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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Co-Occurring Disorders:
Integrated Dual Disorders Treatment

Integrated Dual Disorders Treatment Workbook

Chapter 11: Substance Abuse Counseling for Persons with SMI

INTRODUCTION
For clients who are ready to stop using substances, substance abuse counseling helps them to develop the skills and supports they need to live a satisfying life without substances. This chapter describes a young woman with polysubstance abuse and an acute anxiety disorder. Counseling during the active stage of treatment helps clients to identify thoughts, emotions, behaviors, and situations that lead to substance use, and to change these patterns in order to avoid substance use.

VIGNETTE
Susan is an attractive 18-year old, single student. After an episode of intoxication at the local emergency room a week earlier, her mother brought her in for treatment at the mental health center.

The counselor met with Susan alone first and then was joined by her mother. During the intake, Susan appeared disheveled, tremulous, and distracted. Her eye contact was poor. She described increasing substance use, depression and anxiety over several months with the following symptoms: insomnia, rapid changes in mood, difficulty concentrating in class and doing homework, and feeling tense and worried most of the time. She gave the following history of substance use: she first drank alcohol at age 14 and for the past 6 months has been drinking up to 6 drinks a night on weekends (with friends and at parties); she first used ecstasy at age 17 and now uses it once or twice per month; she first used cocaine 6 months ago and now uses every weekend at parties; and she tried heroin last week at a party prior to going to the emergency room. She said that when she starts drinking at parties she drinks more mixed drinks or wine than she plans to, but that all her friends "get wasted" like that.

Susan reported several problems. She had been struggling to do her work in high school. She recently quit working on the school paper. She also revealed that she often "hooks up" with guys at parties and doesn't use any birth control or other protection. She is concerned about the possibility of being pregnant. The counselor asked her if she had ever been sexually touched when she didn't want to be. After a lengthy pause, Susan revealed that she had been raped six months earlier after an all-night party, a "Rave." She had been afraid to tell her parents or anyone.

Susan was tearful and tremulous talking about the rape. The clinician asked her about post-traumatic stress disorder (PTSD) symptoms. She reported intrusive memories, occasional nightmares, and that she always felt "on the edge" and extremely alert. She felt nervous and cried when she thought about what happened. The memories bothered her all the time. She avoided situations that reminded her of what happened, including the young man, and when she saw him she experienced feelings of panic. Sometimes she wished she were dead, but she had not made plans to harm herself because she wouldn't shame her family that way.

The clinician asked her whether these feelings led her to want to drink or use drugs. Susan said that when she experienced intrusive memories of her assault and when she had trouble sleeping at night, she thought about drinking, but that she only drank when she went out with friends. Whenever she was on a date or at a party, she couldn't wait to have a drink. She always used drugs at parties when she was offered, but she didn't think she had the urge to use in other situations. She couldn't remember actually saying "no" when offered a substance and didn't know if she could.

Susan's mother reported a strong family history of anxiety, depression, and substance abuse in several family members. She was shocked and angry with Susan for using substances, but wanted to help her address her problems.

The counselor empathized with the symptoms and problems that Susan was experiencing. She suggested that the problems might be made worse by using substances. She asked for Susan's input about the effect of using substances on her current situation. Susan wasn't sure, but thought if she felt better she might not feel like using substances so much. The counselor suggested that they try an experiment. Susan was to keep a journal for a week. She would write down every time she used substances, what was happening and what she was thinking and feeling before using, and also what she experienced during and after using. The counselor gave her a worksheet to use for this assignment.

At the end of the evaluation, Susan agreed she wanted to work on feeling better, even if it meant changing her substance use. She agreed to come weekly to therapy, but she did not want to see a doctor for a psychiatric or for a physical evaluation. Her mother agreed to keep an eye on Susan and to restrict her from dates and parties until they met again and developed a plan of action.

