosis is one of bipolar II disorder.

Though seemingly minor, the difference carries considerable prognostic value—people who experience a true manic episode along with alternating episodes of major depression have an extremely high probability of having another manic episode. Usually, the manic episode will occur immediately before or immediately after a major depressive episode (). Thus, what can seem to be a small diagnostic matter can be significant, and in this case it is likely that bipolar I and bipolar II represent meaningfully distinct clinical entities.

Cyclothymic disorder is a mood disorder that involves fluctuating moods from above normal to below normal, but never has symptoms so severe or persistent as to meet the diagnostic criteria for a bipolar disorder. To be considered a disorder, the disturbance must reach a level great enough to have a negative impact on someone’s interpersonal or vocational life. With a co-occurring substance use disorder, all forms of mood disorders can worsen acutely over the long run.

Major depression

Symptoms of major depression may occur at mild or moderate levels of severity. Major depression typically is experienced as a more intense and acute depression, often with strong physiological changes in appetite, sleep, energy level, and ability to think, as well as excessive feelings of worthlessness with possible suicidal ideation or plans. Though two thirds of people who experience a major depressive episode recover fully (), one third may recover only partially and a number of individuals develop a persistent major depressive disorder, often meeting criteria for evidence of severe and/or persistent mental illness.

Severe depressive episodes can include psychotic features, such as an auditory hallucination of a voice saying that the person is “horrible,” a visual hallucination of a lost relative mocking the person, or a delusion that one’s internal body parts have rotted away. However, most people who have a major depressive episode do not exhibit psychotic symptoms even when the depression is severe (for more information see the next section on schizophrenia and psychosis).

Chapter 8 contains a full description of the characteristics of a Major Depressive Episode.

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 (). Dysthymic disorder “is characterized by a depressed mood for most of the day, for more days than not, for at least 2 years” (, 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 (). 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

Panic attack, panic disorder, specific phobia, and social phobia

A panic attack is a distinct period of intense fear or discomfort that develops abruptly, usually reaching a crescendo within a few minutes or less. Physical symptoms may include hyperventilation, palpitations, trembling, sweating, dizziness, hot flashes or chills, numbness or tingling, and the sensation or fear of nausea or choking. Psychological symptoms may include depersonalization and derealization (feeling as if things are not real) and fear of fainting, dying, doing something uncontrolled, or losing one’s mind.

A panic disorder consists of episodes of panic attacks followed by a period of persistent fear of the recurrence of more panic attacks. Sometimes panic attacks are associated with fears of going places where rapid exit would be difficult or embarrassing, such as over bridges, in airplanes, or in stores or markets. When the focus of anxiety is an activity, person, or situation that is dreaded, feared, and probably avoided, the anxiety disorder is called a phobia. Panic disorders often are underdiagnosed at the beginning of treatment, or else are seen as secondary to the more significant disorders, which are the primary focus of treatment. However, panic disorders can impede significantly a person’s ability to do the tasks of recovery, such as getting on a bus to go to a meeting or sitting in a 12-Step meeting. Sometimes these can erroneously be identified as manipulative or treatment-resistant behaviors.

Phobia-inspired avoidance behavior, with its associated travel and activity restrictions, may become intense and incapacitating. The phobias include agoraphobia, social phobia, and simple or specific phobia; panic attacks and panic disorders often are involved, but not necessarily. Specific phobia, also called single or simple phobia, describes the onset of intense, excessive, or unreasonable fear stimulated by the presence or anticipation of a specific object or situation. The causes may be naturally occurring (e.g., animals, insects, thunder, water), situational (such as heights or riding in elevators), or related to receiving injections or giving blood. Social phobia describes the persistent and recognizably irrational fear of embarrassment and humiliation in social situations. The social phobia may be quite specific (e.g., public speaking) or may become generalized to all social situations.

Though panic disorders, phobias, and social phobias may seem relatively straightforward, they are quite complex, as they often are historically intertwined for each and every person. For example, the client who says he or she is “claustrophobic” and fears getting into an elevator may have had a few panic attacks 20 years beforehand, has successfully avoided going into any elevators in the past 2 decades, and may barely remember the panic symptoms associated with the original reaction to elevators that led to the avoidant behavior. There is considerable evidence that both non-medication behavioral approaches and medications can be useful, either alone or in combination in the treatment of these mental disorders.

Obsessive-compulsive disorder (OCD)

OCD is an anxiety disorder involving obsessions or compulsive rituals, or both. Obsessions are repetitive and intrusive thoughts, impulses, or images that cause marked anxiety. They often involve transgressing social norms, harming others, and becoming contaminated, but they are more intense than excessive worries about real problems. Compulsions are repetitive rituals and acts that people are driven to perform and which they perform reluctantly to prevent or reduce distress. The frequency and duration of their repetition make them inconvenient and often incapacitating. Examples include ritualistic behaviors (such as hand washing and rechecking) and mental acts (e.g., counting and repeating words silently). Obsessions are often time consuming and interfere significantly with daily functioning.

PTSD and acute stress disorder

Although PTSD is one of the anxiety disorders and many of the possible symptoms of PTSD are anxiety-like symptoms, PTSD has been identified as so prevalent in populations with COD that it is described in full in the following section. There is only a diagnostic difference between PTSD and acute stress disorder in that PTSD cannot be diagnosed until and unless a person experiences the symptoms for a month; therefore, if the symptoms last less than 1 month or it has been less than 1 month since the traumatic event, then acute stress disorder rather than PTSD would be diagnosed.

Except for these timeframe criteria, the symptoms of acute stress disorder that follow a traumatic event are, by and large, the same types of symptoms as PTSD. The client may have a subjective sense of “being in a daze” with emotional detachment, inability to recall aspects of the event, feeling as if things are not real (derealization), feeling that one is not oneself or disconnected from feeling oneself (depersonalization). The client may also report the phenomena of re-experiencing the event, avoidant behavior, increased arousal, distress, and interference with functioning. See the section on PTSD for a thorough description.

Differential Diagnosis

It comes as no surprise to the substance abuse treatment counselor that licit and illicit drugs of abuse cause symptoms that are identical to the depression and anxiety symptoms that have been discussed. In addition, many medications, toxins, and medical procedures can cause or are associated with an eruption of an anxiety and/or depressive reaction. Moreover, these reactions run the gamut from mild manifestations of short-lived symptoms to full-blown manic and other psychotic reactions, which are not necessarily short-lived.

For substance abuse counselors and clinicians, the role of personality, preexisting mood state, personal expectations, drug dosage, and environmental surroundings all warrant consideration in developing an understanding of how a particular client might experience a substance-induced disorder. While many people with substance use disorders will experience sensory and perceptual distortions, some will experience euphoric religious or spiritual states that may resemble aspects of a manic or psychotic episode. Others may have a deeply troubling introspective experience, causing symptoms of depression. Some may have a positive experience that they seek to repeat.

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.

Figure D-10. Drugs That Precipitate or Mimic Mood Disorders

Mood Disorders During Use (Intoxication) After Use (Withdrawal)
Depression and dysthymia Alcohol, benzodiazepines, opioids, barbiturates, cannabis, steroids (chronic), stimulants (chronic) Alcohol, benzodiazepines, barbiturates, opioids, steroids (chronic), stimulants (chronic)
Mania and cyclothymia Stimulants, alcohol, hallucinogens, inhalants (organic solvents), steroids (chronic, acute) Alcohol, benzodiazepines, barbiturates, opioids, steroids (chronic)

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.

Stimulant withdrawal

Stimulant withdrawal may provoke episodes of depression lasting from hours to days, especially following high-dose, chronic use. Stimulant-induced episodes of mania may include symptoms of paranoia lasting from hours to days. Stimulants such as cocaine and amphetamines cause potent psychomotor stimulation. Stimulant intoxication generally includes increased mental and physical energy, feelings of well-being and grandiosity, and rapid pressured speech. Chronic, high-dose stimulant intoxication, especially when combined with sleep deprivation, may prompt an episode of mania. Symptoms may include euphoric, expansive, or irritable mood, often with flight of ideas, severe impairment of social functioning, and insomnia.

Acute stimulant withdrawal generally lasts from several hours to 1 week and is characterized by depressed mood, agitation, fatigue, voracious appetite, and insomnia or hypersomnia (oversleeping). Depression resulting from stimulant withdrawal may be severe and can be worsened by the individual’s awareness of substance-abuse-related adverse consequences. Symptoms of craving for stimulants are likely and suicide is possible.

Protracted stimulant withdrawal often includes sustained episodes of anhedonia (absence of pleasure) and lethargy with frequent ruminations and dreams about stimulant use. There may be bursts of dysphoria, intense depression, insomnia, and agitation for several months following stimulant cessation. These symptoms may be either worsened or lessened by the quality of the client’s recovery program.

Assessment Case Studies: George M. and Teresa G

George M.
George M. is a 37-year-old divorced male who was brought into the emergency room intoxicated. His blood alcohol level was .152, and the toxicology screen was positive for cocaine. He was also suicidal (“I’m going to do it right this time!”). He has a history of three psychiatric hospitalizations and two inpatient substance abuse treatments. Each psychiatric admission was preceded by substance use. George M. has never followed through with psychiatric treatment. He has intermittently attended AA, but not recently.
Teresa G.
Teresa G. is a 37-year-old divorced female who was brought into a detoxification unit with a blood alcohol level of .150. She was observed to be depressed and withdrawn. She has never used drugs (other than alcohol), and began drinking alcohol only 3 years ago. However, she has had several alcohol-related problems since then. She has a history of three psychiatric hospitalizations for depression, at ages 19, 23, and 32. She reports a positive response to antidepressants. She is currently not receiving mental health services or substance abuse treatment.

Differential diagnostic issues for case examples. Many factors must be examined when making initial diagnostic and treatment decisions. For example, if George M.’s psychiatric admissions were 2 or 3 days long, usually with discharges related to leaving against medical advice, decisions about diagnosis and treatment would be different if than if two of his psychiatric admissions were 4 to 6 weeks long with clearly defined manic and psychotic symptoms continuing throughout the course, despite aggressive use of psychiatric treatment and medication.

Similarly, if Teresa G. had abstained from alcohol for 6 months “on her own,” had relapsed the night before while thinking about killing herself, had become increasingly depressed and withdrawn over the past 3 months, and had suffered from disordered sleep, poor concentration, and suicidal thoughts, a different diagnostic picture would emerge.

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.


Approximately one quarter of U.S. residents are likely to have some anxiety disorder during their lifetime, and the prevalence is higher among women (30.5 percent) than men (19.2 percent) (). Estimates of lifetime prevalence for major depression range from 10 to 25 percent for women and half that for men. For dysthymic disorder, estimates are 6 percent for both women and men ().

Data from the National Comorbidity Study indicate that about one half (41 to 65 percent) of individuals with a substance use disorder have an affective or anxiety disorder at some time in their lives (). Among women with a substance use disorder, mood disorders may be prevalent, and women are more likely than men to be clinically depressed and/or to have PTSD. Research suggests that 4.5 percent of clients with substance use disorders have panic disorder and 16 percent of panic disorder clients have a co-occurring substance use disorder ().

Certain populations are at risk for anxiety and mood disorders. American Indians, clients with HIV, clients maintained on methadone, and older adults may all have a higher risk for depression. The elderly may be the group at highest risk for combined mood disorder and substance problems (see TIP 26, Substance Abuse Among Older Adults []). Episodes of mood disturbance generally increase in frequency with age. Older adults with concurrent mood and substance disorders tend to have more mood episodes as they get older, even when their substance use is controlled. Also, from 20 to 25 percent of individuals who have chronic or severe general medical conditions, such as diabetes or stroke, develop major depressive disorder. The data on high prevalence of these disorders and the information on the most vulnerable groups point to the need for counselors to consider in treatment planning that the observed behavior of depression, anxiety, and elation may likely be associated with a mental disorder.

Substance Use Among People With Mood or Anxiety Disorders

People with co-occurring mood or anxiety disorders and a substance use disorder probably have used many substances. Though those with depression may favor stimulation while those with anxieties may favor sedation, considerable overlap is apparent. The use of alcohol, perhaps because of its availability and legality, is ubiquitous.

The notion that substance use disorders are caused, in whole or part, by an individual’s attempts to “self-medicate” specific symptoms with alcohol or illicit drugs has been a source of debate. Many prominent researchers and clinicians have concluded that substance use is a cause rather than an attempt to cure symptoms. Vaillant, for example, noted that “depression is a symptom caused by alcoholism more often than the reverse” (, p. 80). Both and Raimo (1998) point out that insomnia, depression, and other “psychiatric” symptoms often are more likely substance-use related, thus self-medication in this case becomes using alcohol (or other drugs) to block acute or protracted substance withdrawal symptoms.

The “self-medication hypothesis” first proposed by did not focus on withdrawal symptoms, but proposed that those who abuse drugs do so to deal with core psychopathology that might range from anger to mania. While an attractive theory, research does not entirely support this hypothesis. For example, adolescents with attention deficit disorder should likely prefer to abuse stimulants such as cocaine or amphetamines; however, marijuana is by far the most commonly abuse drug in this population () and it has been demonstrated to make attention issues worse. Likewise, patients with bipolar disorder in either depressed or manic states should correspondingly use stimulants or depressives, but , after following such patients for a year after acute hospitalization, could find no pattern to their use, nor types of substances used. In addition, there have been negative studies on schizophrenia (), and the only symptom/diagnosis in which data appear to support that core mental disorder symptoms lead to substance use, and substance use leads to decreased symptoms, is that of social anxiety, as demonstrated by Thomas and colleagues (), though even in this case there have been negative studies (e.g., ).

The consensus panel cautions that the term “self-medication” should not be used, as it equates drugs of abuse (which usually worsen health) with true medications (which are designed to improve health). Equating substances of abuse with medications can be taken quite concretely by some patients, especially those who are either psychotic or are looking for a clever rationalization for their addictive behavior. Thus, such patients might conclude, “Well, I’ll use the doctor’s medications during the week, but my ‘medications’ on the weekend (didn’t the doctor say ‘self-medication with alcohol?’).”

Key Issues and Concerns

The key issues and concerns for the client with mild-to-moderate mood and/or anxiety disorders center on making the client comfortable with, or at least able to tolerate, the treatment environment. Often, the specific type of disorder and its symptoms need to be examined in light of treatment demands. How does the client get to the meeting? Are there any aspects of the treatment environment that duplicate or remind a client of a prior trauma experience? Can a client who wakes up 2 hours earlier than normal, say 5:00 a.m., develop some non-maladaptive way of coping with the monotony that can feed the client’s feelings of depression? Do other clients make fun of the obsessive-compulsive rituals of a client? An insightful counselor and a dedicated staff can go a long way in assisting the anxious or depressed client.

The majority of clients receiving treatment for combined mood or anxiety disorders and substance use disorders improve in response to treatment. When they don’t improve, a re-evaluation of the treatment plan is warranted. A client receiving antidepressant medication who is abstinent from substances but anhedonic requires a careful evaluation and assessment to identify resistant psychiatric conditions that require treatment. Based on assessment, an additional treatment service such as psychotherapy may be added. Indeed, psychotherapy has been shown to improve the efficacy of substance abuse treatment and of mental health services that involve antidepressant medication.

When clients do not improve as expected, it is not necessarily because of treatment failure or client noncompliance. Clients may be compliant and plans may be adequate, but disease processes remain resistant. Clients with severe and persistent substance use and mood disorders should not be seen as resistant, manipulative, or unmotivated, but as extremely ill and in need of intensive support.

Strategies, Tools, and Techniques


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

Medical assessment

Clients with mood/anxiety disorders, particularly older adults, may have life-threatening medical conditions, including hypoglycemia (insulin overdose), stroke, or infections. These conditions, as well as withdrawal and toxic drug reactions, always must be considered and require a thorough physical examination and laboratory assessment. Clinical staff should make appropriate referrals for medical assessment and treatment. Facilities that have no medical component should train assessment staff in triage and referral, especially as part of the intake process.

Assessing mood and anxiety symptoms

During initial screening sessions, clients with substance use disorders may overemphasize or underemphasize their psychiatric symptoms. For instance, clients who feel depressed during the assessment may distort their past psychiatric experiences and unwittingly exaggerate the intensity or frequency of past depressive episodes. Some clients experience feelings of guilt that are excessive and inappropriate. Other clients do not accurately label their depression and fail to remember that they have experienced depression before. Since clients frequently confuse depression with sadness and other emotions, it is important to obtain collateral information from other people and from documents such as medical and psychiatric records. It is critical to continue the process of evaluation past the period of drug withdrawal.

For anxiety and mood symptoms especially, observation is an important component of screening and assessment. Does the client seem calm and relaxed or nervous and distraught? Often, with training in screening or assessment, the counselor will learn to recognize some of the features that provide clues to a client’s mental status, such as rate of speech, affective tone, cooperativeness, and so on.

Assessment instruments

A differential diagnostic evaluation can include the clinical application of the DSM-IV, perhaps in the form of a structured clinical interview. Some specific and general standardized assessment measures are available for anxiety and mood disorders. The Beck Depression Inventory-II (BDI-II) (and its predecessor) has been used in a wide variety of settings for the past 25 years, and a Beck Anxiety Inventory is available; both have English and Spanish versions and are proprietary. Substance abuse treatment agencies need to provide training in the use of assessment instruments so that counseling staff can take full advantage of the information and can play the most effective roles possible in assessment processes.

Case Study: Assessment of Mood and Anxiety Disorders

Jim R. enters the substance abuse treatment center after detoxification at the hospital. He was admitted following a drinking and driving incident in which he hit the side of a building, fortunately injuring no one. The counselor immediately sees that Jim R. is depressed and somewhat anxious. He talks about how he has screwed up, will probably lose his license, and will then not be able to work. He says he has tried repeatedly to stop drinking and cannot succeed; his life is hopeless.
Jim R. is not thinking of suicide, but he has lost a great deal of weight recently, has difficulty concentrating, feels worthless, moves suddenly in an agitated way (he shifts his position in the chair continually), and admits to difficulty sleeping. The counselor senses that the client may be depressed and notes the indications of depression in the record. To obtain further collaboration, the counselor immediately uses the BDI-II and finds that Jim R. scores 15. A score of 15 represents a moderate level of depression, but the treatment program’s protocol for the use of the BDI-II by counselors calls for weekly monitoring of moderately scoring clients with repeat administrations of the BDI-II. In the next session, the counselor notes signs of increased depression and reevaluates the symptoms. He finds that Jim R. now scores 40 on the BDI-II. According to the established protocol, he now refers him to a psychiatrist, suggesting that Jim R. may be in need of medication and a differential diagnosis.
The psychiatrist does a longitudinal assessment in which she explores Jim R.’s drinking and establishes a diagnosis of alcohol abuse disorder. The psychiatrist also explores when Jim remembers being depressed and gauges the severity and persistence of these depressions. Finding a pattern of persistent depression with anxious features, such as excessive worry, that precedes Jim R.’s drinking, she prescribes an antidepressant with a calming effect. She tells Jim R. the pills should help him feel less worried and sleep better even though the pills are neither tranquilizers nor sleeping pills, and she stresses the importance of taking them regularly. Noting that Jim R. is a college graduate, she prescribes a workbook on depression (David Burns, The Feeling Good Handbook) to help him learn about the disease. The psychiatrist informs the substance abuse treatment counselor of her action and asks the counselor to continue monitoring the client’s depression. She also refers Jim R. for cognitive-behavioral sessions with a mental health clinician to help him overcome his negative thinking and regain his sense of worth.
On Jim R.’s next visit, the substance abuse treatment counselor checks Jim R.’s pill box and finds that many of the pills have not been taken. He uses motivational therapy techniques to encourage Jim R. to take the pills regularly. He also reinforces the work of the mental health counselor, pointing out that the “stinking thinking” discussed in AA as a bad rationale for drinking is similar to the thought patterns that drive his depression. Gradually, Jim R. is able to manage his disorder through medication and improved thought patterns.

Discussion of case study: While many clients are depressed and anxious at the onset of treatment—and someone in Jim R.’s position might well be expected to have these symptoms—it is still important to consider the possibility that the depression or anxiety might be a co-occurring mental disorder. The counselor notes the indications of depression and formally screens for depression using the BDI-II. Upon review at the next session the counselor notes and evaluates the increase in depression and refers the client to a psychiatrist when the symptoms persist and intensify. The psychiatrist establishes the co-occurring mental diagnosis and, with the counselor, develops a treatment plan that involves medication, cognitive-behavioral mental health counseling and continued substance abuse treatment and monitoring of medication. With this integrated treatment approach, based on a sound observation, rapid referral, and accurate diagnosis, the client begins making good progress in treatment.

Psychosocial assessment

A comprehensive psychosocial assessment, including an evaluation of the client’s support system, is an important aspect of the overall assessment. Such information is essential for understanding the full context of anxiety and mood troubles. Effective treatment planning for both disorders depends on understanding the total life situation of the client.

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., ).

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.

Use of 12-Step and other mutual self-help programs

Participation in 12-Step programs provides valuable therapeutic experiences for many recovering people who have mood or anxiety disorders. People who have a social phobia and the fear of public speaking often are extremely resistant to attending self-help meetings. Yet, such people can make tremendous recovery gains in terms of anxiety desensitization and substance abuse recovery.

Few situations are as safe, supportive, predictable, and undemanding as the average 12-Step group meeting. For this reason, groups such as AA and Narcotics Anonymous (NA) provide constructive opportunities to help clients desensitize social fears. However, anxious clients must not simply be thrust unprepared into 12-Step group meetings. Counselors should educate and prepare such clients regarding the process and approach of 12-Step other self-help group meetings.

A stepwise approach to using mutual self-help

It is important for substance abuse treatment staff to appreciate the difficulty and distress that are experienced by people who have social phobias and fears of speaking in public. Staff who assist such clients with 12-Step group participation should become knowledgeable about the signs and symptoms, course, and treatment of generalized anxiety disorder, panic disorder, and the phobias, especially social phobia and other anxieties related to public speaking and social situations.

Staff can help socially anxious clients participate in 12-Step group meetings by using a stepwise approach of progressively active exposure and participation based somewhat on the principles of systematic desensitization:

  • One of the least intense levels of preparation involves the use of mock AA/NA meetings consisting of staff and clients. This process makes it possible to stop the meeting frequently, discuss various meeting components, examine group methods, and allow potential participants to observe and practice.
  • The next level of intensity involves attending a 12-Step group meeting as a nonspeaking observer. Staff should help clients to understand that being a nonspeaking observer is a transitional phase and is not a substitute for active participation. For this reason, it may be helpful to limit nonspeaking observation by the client to a specific number of meetings. At first clients can attend meetings with someone they know and trust, and they can stay in the back of the meeting room close to an exit door.
  • The next level of intensity involves clients attending a limited number of 12-Step meetings during which they identify themselves but do not talk about themselves. The counselor can give assistance by providing easily rehearsable suggestions for self-introductions such as, “Hi, my name is Mary. I’m an alcoholic and I am glad to be here, although I am a little nervous.”

Since the mutual support associated with the 12-Step group meetings can occur outside of the meeting, anxious clients should be encouraged to do more than merely attend and participate in the meetings. Rather, they should arrive before the meeting begins and should linger and mingle with others following the meeting. Clients can be encouraged to volunteer to help set up the room, make the coffee, or clean up afterward. In particular, socially phobic clients can be encouraged to join others for coffee and conversation after the meetings on a more one-to-one basis, a traditional aspect of 12-Step group involvement.

By participating in step-by-step, rehearsed activities, many anxious and depressed clients seem to break through an internal barrier. As they do, participation in self-help group meetings becomes an integral aspect of recovery from substance use disorders and mental health problems.

The stepwise approach described for clients with anxiety disorders can be adapted for clients who are depressed. Anxious clients often avoid group participation and public speaking, saying to themselves, “If I talk or if I am noticed, I will freak out.” Similarly, depressed clients often avoid group participation and other recovery activities, perhaps thinking, “I just don’t have the energy to go. Why bother?” The counselor must elicit comments, understand them, and help clients to reverse these internal barriers to recovery and participation in group and other social activities.

Case Study: Phobia, Tranquilizers, and Alcohol

Lan S. has been referred to the substance abuse treatment clinic by her physician because of abuse of prescribed tranquilizing drugs and alcohol. The counselor finds Lan S. somewhat nervous but apparently in stable condition and willing to discuss her substance abuse problems. During the course of conversation, she mentions her discomfort in restaurants and malls. When the counselor refers her to a 12-Step group, Lan S. seems hesitant and uncomfortable. The counselor identifies her symptoms as resistance to treatment and strongly emphasizes the importance of attendance if she wants to change.
In future sessions, however, the counselor finds her refusal to go to group remains steadfast. After conferring with a mental health counselor, she probes Lan S.’s discomfort about going to group and explores the possibility of other similar problems. She finds that Lan S. orders all her clothes online to avoid going to stores and that she rarely appears in public. Coming to the counseling session is an ordeal made possible only by the fact that her mother takes her to the clinic and waits for her in the counseling center.
The counselor refers Lan S. to the psychiatrist, who finds that Lan S. has a social phobia. He prescribes Zoloft, a selective serotonin reuptake inhibitor (SSRI) antidepressant, and arranges for a course of treatment with a mental health counselor who specializes in phobias. He asks the substance abuse treatment counselor to coordinate closely with the mental health counselor to develop a strategy to enable Lan S. to attend meetings. Together, they work out a phased approach to regular attendance at meetings in which she first attends a meeting at the clinic, then is escorted to a meeting at another part of town. The counselors also provide psychoeducation for both Lan S. and her mother to help them understand her mental disorder. The substance abuse treatment counselor works with Lan S.’s sponsor to ensure understanding of her limitations. Gradually, Lan S. is able to attend AA regularly on her own.

Discussion : Counselors should be aware that some “resistance” may actually indicate a mental disorder. Until the disorder is treated, this obstacle will remain in the client’s path and deter recovery. At the same time, some clients with social phobia or other anxiety disorders may choose not to attend 12-Step groups; this is a legitimate choice. Such clients should be offered alternatives, such as increased amounts of individual therapy. As long as they can engage in such treatment alternatives, it is important not to convey to clients that they are “wrong” or “bad” or “not doing recovery right” by choosing not to attend 12-Step groups.

Case Study: OCD and Alcohol

Marla W. is a 40-year-old woman with a secret: She has been compulsively washing her hands for many years, and cannot stop. She began drinking to try to relax, but found herself gradually drinking more and more in an attempt to cope with what she knew was very unhealthy behavior. She feels triggered to wash her hands whenever she thinks of “germs,” and feels that she cannot get them clean enough. She sometimes washes up to 100 times a day, and has constricted her life so others will not see her. When she drinks, she is alone.
The substance abuse treatment counselor discovers Marla W.’s obsession when she notices Marla W.’s repeated trips to the rest room. She discusses Marla W.’s symptoms and assures her that some medication and therapies may be able to help her overcome the disorder. She refers Marla W. to the psychiatrist for assistance.

Discussion : Substance abuse treatment counselors often consider compulsive behaviors (gambling, shopping, overeating, sex, work, etc.) to be addictions. However, they should also consider that some compulsive behaviors may be part of an OCD and clients may benefit by having further evaluation and the knowledge that specific medication and therapies are available to assist them.

Case Study: GAD and Protracted Withdrawal

Ray Y., a 50-year-old husband and father of teenagers, is going through protracted alcohol withdrawal. He appears “edgy” and irritable, sometimes sad, and complains to his substance abuse treatment counselor of insomnia, headaches, and an upset stomach. He tells the counselor he can barely stand not to drink: “I’m jumping out of my skin.” Although these symptoms are common during protracted withdrawal, because they have persisted for over a month, the counselor begins a more detailed exploration.
The counselor asks Ray Y. whether he had these symptoms before he used alcohol and Ray Y. says he’s “always been this way.” He worries about everything, even events that are weeks away. His family vacations are nightmares because every aspect of vacation planning troubles him and keeps him awake. During family therapy, it becomes apparent that his daughter deeply resents his controlling and distrustful behavior, as well as his overprotective stance toward all her social commitments. The counselor refers Ray Y. to the psychiatrist, who diagnoses generalized anxiety disorder and begins a course of medication and initiates mental health counseling. The family receives help coping with Ray Y.’s disorder and the daughter is referred for short-term counseling to help her address the mental problems she is beginning to develop as a result of her father’s excessive control.

Discussion : Even though anxiety symptoms are quite common during protracted withdrawal, counselors are advised to consider the possibility that an anxiety disorder is sometimes indicated. Symptoms should be tracked to see whether they persist beyond the normal time that might be expected for protracted withdrawal (about a month). Counselors should also be aware of the effect of such disorders on close family members. Children and adolescents may not understand that a parent has a mental disorder and may be relieved to have a way of understanding and coping with difficult behavior.

Schizophrenia and Other Psychotic Disorders


Psychosis is the term for a severely incapacitated mental and emotional state involving a person’s thinking, perception, and emotional control. Psychosis refers to distorted thoughts in which an individual has false beliefs, sensations or perceptions that are imagined, and/or very extreme and unusual emotional states along with deterioration in thinking, judgment, self-control, or understanding. In everyday terms, people who are acutely psychotic cannot tell the difference between what is real and what is not, but this common distinction is too simplistic to be clinically useful. Psychosis usually is expressed clinically as a combination of one or more of the following symptoms:

  • Belief in delusions (such as that one is being followed by people from Mars, or that one is a very important person whom the President wants to talk to right away, or that one is eternally damned).
  • Hearing or seeing things that are not there (hallucinations) and being unable to recognize that what is being experienced is not real, such as hearing voices that say self-condemning or other disturbing things, or seeing a mocking or threatening face of the Devil.
  • Severe emotional excitement, which can manifest as a “manic” state with feelings of exuberance, invincibility, grandiosity. Often this state is accompanied by poor judgment and prolonged functioning with little sleep, as is seen in people with bipolar disorder during the manic phase. Alternatively, an emotional state reflecting psychosis may manifest as severe agitation, sometimes with vaguely expressed worries or fears and/or with tears and depressive consternation.
  • On rare occasions, a very different type of psychotic reaction can occur, one that manifests as immobility, stupor, or rigid body position over extended periods of time. This is known as catalepsy, one of several forms of catatonic states that occur during certain types of schizophrenic episodes.