When Susan and her counselor met the next week, they looked at the journal and worksheets together and talked more. Susan had not used any substances because her mother "barely let me out of the house!" Susan was able to identify thoughts, feelings, and situations in the past that led to using drugs and alcohol that allowed them to complete a contextual assessment of her use of alcohol, cocaine, and ecstasy. Key triggers for wanting to use alcohol were memories of being raped and the anxiety she felt around boys, dating, and parties. Key situations leading to other substance use were being at a party where others were using and offering substances to her. She and her counselor began to look at other ways to handle these situations without using substances. During this meeting, the counselor talked with Susan about alcohol and other substances, giving her information about how they affected her body and her mood. She also gave her information about post-traumatic stress disorder, which helped Susan to understand most of her symptoms. They agreed to talk more about what to do next the following week. She agreed to continue to write in her journal and to stay at home.

At the next meeting, they came up with an action plan. They also met with Susan's mother, and Susan revealed more about her problems with substances and shared the plan with her. Susan asked her mother to help by doing one fun thing with her on Saturdays. Her mother agreed. They also agreed on a 10 p.m. curfew and a one-week grounding if it was broken.

Susan and her counselor met weekly for a year. In the first four months they focused mostly on helping Susan learn and practice relaxation skills and the social and assertiveness skills to stay away from parties and to say no when substances were offered. The counselor and Susan's mother also encouraged her to engage in other fun activities, which helped Susan's mood. After a few months, she agreed to see a psychiatrist for a medication evaluation and decided to try an antidepressant medication. She also agreed to get a medical evaluation and testing for infectious diseases. She stopped using substances but then had three different one-night lapses of heavy alcohol use, which she reported were related to going on a date and being offered alcohol. By the third month of treatment, the memories of the rape and anxiety related to them were less bothersome, but her social anxiety was not.

Susan, her mother, and the counselor reviewed her action plan at this point. In the next six months she and her counselor worked on reducing her social anxiety and developing more positive self-esteem by improving her conversation and assertiveness skills. In this context, she talked in more detail about how she was raped and her shame around this event. Her counselor suggested an AA group for young people and a rape survivors group to give her a place to make new friends and get further support, but Susan adamantly stated she would have nothing to do with groups. She did make a new friend at the afternoon homework club and started dating a boy from her Karate class. Neither one used drugs. She remained substance free for six months and stopped seeing the counselor when she entered college.

DIAGNOSIS AND COMPREHENSIVE ASSESSMENT
This vignette is simplified for the sake of being brief, but it illustrates that clinicians have to clarify the psychiatric diagnosis and the extent of the substance abuse problems, as well as complete a contextual assessment of the substance abuse to be able to do effective substance abuse counseling. Susan's diagnoses were PTSD and polysubstance abuse (not dependence). She became aware that substance use worsened her problems in many ways and quickly became committed to giving up substance abuse. She was fully in the active treatment stage by the third meeting with her counselor.

COGNITIVE BEHAVIOR COUNSELING AND STAGES OF TREATMENT
Substance abuse counseling aims to help clients recover from substance use disorders. What the clinician does depends on the client's stage of treatment. During the engagement stage, the clinician focuses on establishing a trusting relationship in which substance use and other personal issues can be discussed openly. During the persuasion stage, clinicians focus on helping the client to develop motivation to change substance-abusing behaviors. These skills are described in the chapters on engagement and persuasion. Cognitive behavioral counseling skills are particularly important when the client is actively trying to reduce or eliminate substance use in the active treatment stage or when the client is abstinent and attempting to maintain abstinence in the relapse prevention stage.

THE ACTION PLAN
Substance abuse counseling is based on an action plan that outlines a roadmap for how the client can get the needed skills and supports to reduce use of substances, obtain abstinence, or manage her illness better. The plan is based on a detailed analysis of the emotions, thoughts, behaviors, and circumstances before, during and after substance use. This information is gathered during the engagement and persuasion stages of treatment as the counselor gets to know the client's world through the client's eyes, learns about the details of the client's substance use, and helps the client to develop motivation for pursuing life goals. Individual targets of the plan can include biological, psychological, cognitive, interpersonal, and environmental antecedents or consequences to substance abuse. An action plan is always developed with the client. If the client is part of the process of developing the plan, she is more likely to understand it fully and to be confident in the plan. It also makes it clear that the client is a responsible participant in carrying out the plan.