Although schizophrenia is the illness most strongly associated with psychotic disorders, people with bipolar disorder (or what used to be termed “manic-depressive illness”) may experience psychotic states during periods of mania—the heightened state of excitement, little or no sleep, and poor judgment described above. Other conditions also can be accompanied by a psychotic state, including toxic poisoning, other metabolic difficulties (infections [e.g., late-stage AIDS]), and other mental disorders (major depression, dementia, alcohol withdrawal states, brief reactive psychoses, and others).

For the purpose of this TIP, the focus will be on schizophrenia and bipolar disorder. Although schizophrenia is a “thought” disorder and bipolar disorder is a “mood” or “affective” disorder, these often are the diagnoses that States and/or other funding agencies use to establish special programs for people with “severe and persistent mental illness” or the “severely mentally ill.” In practice, however, eligibility for such programs often is more largely determined by the mental health problems and their impact on the basics of the client’s life—living arrangements, employment, hospitalizations, ability to care for self—than by the client’s specific diagnosis.

Substance abuse treatment counselors typically do not see clients in the throes of an acute psychotic episode, as such psychotic patients more likely present, or are referred to, ERs and mental health treatment facilities. Counselors are more likely to encounter such clients in a “residual” or later and less active phase of the illness, the time at which these individuals may receive treatment for their substance use disorders in an addiction treatment agency. Even if the substance abuse treatment counselor never sees a client during an actively psychotic period, knowing what the client experiences as a psychotic episode will enable the counselor to understand and assist the client more effectively. On the other hand, counselors are increasingly treating clients with methamphetamine dependence who often have residual paranoid and psychotic symptoms, and may need antipsychotic medications. These clients may continue with such psychotic symptoms for months, or even years ().


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 (). However, clients with bipolar disorder who are successfully treated frequently return to positive and productive lives without any future disruption.

Differential Diagnosis

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” (, p. 971). In addition, withdrawal from some substances, especially alcohol, can produce states that can mimic psychosis. Consider the following descriptions by , 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 (, 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….” 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 (). 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., ). 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, 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.



The lifetime prevalence rate for adults with schizophrenia is between 0.5 and 1.5 percent (). The Epidemiologic Catchment Area (ECA) studies reported that among clients with schizophrenia, 47 percent met criteria for some form of a substance use disorder (). Fifteen years earlier, 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 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, 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 (), 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 (). 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 ().

Substance Use Among People With Bipolar Disorder or Schizophrenia

The search for specific patterns of use among clients with schizophrenia or bipolar disorder has not led to any clear pattern of drug choice. Instead, there appears a strong likelihood that whatever substances happen to be available will be the substances used most typically (). In research on the substance use of Australian and American patients with schizophrenia, attributed the “slightly different pattern of substances abused (i.e., absence of cocaine)” to the “relative differences in the availability [of] certain drugs” (p. 443).

There is evidence of increasing use of alcohol and drugs among persons with schizophrenia. Fowler and colleagues reviewed studies on the substance use of people with schizophrenia, concluding that alcohol abuse and dependence increased “from 14 to 22 percent in the 1960s and 1970s … to 25 to 50 percent in the 1990s” (1998, p. 444). The same analysis showed that stimulant abuse or dependence also may have nearly doubled from the 1970s to the 1990s, from about 13 percent to between 17 percent and 31 percent, respectively. However, Fowler and coworkers also found that hallucinogen abuse or dependence declined from roughly 12.5 percent in the 1970s to 7 percent in the 1990s, and they estimate that cannabis use has remained stable at an estimated range of 12.5 to 35.8 percent.

, p. 611) report that some individuals with bipolar disorder use cocaine to “intensify and lengthen euphoric mood states rather than to self-medicate depressive episodes.” However, other clinicians see the use of alcohol by people with manic behaviors as their way of trying to sedate the heightened emotional state. Many authors report that clients will claim to use substances to counteract feelings of hopelessness or other symptoms of illness, but a majority of clients report that they use drugs or alcohol in a manner similar to persons who are not mentally ill—that is, to “get high” and/or to be sociable and fit in with others. It seems likely that clients can be confused about their substance use. report that clients state they use substances to feel less depressed—even though 65 percent of them indicated that alcohol increased their symptoms of depression.

Key Issues and Concerns

Suicide and suicidal behaviors are major, ongoing concerns for this client population, and the substance abuse counselor should have a thorough understanding of her or his role in preventing suicide. Medication compliance should be emphasized strongly and monitored at every session. The cyclical nature of bipolar disorder, frequently punctuated by bouts of deliberate medication noncompliance, can test a counselor’s patience, and it is crucial to cultivate and convey an understanding of the allure of the manic episode.

Individuals with bipolar disorder do not have the same cognitive limitations as individuals with schizophrenia. Therefore, people with bipolar disorder can function at a high level in the work environment, and the maintenance of their work position can be a key factor in their long-term, successful treatment. Consequently, quick attention to signs of depression or mania can be critical, especially as medication might be able to ward off the worsening of the client’s condition. For developing mania, which is virtually nonresponsive to psychosocial interventions, a variety of mood stabilizers have demonstrated remarkable efficacy. Their timely use can avert potentially life-altering, negative events.

Family members and community supports, when appropriate, should be considered for inclusion in the overall treatment process for these clients. The psychoeducational component of treatment should include both mental health and substance use disorder information, from causes and the natural histories of the disorders to the recovery process and how the illnesses can interact.

A recovery perspective and a compassionate attitude toward clients can convey hope and allow them to envision significant recovery and improvement in their lives. For example, in a focus group study of 18 clients with schizophrenia and a substance use disorder, 16 had received a course of individual therapy, and all cited contact with their individual therapist as “…helpful in their efforts to change substance abuse patterns.” Many of the focus group participants stressed the importance of the human-to-human nature of their relationship with the therapist and the key role of family members and friends (, p. 223).

Strategies, Tools, and Techniques


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.

Figure D-11. Engaging the Client With Chronic Psychosis

Positive Engagement Techniques Coercive Engagement Techniques
• Assistance obtaining food, shelter, and clothing • Involuntary commitment
• Assistance obtaining entitlements and social services • Use of a representative payee
• Drop-in centers as entry to treatment • Mandated medications
• Recreational activities
• Low-stress, nonconfrontational approaches
• Outreach to client’s community

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.

Assessment of high-risk conditions

The initial step of every assessment is to determine whether the individual has an imminent life-threatening condition. Three domains of high risk require assessment: biological (or medical), psychological, and social. At any given time, one aspect of this biopsychosocial approach may be more urgent than the others.

Medical risks

The goal of medical or biological assessment is to ensure that clients do not have life-threatening disorders such as substance-induced toxic states or withdrawal, delirium tremens, or delirium.

Clients may exhibit symptoms that represent an exacerbation of their underlying chronic mental illness. Their symptoms may be due to an aggravation of medical problems such as neurological disorders (e.g., brain hemorrhage, seizure disorder), infections (central nervous system infection, pneumonia, AIDS-related complications), and endocrine disorders (diabetes, hyperthyroidism). The presence of cognitive impairment (such as acute confusion, disorientation, or memory impairment), unusual hallucinations (such as visual, olfactory, or tactile), or signs of physical illness (such as fever, marked weight loss, or slurred speech) show a high risk for an acute medical illness. Clients who exhibit this degree of risk need to be referred immediately for a comprehensive medical assessment.

Social risks

The primary goal is to ensure that clients have access to adequate supports and that their basic needs are met. Clients with COD involving psychosis are particularly vulnerable to homelessness, housing instability, victimization, poor nutrition, and inadequate financial resources. Clients who lack basic supports may require aggressive crisis intervention, such as the provision of food and assistance with locating a safe shelter. Lack of these social supports can be life threatening and can exacerbate and intensify both medical and psychiatric emergencies.

Psychological risks

The primary goal of psychological assessments must be an evaluation of the danger to self or others and other manifestations of violent or impulsive behavior. Clients with COD involving psychosis have a higher risk for self-destructive and violent behaviors, and should be assessed for plans, intents, and means of carrying out dangerous intent. Clients who are imminently suicidal, homicidal, or otherwise pose a danger need to be placed in a secure setting for further assessment and treatment (see Figure D-12). Some clients may have a cognitive impairment related to their disorder and be unable to attend adequately to basic needs. An assessment for these types of problems need to be conducted by appropriately trained and experienced graduate-level professionals. When a substance abuse counselor participates in these assessment processes, he or she can provide vital information on the client’s behavior and emotional state.

Figure D-12. Biopsychosocial Assessment of High-Risk Conditions

Biological risks: Assess for life-threatening medical problems
Psychological risks: Assess for violent and impulsive behaviors
Social risks: Assess basic needs and life supports
Clients should be asked direct questions about past and current access to basic needs such as food, shelter, money, medication, or clothing. Clients should be assessed for past and recent episodes of victimization and of exchanging sex for money, drugs, and shelter.
Clinician’s observations

The clinician’s observations are an important aspect of the assessment. The clinician should make careful note of the client’s overall behavior, appearance, hygiene, speech, and gait. Of particular interest are any acute changes in these behaviors, as well as the emergence of disorganized or bizarre thinking and behavior. A long-term therapeutic relationship with the client increases the opportunity to make clinical observations that assist in making the differential diagnosis. Within this context, clinicians can better understand the relationships between the substance use and the symptoms of mental disorders.

Collateral resources

As previously mentioned, data obtained from direct interviews and self-reports, as well as observational data, are limited. One important way of augmenting these approaches is to obtain information from collateral sources by direct interviews with family members and significant others concerning the psychiatric and substance-related behavior of clients. The family interview can also be a useful means of obtaining further information regarding a family history of psychiatric and substance use disorders.

Useful documentation includes medical and criminal justice records, as well as information gathered from other sources such as landlords, housing settings, social services, and employers. Case managers are in a unique position to compile aggregate reports from these various sources, since they follow clients over an extended period of time in a variety of settings.

Laboratory tests

Laboratory tests for drug detection can be valuable both in documenting substance use and in assessing substance use in relation to psychotic symptoms. Objective urine and blood toxicology screens and alcohol Breathalyzer tests can be useful. Besides being a diagnostic tool, data from urine screens may be particularly important for clients who deny regular use of substances and who can benefit from objective evidence of substance use. Toxicology screens that document the absence of drug use can provide positive feedback for abstinent clients who are actively working to maintain sobriety.

Social issues

While psychiatric, medical, or substance-induced disorders may be more visible to the clinician than social problems, the latter can contribute significantly to the elaboration of the disorder and to the client’s receptivity to treatment. Indeed, the client with a co-occurring substance use disorder is more likely than not to have significant impairment in the social area. Thus, identifying the problem areas of a specific client’s social life becomes a core component of the service or treatment plan.

Primary health care

A current or recent comprehensive medical evaluation is an essential aspect of the overall assessment for clients with psychotic disorders, since they generally have a high prevalence of medical problems. It is also important to evaluate the relationships between clients’ medical problems and their psychotic and substance use disorders. For example, medical problems may: (1) coexist with co-occurring disorders, (2) prompt or exacerbate psychotic and/or substance use disorders, or (3) be the direct or indirect result of perpetuating co-occurring disorders.

It is especially important for these clients to have easy access to treatment for medical conditions that are strongly associated with substance use, such as tuberculosis, hepatitis, diabetes, and HIV/AIDS. They should also have easy access to primary care treatment for basic medical needs, such as hypertension, as well as cardiovascular, respiratory, and neurological disorders. Prenatal care and monitoring should be available to pregnant women who may be especially at risk for relapse when her regular antipsychotic medication regimen is contraindicated.

For clients who are taking prescribed medications, it is important to assess the types of medications, whether the medications are being taken as prescribed, and the types of side effects they may cause. Clients should be asked specifically about the frequency, dosage, and duration of any prescription medication.

Medication noncompliance is the rule, not the exception, for people with co-occurring disorders. Psychiatric medication noncompliance is particularly associated with co-occurring disorders that involve psychosis, and has a significant impact on presenting symptoms and level of function. Because of this common association between substance use and noncompliance, and the limited utility of self-reports in this area, prescribing physicians often order serum drug level tests for psychiatric medications.

In addition to considering substance use as a primary factor that affects the use of psychiatric medications, it is also important to consider the potential role of psychiatric medications in subsequent substance use. For example, side effects such as akathisia (severe restlessness) or sedation may be caused by antipsychotic medications, and clients may take alcohol and/or other drugs in an attempt to medicate these unwanted side effects.

Frequently, clients spend money on psychoactive substances rather than on adequate and nutritious food; the resulting nutritional impairment can lead to impaired cognition. A lack of regular meals and poor nutrition are common occurrences among clients with COD; therefore, access to regular meals should be assessed. Acute dental problems as well as regular periodic dental care also should be assessed. Because this group frequently experiences financial difficulties, dental care often is limited or nonexistent. Attention should be given to the social and emotional consequences of poor dental health, such as poor self-esteem and diminished social interaction.

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.

High-risk conditions

The initial critical consideration for high-risk conditions is to determine if a client requires emergency medical treatment, psychiatric treatment, or both. If the client is found to require hospitalization, it is then necessary to determine the type of treatment that is required (e.g., primary health care, detoxification, or psychiatric care). Such determinations necessarily involve medical assessment and intervention. Coordination with emergency mental health services and the local police department may be necessary to ensure the immediate safety of the client and others. Substance abuse treatment programs should have clear and readily available policies and procedures for addressing these situations, and staff members should be thoroughly familiar with their roles and responsibilities.

With regard to high-risk social conditions (homelessness, housing instability, victimization, and unmet basic needs), the priority is to implement aggressive case management. Meeting clients’ basic needs is critical to the treatment of COD, including psychosis. High-risk conditions may be related to medical, substance use disorder, and/or psychiatric crises, and often will require followup upon hospital discharge. Regardless of the priority of the immediate needs, the overall biopsychosocial needs of clients must be addressed in a holistic manner, considering both the psychosis and the substance use disorder. The approach must be integrated and comprehensive despite the higher visibility of one of the disorders at a given time.

Therapeutic coercion

Those clients with severe mental or substance use disorders who do not respond to these initial attempts at engagement in the treatment process may require the use of therapeutic coercive approaches. Clients with severe COD may have gross cognitive impairment due to substance dependence and may be severely disorganized due to mental illness. They may be impulsive, exhibit extremely poor judgment, or be subject to repeated episodes in which they are dangerous to themselves or others. Without therapeutic coercive interventions, some of these clients may be at substantial risk of catastrophic outcomes, including death, injury, violent behavior, or long-term incarceration.

Examples of therapeutic coercive approaches include the appointment of a representative payee, guardian, or conservator, and the use of parole or probation. Legal advocacy by a case manager for court-mandated treatment services may be essential for engaging in and maintaining treatment services. Other mechanisms include commitment to outpatient treatment services, conditional discharge, and commitment to appropriate inpatient treatment.

Therapeutic coercive efforts should be temporary and reserved for clients for whom other interventions have failed. The long-term goal for these clients is to regain control over their lives. Even when coercion is necessary, the counselor can focus on the dangerous or harmful circumstances and avoid having the client take commitment or other coercion as a sign of personal failure, or as an indication of the counselor rejecting the client. Although at the time the client may protest, claiming to be mistreated and misunderstood, he or she often later expresses appreciation to the counselor for the concern shown in seeing that the client’s basic needs were met. This turnabout especially is likely when the counselor is able to convey compassion and understanding (though not agreement) throughout the process involving coercive elements.

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.

Group treatment

Group process is a core element of substance abuse and mental health treatment. However, for clients with psychosis, group treatment should be modified and provided in coordination with a comprehensive service plan. Clients who have accepted the goal of abstinence, have maintained mental health stability, and have essential social skills may benefit from carefully selected traditional 12-Step programs that are sensitive to the needs of people with serious mental illness. However, during the early phases of treatment, an unfacilitated referral to traditional 12-Step programs could result in a poor response. Fortunately, the growing movement for dual recovery mutual self-help groups (as described in chapter 7) is providing an attractive alternative for clients with COD. The core approach should include psychoeducational, supportive, behaviorally oriented, and skill-building activities.

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.
Discussion of case examples

Louisa F. and James T. have different long-term needs. Louisa F.’s brief reactive psychosis and depression may never recur, but the relationship between her alcohol use and mental disorder symptoms should be explored. James T.’s chronic psychosis and frequent substance abuse episodes are woven together intricately and require combined treatment.

These case examples are valuable to demonstrate how the absence of a dual-focus approach can lead to treatment failure. While Louisa F.’s psychotic episode was related to overwhelming stress, her alcohol use might be underemphasized in a traditional mental health setting. Doing so may obscure the possibility that her drinking severely deepened her depression, increased daytime agitation, and exacerbated the psychotic episode.

While James T. has ongoing psychosis and substance abuse problems, focusing on only one set of these problems means that he bounces back and forth between the mental health and substance abuse treatment programs, depending on his current symptoms. His involvement with the local medical clinic for treatment of physical injuries that are sustained during episodes of impaired thinking often complicates his already uncoordinated treatment, especially if he is given psychoactive agents for pain relief or what seems to the medical clinic staff to be anxiety.

As these case examples illustrate, clients who experience psychosis and substance abuse or dependency often are highly symptomatic and may have multiple psychosocial and behavioral problems. It is common for such clients to have undergone different approaches to treatment by different providers without long-term success. Furthermore, clarifying the diagnosis and “underlying disorder” is extremely complicated in the early phases of assessment. The first step in treatment of a person with COD is an assessment that addresses biological, psychological, and social issues.

Clients with severe or persistent mental and substance use disorders, such as James T., require dually focused, integrated treatment. Clients like Louisa F., who have mild or brief symptoms of mental illness, may benefit from consultations, collaborations, and mutual self-help groups.

Long-term perspective

Both psychotic and substance use disorders tend to be chronic disorders with multiple relapses and remissions, supporting the need for long-term treatment. For clients with COD involving psychosis, a long-term approach is imperative. Research has shown that individuals become abstinent and gain control over psychiatric symptoms through a process that frequently takes years, not days or months. Front-loaded, intensive, expensive, and highly stimulating short-term treatment modalities are likely to have limited success with this group of clients. Also, an accurate diagnosis and an assessment of the role of substances in the client’s psychosis necessitate a multiple-contact, longitudinal assessment and treatment perspective.

Treatment teams

Especially for programs that treat clients with psychotic and substance use disorders, it is important that the program philosophy be based on a multidisciplinary team approach. Ideally, team members should be cross-trained, and the team should include representatives from the medical, mental health, and substance abuse treatment systems. All staff members—clinical, administrative, and operational—should learn to use gentle or indirect confrontation techniques with these clients when necessary. Many clients with co-occurring schizophrenia require a temperate approach all the time, and some people with bipolar disorder can take any criticism as an extreme insult, particularly if they are experiencing the grandiosity that often accompanies hypomanic, manic, or residual states of the illness.

Assertive case management

Team members should endorse an assertive case management approach, wherein the case manager is expected to provide services to clients in their own environments as well as at the treatment site. The case manager must not attempt to be the sole broker of treatment services or the exclusive provider of office-based treatment. A supportive and psychotherapeutic approach to individual, group, and family work should be employed.

Flexible hours are necessary to provide services to these clients. Services need to be available during evening and weekend hours when crises frequently occur. In addition, alternative social activities and peer group activities often take place in the evening and on weekends.

Using a behavioral and psychoeducational perspective

The individual and group programs for clients whose COD involves psychosis should be based on a behavioral and psychoeducational perspective, not a psychodynamic approach. Educational information should be repeated often and presented in concrete terms using a multimedia format. Programs should be modified to include frequent breaks and shorter sessions than normal.

Special care should be taken with regard to client education and group discussion about “Higher Power” issues. If a program has this focus, staff members should be trained to teach clients and lead group discussions about spirituality and the concept of a Higher Power. Staff members should understand the difference between spirituality and religion, and especially the differences between spirituality, religion, and delusional systems that have a religious or spiritual content.

Associated psychosocial needs

Even intensive, carefully designed substance abuse treatment is likely to have limited success if the extensive psychosocial problems faced by the client are not addressed concurrently. Common psychosocial concerns of this group include housing, finances and entitlements, legal services, job assistance, and access to adequate food, clothing, and medication.

A particularly common complication of clients with psychosis and substance use disorders is housing instability and homelessness. Among the possible housing services that may be particularly useful are shelters, supervised housing settings, congregated living settings, treatment milieu settings, and therapeutic communities. Ideally, residential options and placements should be long term, with the goal of promoting independent, stable, and safe housing. However, short-term options that are less than ideal should be explored to ensure the client’s basic safety from weather and violence.

Vocational services

Vocational services also are essential for long-term stabilization and recovery. Both substance abuse and mental health services have traditionally referred clients to generic vocational rehabilitation services; however, to be effective these services must be integrated and modified for the specialized needs of the individual with psychosis and substance use disorders. Temporary hire placements and job coaching options are important elements to incorporate into rehabilitation services for this group.

Alternative support groups

An essential part of treatment for clients is the development of alternative peer group relationships that do not include substance use. Developing these non-substance-using social networks can be enhanced by programs that provide social club activities, recreational activities, and drop-in centers onsite, as well as linkages to other community-based social programs. At the same time, clients should be encouraged to establish and maintain relationships, including family relationships, that are supportive of treatment goals.


Treatment can be substantially supported and enhanced by direct involvement of the client’s family. Services can include family psychoeducational groups that focus on education about substance use disorders and psychosis, including those multifamily treatment groups that the individual with the COD attends with his or her family members.

Families also may be helpful in identifying early signs of mental disorder or substance use relapse symptoms. They can work with the treatment team in initiating acute relapse prevention and intervention. Confidentiality[2] needs to be addressed at the beginning of treatment, with the goal of identifying a significant support person who has the client’s permission to be involved in the long-term treatment process.

Relapse prevention

An essential component of relapse prevention and relapse management is close monitoring of clients for signs of substance abuse relapse and a return of psychotic symptoms. Relapse prevention also includes closely monitoring the development of clients’ substance refusal skills and their recognition of early signs of psychiatric problems and substance use. The goals of relapse prevention are (1) identification of clients’ relapse signs, (2) identification of the causes of relapse, and (3) development of specific intervention strategies to interrupt the relapse process.

Close monitoring involves the long-term observation of clients for early signs of impending psychiatric relapse. Such signs may include the emergence of paranoid symptoms and symptoms related to substance use, such as hostile or disorganized behavior. For example, a sign of paranoid symptoms may be the client’s sudden and constant use of sunglasses. Additional important clues may involve changes in daily routine, changes in social setting, loss of daily structure, irritation with friends, and rejection of help. Family members who reside with the client often are the first to detect early signs of psychotic or substance use relapse. Even routine daily stressors may have an intense impact on the client with chronic psychosis and may prompt relapse.

Objective laboratory tests also may be useful in detecting relapse. These include the use of random urine toxicology screens, current noninvasive measures of alcohol use (e.g., saliva or breath analysis), and blood tests to detect street drugs. As medication noncompliance is associated strongly with both substance use and psychotic relapse, blood medication levels (including antipsychotic and lithium levels) particularly may be useful. Finally, the use of intramuscular forms of antipsychotic medications may be particularly useful with very difficult noncompliant clients for ensuring long-term compliance with antipsychotic medications.

In addition to close monitoring by healthcare professionals, family members, and significant others, an important component of relapse prevention is assisting the client with developing skills to anticipate the early warning signs of mental and substance use disorders. These skills can be acquired through direct individual psychoeducation and participation in role-play exercises and psychoeducation groups. These clients should be trained in substance refusal skills and to recognize situations that place them at risk for substance use.

Similarly, these clients may benefit significantly from behavioral therapy; development of relaxation, meditation, and biofeedback skills; exercise; use of visualization techniques; and use of relapse prevention workbooks. Pharmacologic strategies may include the use of disulfiram or naltrexone for certain clients.

have developed a promising relapse prevention model for group therapy with persons who have a bipolar disorder. The treatment consists of 20 weekly therapy groups, each of which focuses on a topic relevant to both disorders. Topics include (1) denial, ambivalence, and acceptance; (2) self-help groups; and (3) identifying and fighting triggers. The group is based on a relapse prevention model, which was adapted to integrate the treatment of bipolar and substance use disorders by focusing on similarities between the recovery and relapse processes for each. For instance, just as many people with substance use disorders are tempted to abandon attempts at abstinence after a “slip,” those with bipolar disorder may feel like stopping their medications after experiencing a mood episode despite medication compliance. The group reviews strategies for coping with a temporary setback in either disorder, emphasizing the role of thoughts and behaviors that can either improve or worsen such a situation in either disorder. (For a more detailed account of this approach see .)


With clients who have COD that involve psychosis, lack of attention to medication issues is a common provider mistake that often leads to mental disorder or substance use relapse. Most important, treatment programs must provide aggressive treatment of medication side effects, as ignoring the side effects of prescribed medication often results in clients using substances to diminish such effects.

Equally important, clients should be educated and thoroughly informed about (1) the specific medication being prescribed, (2) the expected results, (3) the medication’s time course, (4) possible medication side effects, and (5) the expected results of combined medication and substance use. Whenever possible, family members and significant others should be educated about the medication.

Medication should not simply be prescribed or provided to the client with psychosis. Rather, it is critical to discuss with clients (1) their understanding of the purpose for the medication, (2) their beliefs about the meaning of medication, and (3) their understanding of the meaning of compliance. It is important to ask clients what they expect from the medication and what they have been told about the medication. Overall, it is important to understand the use of medication from the client’s perspective. Indeed, informed consent relative to a client’s use of medication requires that the client have a thorough understanding of the medication as described above.

It also is important to help clients prepare for peer reaction to the use of medication during participation in certain 12-Step programs. Clients should be taught to educate other people who may have biases against prescription medications or who may be misinformed about antipsychotic medications.

Ideally, clients receiving medication should participate in professionally led medication education groups and medication-specific peer support groups. These groups will help clients to manage the emotional and social aspects of medication, promote medication compliance, and help clinicians and clients identify and address early noncompliance and side-effect problems.

Overall, a specific and aggressive treatment strategy that helps make medication use simple and comfortable is essential. The scheduling and administration of medication should be simple and convenient for clients. The ideal schedule for oral medications is once per day. The use of depot scheduling may be the most comfortable and effective option for some clients with COD involving psychosis.

Case Studies

Individuals with psychosis and substance use disorders more often present for treatment in the mental health setting. However, in some situations individuals with psychosis will report to substance abuse treatment settings. For example, counselors may encounter a paranoid disorder that does not become apparent until the client has been in treatment for some time, as in the case study “A Hidden Psychosis.”

Case Study: A Hidden Psychosis

John R. was a 33-year-old client who had been treated for about 2 months in the substance abuse treatment clinic. He was mostly quiet in treatment groups and had limited, though appropriate, social interaction with his peers. His affect was somewhat restricted, but he initially denied a history of mental health services. He was single, attended community college part time, and lived with his parents. During the first 2 months he complained about somatic symptoms and cravings. During discussions in group treatment, he started to become more vocal. He laughed inappropriately at times and often appeared to be laughing quietly at his own jokes. Later, he confided in his therapist that he thought he was ugly and that his nose was disfigured because he lied. He was also focused on the fact that he was 5 feet 5 inches; he wanted to have a surgical procedure to increase his height because he would never get a girlfriend if he wasn’t taller.

Discussion: Some cases of schizophrenia are mild and are only uncovered over time. A case this mild might be treatable in the substance abuse treatment setting, with a consultation with the psychiatrist to evaluate the need for medication.

Case Study: Denial of Psychosis

Bob K. was a 31-year-old client who was homeless and living in and out of shelters. He stated that he loved smoking pot but that the cocaine was taking a toll on him. Cocaine binges would cause him to hear voices and become suspicious of others. Bob K. presented disheveled, with poor hygiene. He denied prior mental health services and refused to see the psychiatrist because he didn’t want to be put on any medications. He admitted later that he had some mental health services previously, but didn’t agree with the therapist’s diagnosis of schizophrenia. He did have periods of hallucinations and paranoia even when he had not used cocaine for several weeks. He stated that the voices he heard were due to a bad LSD trip when he was 21 years old and that since then God has been punishing him for doing drugs and not listening to his mother.

Discussion: With an unmotivated client like Bob K., it is best to go easy and not challenge his belief system head-on. The initial goal is to keep him in treatment, not to insist on his acceptance of the label of “schizophrenic.” It would be best to assure him, for example, that even if his symptoms are a result of drug use, medication could be helpful. The psychiatrist would do well to start him at a low dose of medication, because he might bolt from treatment if he experienced side effects.

Case Study: Aftereffects of Drug Use

Sue P. was a 24-year-old who became extremely frightened and agitated upon returning from a “rave” party. Her mother brought her to the emergency room because of her daughter’s strange behaviors and odd comments. Sue was a college graduate who was working in sales and living at home. She wanted to stay in a fetal position, was fearful of others, and worried that the police had planted listening devices in her home. After about 48 hours Sue was less paranoid and more relaxed. She then was able to admit to doing ecstasy and ketamine at the rave.

Discussion : Sue will probably recover well in a quiet room with supervision, possibly from her mother or possibly as an inpatient. She should have a low dose of antipsychotic medication for about a week and should be carefully assessed for suicidal tendencies. She should be told clearly that the effects she is experiencing are the result of drug use.

Case Study: Counseling a Binge Drinker With Bipolar Disorder

Francisco H. has come for treatment after losing his job because of binge drinking. Francisco H. has little energy and his voice is so low the counselor can barely hear it. Probing for depression, the counselor learns that Francisco H. has at least five symptoms of depression and has previously been diagnosed as having bipolar disorder. He says he sometimes drinks to calm down “when he’s flying too fast.” However, he has not taken his medication regularly and believes if he can just stop drinking he will be fine. He has been attending AA meetings sporadically and has been told that medication is just another form of drug.
The counselor gives Francisco H. a brochure from AA on medication for mental illness (). He points out that acceptance of medication is an important step in recovery, suggesting that Francisco H.’s bipolar disorder and alcohol abuse interact with each other. Using motivational interviewing techniques, he finds that Francisco H.’s major concern is his need for work; his wife is pregnant, and his loss of a job has put the family in a precarious position. He suggests that taking the medication will help Francisco H. level out mentally and enable him to seek employment. If he uses the medication consistently along with other recovery supports, including a 12-Step group that meets at the center, he may be able to break the interactive cycle between the two disorders. The counselor cautions that 3 or 4 weeks may be needed to feel the full effects of the medication and alerts him to the possibility of side effects, which should be reported immediately. He lets him know, however, that if Francisco H. does experience side effects with one antidepressant, he may be able to take others. Francisco H. accepts a consultation with the psychiatrist to explore the possibility of medication.

Discussion : Often, a client is motivated to address one disorder but not the other. The counselor should help the client recognize the possible relationship between the two. When the use of medication is a concern, the counselor should be prepared to explain the difference between drugging or drinking to get high and using a prescription drug to stay at a normal level of functioning. AA literature that addresses this topic is often helpful (see appendix J for information).

Attention Deficit/Hyperactivity Disorder (AD/HD)


AD/HD is “a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than typically is observed in individuals at a comparable level of development” (, p. 85). People with AD/HD may fail to give close attention to details, be easily distracted, shift among activities without completing tasks, have disorganized work habits, and forget obligations. Hyperactivity may be indicated by “fidgetiness,” difficulty engaging in quiet activities, and general restlessness. Individuals with AD/HD may be impatient and engage in dangerous activities without thinking of the consequences. Strictly speaking, those with attention deficit do not have a deficit in attention but “a lack of consistency in direction and control.” They have been described as “attending to everything” (, p. 394). Often, individuals with AD/HD have poor self-esteem, are demoralized, and may be rejected by their peers.

Symptoms of this disorder are most likely to be evident in a group setting. Usually symptoms lessen as children mature, though adults may continue to have difficulty participating in sedentary activities. Many adults diagnosed with AD/HD complain of having a hot temper, low self-esteem, inability to relax, inability to complete tasks, poor driving skills, family violence, and difficulty sustaining jobs or relationships. Their key “neuropsychological weakness” has been termed “executive dysfunction,” which includes difficulties with planning, sequencing, and organizing activities. Some adults with AD/HD learn to channel their energy into sports-related activities or find other means of coping with the disorder.

There are three types of AD/HD: a “combined type” in which a person has both difficulty paying attention and hyperactivity, a type that is “predominantly inattentive,” and a type that is “predominantly hyperactive-impulsive.” It is important to note that “the validity of the diagnosis of AD/HD, particularly in adults, has been questioned” (, p. 393). However, AD/HD is now recognized as a disorder by DSM-IV, the standard guidance on diagnosis for mental disorders ().

Symptom clusters for inattention and for hyperactivity-impulsivity are illustrated in Figures D-13 and D-14.

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

• Failure to attend to detail, careless mistakes
• Difficulty sustaining attention
• Does not listen
• Poor follow through, failure to finish
• Difficulty organizing tasks and activities
• Avoidance of effort-demanding tasks
• Losing things
• Easily distracted
• Forgetful in daily activities

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

• Fidgets, squirms
• Unable to remain seated
• Runs or climbs excessively (restless in adults)
• Inability to play (relax) quietly
• “On the go,” “driven by a motor”
• Talks excessively
• Blurts out answers
• Can’t wait for turn
• Interrupts, intrudes

Differential Diagnosis

A number of other mental disorders may produce symptoms similar to AD/HD, including substance-related cognitive impairment, bipolar disorder, major depression, anxiety disorder, dissociative identity disorders, social phobia, and personality disorders, especially obsessive-compulsive personality disorder. AD/HD must also be distinguished from personality change that may occur as a result of a medical condition, such as a stroke, head trauma, or hypothyroidism. Both alcohol and marijuana abuse can produce symptoms that mimic AD/HD.

It is important to rule out other causes of inattention or hyperactivity. People with substance use disorders who are newly abstinent or those in active or protracted withdrawal may experience some impairments similar to AD/HD. Some persons with low IQs may also exhibit AD/HD symptoms.

Further adequate assessment and treatment for potential withdrawal syndromes should occur before concluding that the client is either cognitively impaired or has AD/HD (see also TIP 29, Substance Use Disorder Treatment for People with Physical and Cognitive Disabilities []). Keys to reliable diagnosis of AD/HD in adults include the following:

  • Childhood history
  • Corroboration by an outside source
  • Proof of impairment, such as problems with certain types of work or study
  • Persistence of symptoms over time without fluctuation
  • Taking into account the effect of the context (e.g., inability to focus on reading matter in a crowded, noisy subway car does not imply AD/HD)
  • Cognitive testing
  • Questionnaires


A recent review reports the prevalence of AD/HD among children as wide as 2 to 19 percent (). Between 10 and 65 percent of individuals who have AD/HD as children continue to have debilitating symptoms of the disorder as adults (). Studies of the adult substance abuse treatment population have found AD/HD in 5 to 25 percent of persons, suggesting that about one in six clients may have this co-occurring problem (; ; ; ; ). estimate that 33 percent of adults with AD/HD have histories of alcohol abuse or dependence, and 20 percent have other drug abuse or dependence histories. A history of childhood AD/HD has been found in 17 to 50 percent of people with substance use disorders and from 17 to 45 percent in people who abuse cocaine and opioids (). Adults with persistent symptoms of AD/HD who have a history of conduct disorder or have co-occurring APD are at the highest risk for having substance use disorders as well.

Substance Abuse and Dependence Among Adults With AD/HD

Adults with AD/HD have been found to abuse primarily alcohol, with marijuana being the second most common drug of abuse (). While early studies hypothesized that these clients used stimulants in an effort to self-medicate, their preferences seem to be the same as those of the general population (). The relationship between AD/HD and substance use disorders is important because “clients with these combined disorders may require and respond differentially to various therapeutic approaches” (, p. 393). The presence of AD/HD complicates the treatment of substance abuse, since clients with these co-occurring disorders have “more treatment difficulties, poorer substance abuse treatment outcomes, and a greater risk for relapse than clients diagnosed with substance use disorder alone” (, p. 412). Obviously, such clients have more trouble in didactic, lengthy sessions that require focus and sustained attention.

Key Issues and Concerns

Though controversial, AD/HD appears to be a real disorder and must be considered seriously as a possibility for clients who show the symptom clusters depicted in Figures D-13 and D-14.

Though stimulants are the pharmacological treatment of choice for AD/HD in children, clinicians should be aware that antidepressants such as bupropion or desipramine are preferable for chemically dependent adults. Research is lacking on longer term outcomes, and better biopsychosocial treatments remain to be developed.

Strategies, Tools, and Techniques


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.

Engaging the hyperactive client

The counselor may use an adapted form of motivational techniques for the invasive, talkative, hyperactive client. The counselor might tell the client which elements of discussion he or she has successfully completed, then reframe the remainder. For example, during the initial intake question concerning what it was that brought the client to the clinic, a client may begin to talk about his alcohol and marijuana use, but rapidly move into a discussion of the argument he and his wife have been having about his poor work history (he gets jobs but then loses them), then switch to talking about what is wrong with the automobile industry in the United States and pollution control. After a few attempts to redirect, the counselor is left thinking, “How can I get this guy to focus? Why does he talk so fast and always ends up off-topic? Is this denial, resistance, hypomania, or attention deficit disorder?”

In such a situation, the counselor might respond, “You sure pack a lot of information into one answer. It’s hard for me to keep up! So can we take things a bit slower? Now, let’s go back to when you first started to use alcohol.” In this case, the client with AD/HD will more likely be able to focus with frequent gentle reminders. The hypomanic client will most likely keep “revving up” and require more active management. The school histories of these two clients should be different, with the client with AD/HD showing early school problems before substance abuse began.

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” (, 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” (, 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 (), 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 (), 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” (, 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 (; ).
  • 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.

Case management

Case management of suspected adult AD/HD begins by arranging adequate diagnostic assessment. If AD/HD is confirmed as the co-occurring disorder, the counselor should employ the elements of treatment as discussed below in this section (see “Adapting Mental Health and Substance Abuse Treatment Approaches”) and monitor outcomes over time.


Education about AD/HD may be useful and enlightening to many clients; self-help books and AD/HD support groups also can be very helpful (). Waid and colleagues suggest that “modalities other than auditory/verbal ones may be constructive in this population” (, p. 413). For example, consider the use of pamphlets (especially those with diagrams and pictographs) and dramatic videos. In fact, many of the typical alternatives used in standard substance abuse treatment—Alcoholics Anonymous meetings (60 to 90 minutes versus all-day classes), dramatic videos (versus textbooks), relapse diagrams, and standardized short group check-ins—help to focus those with impaired attention rather than overwhelm them with details.

Adapting mental health and substance abuse treatment approaches

Waid and colleagues recommend “structured and goal-directed sessions, with the therapist actively enhancing the client’s knowledge about AD/HD and substance abuse and examining false beliefs about the history of his or her difficulties” to “serve as the framework for an effective intervention” (, p. 413). They caution that “long verbal exchanges, extended group therapy, and overstimulating environments should be avoided, as they often overtax the AD/HD substance abusing client” (, p. 413). Frequent brief sessions are preferable to a few long intense ones. The usual 3 hours, three times weekly in Intensive Outpatient Programs will be difficult for many people with AD/HD, even when the AD/HD is being treated. These clients should be assigned to therapists knowledgeable about both disorders so that appropriate adjustments in treatment strategies can be made as needed.

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.

Posttraumatic Stress Disorder


PTSD follows the experience of a psychologically traumatic stressor such as witnessing death, being threatened with death or injury, or being sexually abused. At the time of the stressful event, the individual experiences intense fear, helplessness, or horror. PTSD entails three sets of symptoms that last longer than 1 month and result in a decline in functioning (e.g., work, social):

  • Intrusion: a persistent reexperiencing of the trauma in the form of intrusive images and thoughts, recurrent nightmares, or experiencing episodes during which the trauma is relived, as in flashbacks
  • Avoidance: persistent avoidance of stimuli related to the trauma such as activities, feelings, and thoughts associated with the traumatic event
  • Arousal: persistent symptoms of increased arousal such as insomnia, irritability, hypervigilance, and exaggerated startle response

Many physical, cognitive, and emotional disruptions can occur in response to an acute traumatic event and/or PTSD. The DSM-IV-TR (, p. 465) lists the following associated descriptive features:

  • Impaired affect modulation
  • Self-destructive and impulsive behavior
  • Dissociative symptoms (Note: Dissociation represents a psychic defense in which a person is so overwhelmed by a traumatic memory or feeling that the mind simply “shuts down,” literally removing itself [disassociating] from the present reality. The person may become suddenly quiet, or stare into space, as if they have entered a trance. Patients have described dissociation as “being out of it,” “losing time,” or “floating away.”)
  • Somatic complaints
  • Feelings of ineffectiveness, shame, despair, or hopelessness
  • Feeling permanently damaged
  • A loss of previously sustained beliefs
  • Hostility
  • Social withdrawal
  • Feeling constantly threatened
  • Impaired relationships with others
  • Change from the individual’s previous personality characteristics

The two conditions may coexist for decades, particularly if both disorders are not addressed adequately in treatment. Interest in the role of trauma and PTSD have increased with the recognition that they are common among substance abuse clients. This co-occurring disorder is particularly prevalent among women, who typically experienced childhood physical or sexual abuse. It also is prevalent in combat veterans and many veterans’ hospitals have PTSD treatment units (; ). The Department of Veterans Affairs’ National Center for PTSD has been a leading clinical and research resource for both the trauma and substance abuse fields (see and the forthcoming TIP Substance Abuse Treatment and Trauma [CSAT in development d]).


Community-based studies indicate the lifetime prevalence of PTSD among adults in the United States is about 8 percent (). Among high-risk individuals (those who have survived “rape, military combat and captivity” or “ethnically or politically motivated internment and genocide”), the proportion of those with PTSD ranges from one-third to one-half (, p. 466).

Among clients in substance abuse treatment, this co-occurring disorder is two to three times more common in women than in men (). The rate of PTSD among people with substance use disorders is 12 to 34 percent; for women who abuse substances, it is 30 to 59 percent. A review of the literature found that PTSD often goes undetected due to lack of screening (). See below for suggestions on conducting a basic screening for PTSD.

Most women with this co-occurring disorder experienced childhood physical and/or sexual abuse; men with both disorders typically experienced crime victimization or war trauma (). Clients sometimes are perceived as “crazy,” “lazy,” or “bad” by others and by themselves (). They may carry a great burden of shame and guilt, as both PTSD and substance abuse may be associated with keeping secrets and denial. Clinicians are advised not to overlook the possibility of PTSD in men; in Kessler’s major study of a community sample, rates for men were higher than for women ().

People with PTSD and substance abuse also are more likely to experience another trauma than people with substance abuse alone (). Repeated trauma is common in domestic violence, child abuse, and some substance abuse lifestyles (e.g., the drug trade). Helping protect the client against future trauma may be an important part of work in treatment. It is also noteworthy that in a high percentage of rape cases (37.9 percent), those who perpetrated the violent assault were using substances at the time ().

Substance Abuse and Dependence Among People With PTSD

People with PTSD tend to abuse the most addictive substances (cocaine and opioids); however, abuse of prescription medications, marijuana, and alcohol also is common. Substance abuse often is viewed as “self-medication” to cope with the overwhelming emotional pain of PTSD (; ; ; ; ). From the client’s perspective, PTSD symptoms are a common trigger of substance use (). The combination of PTSD and substance abuse may present in combat veterans, those with acute PTSD related to terrorist attacks, those with chronic PTSD related to childhood events, and others (; ; ; ; ; ). While under the influence of substances, a person may be more vulnerable to trauma—for example, the woman drinking at a bar who goes home with a stranger and is assaulted.

As a counselor, it is important to recognize—and help clients to understand—that becoming abstinent from substances does not resolve PTSD; indeed, some PTSD symptoms might become worse with abstinence at first (; ; ). As clients give up substance use, they may be overwhelmed by a flood of memories and feelings that their substance use had kept at bay. “You will feel better once you are clean and sober” is not an accurate message to give a client with PTSD and substance use disorders. A more accurate statement would be, “Getting clean and sober will help you, but initially you may find yourself facing feelings and memories of your trauma. We can get through this together, and eventually you can achieve recovery from both the substance abuse and PTSD issues.”

A variety of medications are used in the treatment of PTSD, and since other anxiety disorders (often panic, generalized anxiety) and mood disorders (major depression, dysthymia, bipolar II) often accompany PTSD, patients can be on several medications at once, most often an antidepressant, such as a sertraline or paroxetine (SSRIs—see appendix F, Common Medications for Disorders), which is frequently combined with a sedative medication, such as an anticonvulsant, or even an antipsychotic (; ). Especially as a client with PTSD becomes abstinent, medications targeting mood, anxiety, or severe nightmares may be of crucial importance. While benzodiazepines such as clonazepam and alprazolam often have been prescribed to such clients for anxiety, and though a few case reports exist that document the safe use of these medications, the consensus panel recommends that benzodiazepines usually be avoided, as panel members have observed a great many problems with the use of benzodiazepines. Consensus panel members reported their own experiences with clients who abused benzodiazepines—clients experienced escalating tolerance, had periods of confusion, and became dependent on a medication that is among the most dangerous in its withdrawal symptoms (seizures, etc.), especially if used along with alcohol, as it often is. Recent research has found both prazocin and propranolol, which are older, generic antihypertensives that decrease overactivity in the autonomic nervous system, to hold great promise in decreasing nightmares and flashbacks (, ; ).

Key Issues and Concerns

Treatment of PTSD with co-occurring substance use disorders requires careful planning and supervision. As the client faces painful trauma memories, the desire for intoxication can be overwhelming. By exploring trauma memories, well-intentioned counselors inadvertently may drive a client back to the substance by urging her to “tell her story” or “let out the abuse.” Even if a client wants to talk about trauma and seems safe during the session, after-effects may well ensue, including a flood of memories she is not prepared to handle, increased suicidality, and “retraumatization” where she feels as though she is reliving the event. Such treatment approaches should be undertaken only with adequate formal training in both PTSD and substance abuse and only under careful clinical supervision.

These clients need stability in their primary therapeutic relationship; hence, this work should not be undertaken in settings with high staff turnover, and should never be undertaken without training and supervision. The substance abuse counselor should not try to provide trauma-exploration treatment, in view of the potential for highly destabilizing effects (including worsening of substance use). However, the substance counselor can play an important role in helping to identify PTSD and in providing present-focused psychoeducation about PSTD, such as teaching the client to recognize symptoms of the disorder and how to cope with them. For severe cases of PTSD, treatment typically is long term.

Several well-developed, research-based, and clinically tested models of treatment exist for PTSD (for example and reviews, see ; Follette et al. 1998; ). Some of these models are particularly suited for use with clients who also have a substance use disorder (such as the Seeking Safety model discussed below). For example, the Trauma Adaptive Recovery Group Education and Therapy (TARGET) () has developed a strengths-based approach to education and skills training for trauma survivors that presents a seven-step approach both for changing the PTSD alarm response and for relapse prevention during each of the sessions.

Other models (e.g., ; ) are eclectic—that is, they mix a variety of strategies, techniques, and models. Several of these eclectic approaches and various research studies focus on specific interventions or problems, such as on group therapy for PTSD with alcohol abuse; on the possible use of sertraline; and regarding alcohol use for sleep by female rape victims. Of course, this brief review of models barely begins to cover the immense amount of work related to trauma and substance abuse. Many people working with clients on issues of childhood abuses have long known of the importance of including substance abuse in treatment (e.g., ; ; ). For more information, see the forthcoming TIP Substance Abuse Treatment and Trauma (CSAT in development d).

The following sections are based on the Seeking Safety () model, which the consensus panel deems a practical and helpful approach for most counselors. While Seeking Safety was developed for women, the consensus panel feels it is broadly appropriate for both men and women with PTSD and co-occurring substance use disorders. Several issues need to be considered when working with PTSD/substance abuse treatment clients:

  • Develop a plan for increased safety where appropriate (e.g., this is less critical for chronic PTSD secondary to childhood trauma or war trauma)
  • Establish trust
  • “Listen” to a client’s behavior even more than his or her words
  • Recognize that a client with PTSD and substance use disorder may have a more difficult time in treatment
  • Help the client access treatment for PTSD
  • Recognize the importance of one’s own trauma history
  • Help the client learn to de-escalate intense emotions
  • Reinforce the taking of appropriate medications

Develop a plan for increased safety. Some clients with PTSD have a variety of safety issues, including risk for further trauma, suicidality, and self-destructive behavior (e.g., self-harm such as cutting, unsafe sex that may lead to HIV, and involvement with people who exploit them). Helping the client become aware of these patterns, and identifying concrete actions the client can use to cope with them, may be highly beneficial. For example, a client who is living with a partner who is battering her (domestic violence) needs careful assistance, often through consultation with a domestic violence hotline or other expert who can help advise on this difficult situation (see TIP 25, Substance Abuse Treatment and Domestic Violence []). See below for specific treatment resources for safety-oriented work with people with PTSD.

Establish trust. Sometimes clients who have lived through trauma have difficulty trusting others. The trauma may have been a violation of an important relationship (e.g., in child abuse or domestic violence), or the trauma may have felt like something that could not be talked about (e.g., war, rape). Substance abuse, too, may have isolated the client. Therefore, a key element of successful treatment involves helping the client build trust, never forcing her to talk about something she does not want to, asking permission to talk about sensitive issues, conveying respect and empathy in tone, avoiding harsh confrontation, and generally acting as her advocate and ally, even when difficult behaviors arise.

“Listen” to a client’s behavior even more than words. Clients with PTSD often are not fully conscious of the depth of their inner feelings. They may be prone to internal “splitting” as well, where their feeling-states are not integrated (e.g., they shift between anger and depression). They may find themselves acting in ways that suddenly “happen,” rather than acting in ways that are chosen. They also may keep their feelings to themselves out of the fear of burdening others. Monitoring the client’s actual behaviors is key: Is she using substances more or less? Is he showing up for treatment? Is she able to follow through on commitments?

Recognize that a client with PTSD and substance use disorders may have a more difficult time in treatment. Treatment outcomes for clients with PTSD and substance use disorders typically are worse than for other clients with COD, and worse than for clients with substance use disorders alone (, ). Moreover, as compared to clients with substance use disorders alone, clients whose substance use disorder co-occurs with PTSD have more problems in general (e.g., other Axis I and II disorders, interpersonal and medical problems, HIV risk) (; ), and their treatment may be more fragile and prone to relapse, unstable alliances, and erratic attendance (; ). If the counselor is to work effectively with such clients, extra support and encouragement is needed, along with a positive, optimistic tone and strong outreach.

Help the client access treatment for PTSD. It is recognized widely that integrated treatment—treatment of both PTSD and substance abuse—is likely to be more successful and more sensitive to clients’ needs than substance abuse treatment alone. Yet most clients with PTSD receive only substance abuse treatment, despite the fact that they prefer treatment for both (). The counselor should inquire whether the client would like to address her PTSD, and if so, the counselor can play a pivotal role in providing a referral to such treatment and the encouragement to participate. To help locate a PTSD specialist, the International Society for Traumatic Stress Studies has a listing of members (

Recognize the importance of one’s own trauma history. Counselors may have their own histories of trauma, which can have an impact on their work both for better (increased empathy) and worse (feeling triggered by clients). Honest self-evaluation and self-care skills are important, as well as seeking supervision and support as needed.

Help the client learn to de-escalate intense emotions. The nature of PTSD and substance use is a frequent experience of overwhelming feelings. Clients may find a seemingly small comment or event to be a trigger, which can set off a craving to use substances. Teaching the client to do grounding and to soothe himself can be an important means to regain control. Grounding (also called “centering,” “looking outward,” “distraction,” or “healthy detachment”) uses a set of simple strategies that facilitate detachment from emotional pain, such as drug cravings, self-harm impulses, anger, and sadness. The technique distracts one from the impulse to use substances or to hurt oneself by directing the mental focus outward to the external world, rather than inward toward the self. Figure D-15 provides a basic overview of what is involved in grounding. (For a lesson plan and other materials on grounding, see .)

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

Three major ways of grounding will be described—mental, physical, and soothing. “Mental” means focusing your mind; “physical” means focusing on your senses (e.g., touch, hearing); and “soothing” means talking to yourself in a very kind way. You may find that one type works better for you, or all types may be helpful. Note that grounding is different from relaxation training or meditation. In grounding, it is essential to keep your eyes open the entire time and to keep talking out loud. These strategies keep you focused on the outside world.
Mental Grounding
• Describe your environment in detail using all your senses. For example, “The walls are white, there are five pink chairs, there is a wooden bookshelf against the wall…” Describe objects, sounds, textures, colors, smells, shapes, numbers, and temperature. You can do this anywhere. For example, on the subway: “I’m on the subway. I’ll see the river soon. Those are the windows. This is the bench. The metal bar is silver. The subway map has four colors…”
• Play a “categories” game with yourself. Try to name “types of dogs,” “jazz musicians,” “States that begin with ‘A’,” “cars,” “TV shows,” “writers,” “sports,” “songs,” or “cities.”
• Do an age progression. If you have regressed to a younger age (e.g., 8 years old), you can slowly work your way back up (e.g., “I’m now 9,” “I’m now 10,” “I’m now 11”…) until you are back to your current age.
• Describe an everyday activity in great detail. For example, describe a meal that you cook (e.g., “First I peel the potatoes and cut them into quarters, then I boil the water; I make an herb marinade of oregano, basil, garlic, and olive oil…”).
• Imagine. Use an image: Glide along on skates away from your pain; change the TV channel to get to a better show; think of a wall as a buffer between you and your pain.
• Say a safety statement. “My name is ____; I am safe right now. I am in the present, not the past. I am located in _____; the date is _____.”
• Read something, saying each word to yourself. Or read each letter backward so that you focus on the letters and not on the meaning of words.
• Use humor. Think of something funny to jolt yourself out of your mood.
• Count to 10 or say the alphabet, very s..l..o..w..l..y.
Physical Grounding
• Run cool or warm water over your hands.
• Grab onto your chair as hard as you can.
• Touch various objects around you: a pen, keys, your clothing, the table, the walls. Notice textures, colors, materials, weight, temperature. Compare objects you touch: Is one colder? Lighter?
• Dig your heels into the floor—literally “grounding” them. Notice the tension centered in your heels as you do this. Remind yourself that you are connected to the ground.
• Carry a grounding object in your pocket—a small object (a small rock, clay, ring, piece of cloth or yarn) that you can touch whenever you feel triggered.
• Jump up and down.
• Notice your body: The weight of your body in the chair; wiggling your toes in your socks; the feel of your back against the chair. You are connected to the world.
• Stretch. Extend your fingers, arms or legs as far as you can; roll your head around.
• Clench and release your fists.
• Walk slowly, noticing each footstep, saying “left” and then “right,” with each step.
• Eat something, describing the flavors in detail to yourself.
• Focus on your breathing, noticing each inhale and exhale. Repeat a pleasant word to yourself on each inhale (e.g., a favorite color or a soothing word such as “safe” or “easy”).
Soothing Grounding
• Say kind statements, as if you were talking to a small child. For example, “You are a good person going through a hard time. You’ll get through this.”
• Think of favorites. Think of your favorite color, animal, season, food, time of day, or TV show.
• Picture people you care about (e.g., your children) and look at photographs of them.
• Remember the words to an inspiring song, quotation, or poem that makes you feel better, such as the Serenity Prayer.
• Remember a safe place. Describe a place that you find very soothing (perhaps the beach or mountains, or a favorite room); focus on everything about that place—the sounds, colors, shapes, objects, and textures.
• Say a coping statement. “I can handle this.” “This feeling will pass.”
• Plan out a safe treat for yourself, such as a piece of candy, a nice dinner, or a warm bath.
• Think of things you are looking forward to in the next week, perhaps time with a friend, going to a movie, or going on a hike.
• Create a cassette tape of a grounding message that you can play when needed; consider asking your therapist or someone close to you to record it if you want to hear someone else’s voice.
• Think about why grounding works. Why might it be that by focusing on the external world, you become more aware of an inner peacefulness? Notice the methods that work for you—why might those be more powerful for you than other methods?
• Don’t give up.

Source: . Used with permission.

Strategies, Tools, and Techniques

It may be difficult for clients with PTSD to form a trusting therapeutic alliance. They often have great shame about both their illnesses and may hide, minimize, or even lie about their past as a means of psychological self-protection. Particularly in the case of people with severe PTSD arising from child abuse, distrust of others and fragile treatment alliances are common. Clients often are full of anger, which can be directed at self or at others, including counselors. They are likely to engage in power struggles, especially when they feel helpless.

Counselors must try to maintain professionalism, composure, and empathy in working with such clients, no matter how difficult. If the counselor can stay calm, clear, and understand the relational problems in light of the PTSD, the client is likely to become engaged. However, if the clinician argues, gives ultimatums, or tries to coerce clients, clients are more likely to drop out of treatment prematurely. Harsh confrontation, particularly for PTSD clients, can feel like a reexperiencing of childhood trauma and emotional abuse.

The counselor’s role in reinforcing medications has been discussed extensively in chapter 5 and will not be repeated here.

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 ().

Assuming the client has a trauma, the Modified PTSD Symptom Scale () 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

Safety-oriented, skill-building treatment

For clients with PTSD and substance abuse, providing psychoeducation about the disorders and teaching coping skills to gain control over the symptoms usually form an essential foundation of treatment. For example, the client with PTSD can learn to identify symptoms of “intrusion, avoidance, and arousal” and be trained to use grounding to manage these symptoms. Other skills include rethinking, activity scheduling, seeking out interpersonal support, identifying and fighting PTSD and substance abuse triggers, and learning to communicate with others. Helping clients understand the link between their PTSD and substance use is also part of such treatment; specifically, how each may trigger the other, and how mastery of one disorder can help with overcoming the other.

Notice that such treatment directly addresses PTSD but doesn’t push the client to describe or explore trauma memories. It is considered the safest and most essential “first-stage” approach, and is likely the best choice for most substance abuse treatment settings, particularly those that are short-term, have clients with PTSD and substance use disorders with acute suicidality or self-harm, and/or have staff who have not undergone formal training in PTSD treatment. For treatment manuals, see Najavits’ Seeking Safety model (2002), which has undergone empirical testing, and two manuals in the 12-Step tradition, and .

Trauma exploration work

This type of treatment involves having clients face their painful trauma memories, telling the story of what happened, and facing the associated intense emotions. These treatments, all initially developed on clients who did not abuse substances, include exposure therapy (), mourning (), eye movement desensitization reprocessing (), and the counting method (). Such treatments are considered high-risk for substance abuse clients and should be conducted (or at least supervised) only by providers with formal training in PTSD, and then only when the client is ready. Readiness for such work depends on a variety of factors, including the context of treatment (i.e., length of stay), the client’s safety level, and the availability of staff to manage the intense feelings that surface (often after hours). As noted above, even if the client wants to talk about trauma, he or she may not be ready to do so safely and may underestimate the destabilizing effect such work will have.

Only a few pilot studies so far have evaluated trauma-exploration therapies in substance abuse clients (; ). While some positive results have been found, generally it is believed that more work is needed to define which clients, under what conditions, and with what staff training, are needed for this type of work.

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).

Eating Disorders


Dieting and concern about body weight and shape are ever-present among people (especially women) in Western cultures. Young women who are of normal weight report high rates of dissatisfaction with their body weight and size. Dieting, which is nearly universal among female youth, often is the first step toward developing an eating disorder; however, only a small percentage of women who diet actually progress to an eating disorder. The primary eating disorders are anorexia nervosa and bulimia nervosa; however, the classification system has not yet been perfected, as the majority of individuals who seek treatment for an eating disorder fall under the diagnostic heading of “eating disorders not otherwise specified.”

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 (). 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 (; ; ; ; ). 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.


Anorexia nervosa primarily is a disorder of females, with a gender ratio of approximately 10:1. The disorder is found across social classes and ethnic groups. Epidemiological studies suggest a prevalence of between 0.1 to 0.7 percent of females, although subclinical conditions are more prevalent (; ; ; ). Anorexia nervosa is more prevalent in sports and professions that value thinness (e.g., jockeys, ballet dancers, gymnasts). Males who develop the disorder have presenting symptoms and clinical profiles similar to females.

The gender ratio for bulimia nervosa is also approximately 10:1, with higher prevalence in females. Epidemiological studies suggest that the prevalence of bulimia nervosa is somewhere between 1 and 3 percent across a range of Western cultures (; ; ; ; ; ; ; ). Again, subclinical forms of the disorder are more prevalent. Bulimia is found across all ethnic groups and social classes. Indeed, recent epidemiological evidence suggests that binge eating may be becoming more common in the lower socioeconomic classes and that the gender disparity may be diminishing.

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 (; ; ; ). 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 (; ; ). 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 (; ; ).

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 (; ; ). 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 ().

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 (). 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.

Substance Use Among Individuals With Eating Disorders

Studies of bulimic women with co-occurring alcohol use disorders often have used retrospective interviews to determine the chronology of the onset of both disorders. Patterns vary, with approximately one third of women recalling bulimia beginning first, one third recalling the alcohol abuse beginning first, and one third recalling onset of both problems within the same year ().

Several investigations have found no differences in the core clinical features of bulimia nervosa (i.e., frequency of bingeing and purging) in women with and without co-occurring substance use disorders (), although those with comorbid substance use disorders showed greater use of diuretics and laxatives, more food restriction, greater disruption in financial and work areas, more stealing, more suicide attempts, and more inpatient treatment ().

Personality differences also appear to exist between bulimic women with and without substance use disorders. Women with bulimia nervosa and substance dependence also report higher novelty seeking and lower cooperativeness, higher impulsivity, and a tendency to use more immature defenses. Overall, women with bulimia nervosa and alcohol dependence exhibited a pattern of greater impulsiveness across a broad array of response domains ().

The subgroup of women with bulimia who exhibit these traits have been referred to as “multi-impulsive bulimics,” defined as a combination of bulimia plus other impulsive behaviors such as excessive alcohol use, regular street drug use, stealing, overdosing, self-harm, borderline features, and sexual promiscuity (). Approximately 40 percent of bulimic women seen in clinical settings display substance abuse, stealing, overdosing, or self-harm (). This group of individuals requires higher clinical vigilance and is at higher risk for self-harming and parasuicidal behaviors.

In summary, the core clinical features of the eating disorder (i.e., frequency of bingeing and purging) do not appear to differ significantly whether substance abuse or dependence is present. Individuals with the comorbid pattern do appear to display more frequent impulsive behaviors, use of other drugs, and possibly more Axis II pathology. These data suggest that it is important to consider the critical role of impulsivity in the development of both eating disorders and substance abuse in this group of women. See Figure D-16 for a summary of how eating and substance use disorders are related.

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

• Individuals with eating disorders experience urges (or cravings) for binge-foods similar to urges for drug or alcohol use.
• Many individuals alternate between substance abuse and eating disorders.
• Bingeing and purging can be secretive and shameful behaviors.
• Relapse prevention is critical for individuals with bulimia nervosa.
• Abstinence from bingeing and purging is an essential treatment goal.
• For individuals with bulimia nervosa, alcohol and drugs such as marijuana can diminish normal appetite restraints and increase the risk of binge-eating as well as relapse.
• Individuals with eating disorders experience cravings, tolerance, and withdrawal from drugs associated with purging, such as laxatives and diuretics.
• There is an increased risk of alcohol and drug abuse and dependence in family members of individuals with bulimia nervosa.

Key Issues and Concerns

In addition to “traditional” drugs of abuse and alcohol, women with eating disorders are unique in their abuse of pharmacological agents ingested for the purpose of weight loss, appetite suppression, and purging. Among these drugs are prescription and over-the-counter diet pills, laxatives, diuretics, and emetics. Nicotine and caffeine also must be considered when assessing substance abuse in women with eating disorders.

Drugs related to purging, such as diuretics, laxatives, and emetics, have been shown to be ineffective and potentially dangerous methods of accomplishing weight loss or maintenance. The literature suggests that, like more common drugs of abuse, tolerance and withdrawal occur with laxatives, diuretics, and possibly diet pills and emetics.

A critical message for clinicians is that women with eating disorders often will go to dangerous extremes to lose weight and a comprehensive assessment must document the individual’s full repertoire of weight-loss behaviors. Clinicians also must be mindful of excessive consumption of sugar substitutes, as the long-term effect of consumption of large quantities of these substances in humans is yet to be determined.

Strategies, Tools, and Techniques

Though the presence of a history of alcohol abuse or dependence appears not to affect outcome in trials of cognitive-behavioral or pharmacological therapy for bulimia nervosa, much less is known regarding the effects of current substance use on treatment outcome for bulimia nervosa. Practically, the management of individuals with concurrent active bulimia and substance abuse can be challenging. Given that few treatment programs specialize in the treatment of concurrent eating and substance abuse problems, the phenomenon of treatment ping-pong often is observed. Individuals may alternate between eating disorders and substance abuse treatment programs without ever benefiting from treatment that targets both problems simultaneously.


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 (; ; ; ). 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 ().

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.

Figure D-17. General and Specific Screening Questions for Persons With Possible Eating Disorders

General Screening Questions
• How satisfied are you with your weight and shape?
• How often do you try to lose or gain weight?
• How often have you been dieting?
• What other sorts of methods do you use to lose weight?
Specific Screening Questions
• Have you ever lost a lot of weight and weighed less than other people thought you should weigh?
• Have you had eating binges where you eat a large amount of food in a short period of time?
• Do you ever feel out of control when eating?
• Have you ever vomited to lose weight or to get rid of food that you have eaten?
• What other sorts of methods have you used to lose weight or to get rid of food?

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 (). 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 (), 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 (). 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

Pathological Gambling


Pathological gambling (PG) has been best described as “a progressive disorder characterized by a continuous or periodic loss of control over gambling; a preoccupation with gambling or obtaining money with which to gamble; irrational thinking, and a continuation of the behavior despite adverse consequences” (Rosenthal 1992). The American Psychiatric Association’s criteria for the diagnosis of PG (DSM-IV-TR) () are in many ways similar to those for alcohol and other drug dependence (see Figure D-18).

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

Diagnostic Criteria for Pathological Gambling Comparable Substance Dependence Criteria
• Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: • Maladaptive pattern of substance use, leading to clinically significant impairment of distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
• Is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) • A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects
• Needs to gamble with increasing amounts of money to achieve the desired excitement • Tolerance
• Has repeated unsuccessful efforts to control, cut back, or stop gambling • There is a persistent desire or unsuccessful efforts to cut down or control substance use
• Is restless or irritable when attempting to cut down or stop gambling • Withdrawal
• Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) • N/A
• After losing money gambling, often returns another day to get even (“chasing” one’s losses) • The substance is often taken in larger amounts or over a longer period than was intended
• Lies to family members, therapist, or others to conceal the extent of involvement with gambling • The substance use is continued despite knowledge of having persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
• Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
• Relies on others to provide money to relieve a desperate financial situation caused by gambling
• Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling • Important social, occupational, or recreational activities are given up or reduced because of substance use

• Source: .

Many clients with PG display what amounts to tolerance, needing to gamble with increasing amounts of money (or make increasingly risky bets with what money is available to them) to achieve the desired effect. For some gamblers, often referred to as “action” gamblers, this effect may be excitement (; ). For other gamblers, thought of as “escape” gamblers, the sought-for effect is relief from painful emotions or stress. Consequently, gambling may act as a stimulant such as amphetamine or cocaine for some clients with PG, while acting as a sedative or tranquilizer for others. (See Figure D-19 for a list of differences between action and escape gamblers.)

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

Action Escape
• Gambles for excitement, competition • Gambles for relief, escape from stress or negative affect
• More likely to engage in “skilled” forms of gambling such as poker, horse racing, sports • More likely to engage in “luck” forms of gambling such as lottery, slots, video poker, bingo
• More likely to have early onset of gambling • Later onset of gambling
• Longer progression from regular gambling to addictive/out of control gambling • Shorter progression from regular gambling to addictive/out of control gambling
• More likely to be male • More likely to be female
• More likely to present narcissistic or antisocial traits • More likely to be dysthymic

Pathological gamblers often report withdrawal-like symptoms when attempting to stop gambling. These may include symptoms such as irritability, problems focusing or concentrating, difficulty sleeping, and even physical symptoms such as nausea, vomiting, headaches, and muscular pain (; ). Currently, there are no DSM criteria for gambling disorders that compare directly to criteria for substance use disorders. However, in practice, the term “problem gambling” is most commonly considered to apply to those individuals who meet one to four of the DSM-IV criteria for pathological gambling (). Problem gamblers are individuals who do not meet full criteria to be diagnosed as pathological gamblers, but who meet some of the criteria and indicate that gambling is contributing to some level of disruption in their lives.

While there are similarities between PG and substance use disorders, there are some significant differences between these disorders. Research comparing individuals diagnosed with PG to individuals with substance use disorders is still in early stages, but there have been clinical reports on such differences. To begin with, it may be more difficult to define what constitutes gambling than to define a drug or an alcoholic drink. Gambling can encompass a variety of behaviors: buying lottery tickets, playing cards for money (even in friendly family games), investing in the stock market, participating in a charity raffle, betting on a golf game, betting on horse races, or playing scratch-off games to win money at a fast food restaurant.

One of the main differences between PG and substance use disorders is that there is no biological test to screen for PG. The absence of a clear physical sign of the disorder enables a person to hide gambling behavior for longer periods of time. This also may contribute to the severe and entrenched lying and deception that are included in the diagnostic criteria for PG.

Because no substance is being ingested, often it is very difficult for individuals diagnosed with PG and their families/significant others to accept PG as a medical disorder. Research is beginning to establish a biological/genetic predisposition to PG that is similar to that found in severe alcohol and drug addictions, and that gambling may affect the central nervous system in ways similar to substance use (; ; ; ). However, it is still difficult for individuals with PG, as well as the general public, to accept a medical model for this disorder. It is easier to accept that people with substance use disorders may behave badly (become aggressive or violent) while intoxicated than for gamblers to accept that their harmful behavior can be attributed to their gambling. This possibility could exacerbate the gambler’s sense of shame and guilt and contribute to the development of rigid defense mechanisms to ward off these feelings and to allow gambling to persist. These hypothesized differences need to be investigated empirically.


Legalized gambling is available in 47 States and the District of Columbia. The great majority of adults (81 percent) have gambled sometime during their life. This compares to recent studies of alcohol use in the United States that estimate 91 percent of adults have drunk alcohol. Between 1974 and 1995, the amount of money spent on legal gambling increased 3,100 percent in the United States, from $17.4 billion to $550 billion. A national study estimated the lifetime prevalence of pathological gambling among adults in the United States to be 1.1 percent, while the past-year estimate for problem or pathological gambling combined was 2.9 percent. This can be compared to past-year estimates of alcohol abuse/dependence of 9.7 percent and drug abuse/dependence of 3.6 percent ().

Information on the prevalence of pathological gambling among adolescents has been controversial, with reported rates higher than for adults (). However, adolescent rates of problem or pathological gambling, which range from 9 to 23 percent in various studies, are comparable to rates of adolescent alcohol use (8 to 23 percent). Also, past-year adolescent pathological gambling rates of 1 to 6 percent are comparable to past-month rates of marijuana use of 3 to 9 percent ().

Gambling prevalence studies also illuminate demographic variables and risk for gambling problems. As suggested above, younger age seems to be a risk factor. Adults under the age of 30 report higher proportions of gambling problems. Men, ethnic minorities, and paradoxically, those with household incomes below $25,000 also tend to be overrepresented among problem/pathological gamblers. Employment status did not seem to have any relationship to risk for gambling problems. However, educational level had a moderate relationship with problem gambling, with those with a high school education or less being at higher risk for gambling problems ().

The rate of co-occurrence of PG among people with substance use disorders has been reported as ranging from 9 to 16 percent (; ; ). Among pathological gamblers, alcopethol has been found to be the most common substance of abuse. At a minimum, the rate of problem gambling among people with substance use disorders is 4 to 5 times that found in the general population.

People with substance use disorders and co-occurring PG have been compared to people with substance use disorders without PG. While some findings appear contradictory, there is some evidence that people with co-occurring substance use and PG may have higher levels of negative affect, overall psychiatric distress, impulsivity, higher rates of antisocial personality disorder, AD/HD, and risky sexual behaviors (; ; ; ; , ). The high rates of co-occurrence of substance use disorders and gambling problems clearly emphasize the need for screening and assessment of gambling problems in substance-abusing populations.

Key Issues and Concerns

Despite the high prevalence, treatment services for PG are limited or lacking in many areas. According to a survey conducted by the National Council on Problem Gambling, only 21 States provide some level of funding for addressing problem and pathological gambling. According to the Association of Problem Gambling Service Administrators (, only 16 States provide some public funding specifically for gambling treatment. Additionally, only about 1,000 Gamblers Anonymous meetings are held in the United States, fewer than the number of AA meetings found in some major metropolitan areas.

It is important to recognize that even though PG often is viewed as an addictive disorder, clinicians cannot assume that their knowledge or experience in substance abuse treatment qualifies them to treat persons with a PG problem. Training and supervision should be obtained to work with pathological gamblers, or referral should be made to specific gambling treatment programs.

A second consideration is that clients with PG problems seeking treatment have high rates of legal problems. Research has shown that in most settings, two thirds of people with PG problems report engaging in illegal activities to obtain money for gambling or to repay gambling debts. Pathological gamblers often fail to report such activities as embezzling from their job as an illegal activity. In their own minds they label what they are doing as borrowing rather than stealing, as they are certain that they will make a winning bet and be able to pay the money back. Persons with substance use disorders also have many of these same problems.

Transference and countertransference issues in the treatment of pathological gambling can have a significant impact. Competitive, action-oriented gamblers may attempt to make treatment a competitive sport, and clinicians may become distracted by debating and arguing. Relapsing may become a way for the pathological gambler to “beat” the therapist. The lack of physical signs or biological tests for gambling can contribute to countertransference reactions, such as the therapist becoming overly zealous in trying to “catch” gamblers in their lies or overly accepting of self-reports. Either extreme can impede the therapeutic relationship.

Strategies, Tools, and Techniques


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.


The South Oaks Gambling Screen (SOGS) () is one of the most widely researched instruments. This is a 20-item questionnaire designed to screen for gambling problems and has been found to be effective in substance abuse populations. It can be conducted as a structured interview or a self-report questionnaire in both lifetime and past 6-month versions. The drawbacks are its length and the fact that the items are not specifically based on DSM-IV criteria, which precludes its use as a diagnostic instrument. Someone who scores above the cut-off on the SOGS would then require a more detailed diagnostic assessment.

A brief screening tool, the Lie/Bet Questionnaire, has been found to be effective in identifying probable pathological gamblers (). The questionnaire consists of two questions:

  1. Have you ever felt the need to bet more and more money?
  2. Have you ever had to lie to people who are important to you about how much you gamble?

A “yes” response to either question suggests potential problem gambling. Again, this instrument is likely to over-identify individuals with gambling problems and a positive screen needs to be followed by a more detailed clinical/diagnostic interview.

A computerized problem gambling screening tool that may be particularly useful in criminal justice populations is the Gambler Assessment Index (GAI) which incorporates a problem gambling scale as one of seven scales (truthfulness, attitude, gambler, alcohol, drugs, suicide, and stress). It takes about 20 minutes to complete and includes a descriptive computerized printout of risk levels for all scales ().


A more comprehensive problem gambling assessment needs to be part of a broader biopsychosocial and spiritual evaluation. Only two instruments have been studied and used to evaluate issues of problem gambling severity. An addendum to the ASI, the Gambling Severity Index has been developed and validated (). Another instrument that has been found to be valid and reliable is the Gambling Treatment Outcome Monitoring System, or GAMTOMS (). This is a battery of four questionnaires designed to be used in assessment of problem gambling and in treatment outcome evaluation.

The Gambling Treatment Admission Questionnaire (GTAQ) is particularly useful. A 162-item self-report questionnaire that incorporates the SOGS and DSM-IV criteria, the GTAQ evaluates the range of gambling behaviors and frequency of gambling, gambling debt, treatment history, substance use, and gambling-related financial, legal, occupational, and psychosocial problems.

Structured interviews for the diagnosis of pathological gambling based on DSM-IV criteria currently are being researched and developed, but are not yet publicly available (; ). Most clinicians conduct a clinical interview based on DSM-IV criteria to establish the diagnosis of pathological gambling.

In individuals with COD, it is particularly important to evaluate patterns of substance use and gambling. Among those who abuse cocaine, for example, there seem to be several common patterns of interaction between gambling and drug use. Cocaine use and gambling may coexist as part of a broader antisocial lifestyle. Someone who is addicted to cocaine may see gambling as a way of getting money to support drug use. A pathological gambler may use cocaine to maintain energy levels and focus during gambling and sell drugs to obtain gambling money. Cocaine may artificially inflate a gambler’s sense of certainty of winning and gambling skill, contributing to taking greater gambling risks. Cocaine may be viewed by the gambler as a way of celebrating a win or may be used to relieve depression following losses.

Cocaine and pathological gambling may be concurrent or sequential addictions. With cocaine in particular, it often is difficult to have enough money for both disorders at the same time. There is no clear evidence that one addiction is likely to precede another, although one recent study reported that in a population of people with substance use disorders who are in treatment, the onset of gambling behavior was likely to precede the use of addictive substances ().

Several patterns of interaction may emerge for individuals who are alcohol dependent and are pathological gamblers. One of the more common clinically observed patterns is sequential addiction; for example, someone who has had a history of alcohol dependence—often with many years of recovery and AA attendance—who develops a gambling problem. Such individuals often report that they did not realize their gambling was becoming another addiction, or that gambling could be as addictive as alcohol and drugs. It is not uncommon for such individuals to seek treatment only after a relapse to alcohol (or recognizing they are close to a relapse), secondary to the gambling-related stresses. Other individuals have developed alcohol problems only after their gambling has begun to create serious adverse consequences; they begin using drinking as a response to such problems. Since alcohol is readily available (and often free) in most gambling settings, drinking and gambling may simply “go together” for some individuals.

It often is helpful, if not critical, to obtain collateral information from family and significant others. One scale that is helpful in this process, the Victorian Problem Gambling Family Impact Scale, is undergoing validation ().

Obtaining collateral information often can be challenging, as the gambler may want to control both what the clinician knows and what the family knows. The gambler may not want the clinician to know how angry and devastated the family is feeling, or the gambler may not want the family to know the extent of his or her gambling and gambling debt. Also, the gambler may give specific instructions to family members about what to tell or not to tell the clinician. This may be related to gambling or finances, but it also may relate to substance use.

Therefore, while it is advisable to involve family members as early as possible in the assessment and treatment process, it may take time to develop a trusting clinical relationship with the gambler before he or she gives consent to family involvement. The clinician needs to consider carefully the best way to involve family members or significant others in the assessment and treatment process. Initial sessions with both the gambler and family present may help to alleviate the gambler’s anxiety. Such sessions can be followed up with meetings without the gambler present. It is essential that the therapist not be viewed as taking sides in this process.

Case Study: Pathological Gambling Assessment

A 36-year-old, married male, Andy J. entered treatment for pathological gambling. An initial assessment involving questionnaires and structured diagnostic interviews found indications of excessive alcohol use and use of cocaine. On a family assessment interview, Andy J.’s wife denied knowledge of any excessive alcohol use or any cocaine use on her husband’s part.
As treatment proceeded, it became apparent that Andy J.’s substance use was more extensive and problematic than first presented. Staff members were particularly concerned about his apparent hiding of his substance use from his spouse. Andy J. became angry and agitated, threatening to discontinue treatment when staff indicated that the issue of his substance abuse needed to be addressed at the next family session. Andy J. was given the choice of communicating the extent of his substance use to his wife prior to the session or waiting until the session.
Andy J. initially withdrew consent to communicate with his wife. However, after intensive group and individual work focusing on relapse potential, dishonesty as a relapse risk factor, and assessment of further negative consequences, he decided to tell his wife. In the next joint session, his wife expressed relief and reported that she had been aware of and concerned about his substance use. She had lied at the initial assessment at her husband’s request, as he had convinced her that it would be best for his treatment not to get the therapist distracted by his substance use so that he could fully focus on his gambling problem. Andy J., once the initial anger and anxiety had subsided, acknowledged that he was holding onto his substance use for fear of living life without an addiction to fall back on. He realized that continued substance dependence would continue to maintain all the problems he was attributing only to his 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) (), 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.

Addressing financial and legal issues

Financial crises may involve eviction and homelessness; inability to pay for food or utilities; or families discovering that savings accounts, college funds, and so on are totally depleted. It is important in handling financial crises to make sure the basics of food and shelter are met for the gambler and his family. This may mean referring the family to homeless shelters or finding temporary living quarters with extended family. Resolving the entire extent of financial problems takes more time; however, in the crisis situation it is essential to convey to the gambler and family that coping with financial stress is a part of treatment, and to outline the process for addressing the problems. It is important to help the gambler and family prioritize immediate needs (i.e., food, shelter) separately from those that can be managed later to relieve the feelings of being overwhelmed. The counselor can help the client make specific lists of what can be done now and what can wait until later. For example, if the family is being evicted, the clinician could provide a list of shelters to call or have the client call shelters from the clinician’s office.

Legal issues can create an additional crisis for the pathological gambler and the family. Embezzling from an employer or writing bad checks are two common illegal practices of pathological gamblers. When facing potential legal charges for such activities, the gambler often is in a state of panic, looking for money to borrow from family or friends to pay off the checks or pay the employer back to avoid legal consequences. It often is difficult for the family or friends of the gambler to refuse such requests when they fear the result will be sending the gambler to jail. In such cases, the clinician needs to direct the gambler to obtain legal counsel prior to making impulsive decisions. The clinician needs to work with both the gambler and potential “bail out” sources to explore other options.

Financial and legal issues also can trigger domestic violence. The pathological gambler may face physical violence from a spouse or significant other when he or she confesses to the extent of gambling debt. Alternatively, a spouse or significant other may face violence if he or she attempts to withhold money from the pathological gambler. The clinician needs to assess the history of domestic violence or potential for violence very carefully before suggesting any plan for dealing with money management or financial disclosure.


To assist a client with a PG problem to abstain from gambling, some gambling venues (mainly casinos and some race tracks) offer “self-banning.” This is a process of completing a written document indicating a desire to be prohibited from entering a casino or race track. Some States have made this a legal process with criminal consequences if a gambler who has self-banned is found gambling at the banned location. Information on this process can be obtained from the gambling venue’s responsible gaming office, from State Councils on Problem Gambling, or from State-funded problem gambling treatment programs.

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.

Psychodynamic therapies

Some of the earliest clinical writing on the successful treatment of pathological gambling was based on psychodynamic approaches. Such approaches emphasize identifying the underlying conflicts and psychological defenses that contribute to addictive gambling. Therapy involves helping the gambler gain insight into the psychological meaning of his or her gambling (), decreasing defenses that support denial and irrational thinking, and developing more adaptive coping skills to resolve internal conflicts. Such dynamic therapies generally are incorporated into a comprehensive treatment approach with the therapist taking a more active and directive role than in traditional dynamic approaches.

Case Example: Counseling a Pathological Gambler

Michael B. was a gambler who relished the competitiveness of card playing and had developed a reputation as a tough player and as a winner early in his gambling career. His gambling gradually became out of control and it was clear that he was unable to stop gambling until he had lost all his money. However, when he attempted to abstain from gambling he would feel depressed. In treatment he confessed to feeling increasing anxiety when he was winning, and to feel relief only when he had lost everything.
Michael B.’s father had been a successful business executive who had been very demanding and critical of Michael B. throughout his life. Michael B. had been determined to “beat his father at his own game” and become even more successful. While Michael B. had developed many businesses, they always seemed to collapse after an initial success, a pattern that mimicked his gambling. In therapy, it became clear that Michael B. felt guilty at thoughts of “beating” his father, which contributed to the destructive pattern of his gambling and of his unsuccessful businesses.
Treatment helped Michael B. let go of his guilt-producing fantasy of spectacular success and focus on how he could enjoy his life without feeling a need to compete with his father. He was able to set more realistic goals to achieve a sense of accomplishment and was able to abstain from gambling without feeling depressed and inadequate.
Cognitive-behavioral treatment

While early reports of behavioral treatment of pathological gambling focused exclusively on gambling behaviors using aversive conditioning and systematic desensitization, more recent approaches involve a range of cognitive as well as behavioral interventions. Similar to approaches to substance use disorders, these include relapse prevention strategies, social skills training, problem solving, and cognitive restructuring ().

A component that is specific to pathological gambling in this strategy involves modifying irrational beliefs about gambling and the odds of winning. Research repeatedly has shown that gamblers hold beliefs in “the illusion of control,” biased evaluation, and the gambler’s fallacy ().

  • The illusion of control is the belief that one can control or influence random or unpredictable events, such as picking winning lottery numbers or controlling the fall of the dice by how they are thrown.
  • Biased evaluation involves attributing wins to one’s special skill or luck, while losses are blamed on external circumstances.
  • The gambler’s fallacy is the misunderstanding of independent probabilities. For example, if a coin is tossed 10 times resulting in 10 heads, one would think it more likely to get a tail on the next toss, rather than realizing the odds of a head or tail is the same for any one toss.

Cognitive-behavioral interventions are targeted at identifying and correcting such irrational thinking and erroneous beliefs.

As with substance abuse, relapse prevention includes identifying gambling-related internal and external triggers. Money is a common trigger and interventions generally involve removing money from the gambler’s control. This can include removing the gambler’s name from joint checking and savings accounts, limiting the amount of cash the gambler carries, discontinuing credit cards, and choosing a trusted family member or friend to become the gambler’s money manager. As might be anticipated, this can be a difficult and conflictual process; successful use requires creativity and sensitivity to issues of power and control. The goal is not only to remove the trigger of money from the gambler, but also to protect the gambler’s and the family’s finances. It can be helpful if this is explained as a process of assisting the gambler in regaining financial control of his or her life. Negotiating a workable and tolerable system of financial accountability and safety is a key therapeutic task in the treatment of pathological gamblers, regardless of therapeutic approach.

With clients with co-occurring PG and substance use disorders, it often is essential to identify specific triggers for each disorder. It also is helpful to identify ways in which use of addictive substances or addictive activities such as gambling act as mutual triggers.

Increasing evidence supports the effectiveness of treatment approaches with the goal of reduced or limited gambling, particularly for problem gamblers who do not meet all criteria for a diagnosis of pathological gambling or who are low-severity pathological gamblers. This approach generally involves money management along with cognitive-behavioral interventions to set and achieve goals for controlled or limited gambling. Manuals are available to guide this type of treatment, and a self-help manual also has been published ().

Psychopharmacological treatment

Two main types of medication have been reported to reduce gambling cravings and gambling behavior: SSRIs, such as fluvoxamine (Luvox), and opiate antagonists, such as naltrexone, which has also been found to be effective in treating people with substance use disorders (; ).

As people with co-occurring substance use and PG disorders may be more likely to experience a broad range of additional mental disorders, psychiatric medication to address affective disorders, anxiety disorders, and attention deficit hyperactivity disorder may sometimes be needed.

Integrated multimodal treatment

Treatments combining 12-Step, psychoeducation, group therapy, and cognitive-behavioral approaches have been found to be effective in the treatment of pathological gamblers with co-occurring substance use and mental disorders (; ).

Gamblers Anonymous

It is advisable for persons with substance use and PG disorders to attend separate support groups for gambling and for alcohol and/or drug dependence. While the groups can supplement each other, they cannot substitute for each other.

It may be difficult for some individuals to adjust to both types of groups, as Gamblers Anonymous (GA) meetings can be different from AA. It is not uncommon for people with substance use disorders who have had extensive experience with AA, Narcotics Anonymous, or Cocaine Anonymous to find fault with GA groups. While GA often places less emphasis on step work, sponsorship, and structure than other 12-Step programs, it still provides a unique fellowship to address gambling issues. GA also can be useful in helping gamblers and their families cope with money management, debt, and restitution issues through a process called “Pressure Relief.” Clinicians new to the treatment of pathological gambling are advised to attend open GA and Gam-anon meetings in their area to gain a better understanding of this support system.

The experience of some clinicians is that initially, limited gambling may be an approach for those with substance use disorders and gambling problems who are willing to work on abstinence goals for their substance use, but who are less motivated to abstain from gambling. Rather than distracting from the substance abuse treatment, the clinician can suggest either a limited gambling approach or a time-limited period of abstinence from gambling. These may be presented as experiments. Cravings for both gambling and substances can be monitored in either approach to help clients understand the potential interactions of both disorders and to make better informed decisions about whether they can gamble at all. The same can be done with the client who is motivated to abstain from gambling but more ambivalent about the need to reduce his or her substance use or abuse. This approach may help minimize a client’s defensiveness toward treatment in general and reduce the risk of dropping out of treatment or denying a problem altogether.

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.

  1. A group of clinicians committed to a research agenda for the development of DSM-V have given the following assessment of the status of personality disorders within the DSM-IV-TR (APA 2000): “… there is notable dissatisfaction with the current conceptualization and definition of the DSM-IV-TR (APA 2000). Problems identified by both researchers and clinicians include confusion regarding the relationship between the DSM-IV-TR personality disorders (especially those that are chronic and have their onset in childhood or adolescence); excessive comorbidity among the DSM-IV-TR personality disorder; arbitrary distinction between normal personality, personality traits, and personality disorders; and limited coverage (the most common diagnosed personality disorder is the residual diagnosis of personality disorder not otherwise specified)” (First et al. 2002).
  2. Confidentiality is governed by the Federal “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations (42 C.F.R. Part 2) and the Federal “Standards for Privacy of Individually Identifiable Health Information” (45 C.F.R. Parts 160 and 164).


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