The action plan includes the specific strategies, timelines, and responsibility for addressing each of the targets that can be clarified in the analysis of substance use. Cognitive behavioral counseling was used to help Susan learn to avoid or cope with internal cues and external situations that lead to substance abuse. Before a plan can be specified, however, the counselor needs to know about withdrawal, craving, triggers to use, expectations of use, and what reinforces use for the client.

CUES THAT LEAD TO SUBSTANCE USE
Clients face many situations, emotions, and thoughts that lead to substance use (see the discussion in the chapter on assessment). Situations may be external cues to use substances. For example, being offered substances at a party was an external cue to use for Susan. Clinicians can help clients consider ways to avoid or cope with external cues. This is discussed in more depth in the next chapter on relapse prevention, though these clinicians will often help clients cope with external cues during the active treatment stage.

Many clients have difficulty managing emotions, which then lead to substance use. Emotions can be internal cues to use substances. Common emotions that precede substance use are anger, anxiety, depression, and loneliness, though people who have substance abuse problems report that almost any uncomfortable emotion can lead them to use substances. Helping clients manage uncomfortable emotions is a central part of substance abuse counseling.

Unpleasant emotions often are accompanied by negative or self-defeating thoughts, which can also be internal cues to use. For example, anger at a spouse might lead to these thoughts: "I hate him; I'm miserable in my marriage; it's all hopeless. I might as well drink." Or in Susan's case, anxiety in social situations led to two scenarios in her head: "I'm not popular enough; no guy will ever really love me for who I am; I just need a drink to get rid of how bad I feel." Or "I'm so anxious I can't stand it; people are noticing how stupid I look; I need to drink to relax and fit in."

Thoughts, emotions, and behaviors directly impact and change each other. By changing one of these three, usually the other two will change too. Events outside ourselves over which we have no control may trigger a thought, feeling or behavior that then leads to urges to drink. If clients can learn to monitor the thoughts, feelings, and behaviors that lead to urges to drink before they drink, and then modify them, they can avoid the drinking. Figure 1 describes the process of identifying the negative thought, emotion or behavior that leads to urges to drink, stopping the thought, and replacing the old response of using a substance with a positive thought or a coping behavior.

COGNITIVE INTERVENTIONS
When you examine how clients come to use substances, usually particular thoughts and feelings come before the urge to use, which is then followed by the substance use behavior. One way to help clients to change their substance use behavior is to help them identify the thought or feeling, to stop, and then to change the preceding thought or feeling. Being able to manage negative thoughts and negative feelings can dramatically improve a client's ability to stay away from substances. Figure 1 summarizes the important skills in this area, which include observing and identifying one's thoughts and feelings, stopping the negative thoughts, and replacing them with positive thoughts.

In Susan's case, the clinician helped her understand how her thoughts were linked to her feelings and behavior. Susan did this by keeping a journal of thoughts, feelings and behaviors, and by talking about situations in detail with her counselor. First, they looked at how social situations brought on anxiety for her. When in a dating or group situation, Susan worried about what others thought of her. The clinician taught her about different kinds of negative thoughts (see Table 2). The clinician helped her identify the thoughts she had in these situations, such as making an assumption and then leaping to an overgeneralization, like "he doesn't like me, he thinks I'm ugly, everyone must hate me," which led to negative self-statements, such as "I'm pathetic." These thoughts always made her feel anxious or depressed and led her to want to drink to get rid of her feelings and to forget her memories.

The counselor helped her come up with different thoughts to use when she found her mind going in this direction (which she used in addition to a quick relaxation technique, as described below). What worked for Susan was to repeat a positive slogan she learned in Karate. Other clients may want to develop their own personal affirmation statement, such as "I can do it without alcohol" or "I have faith in myself." Some clients find AA slogans helpful and use them to replace negative thoughts that lead to drinking. Other ways to reduce negative thinking are listed in Table 3.

BEHAVIORAL INTERVENTIONS
Behavioral interventions to reduce or stop using substances include helping clients to improve conversation and assertiveness skills, to learn relaxation skills, and to increase pleasant activities to replace the substance use activities and to manage mood problems. These skills are also discussed in the next chapter on relapse prevention.

Susan experienced anxiety related to PTSD symptoms and social situations, which led her to crave alcohol. Therefore, the clinician worked with her on skills to manage the anxiety without alcohol. She focused on relaxation training, which includes helping the client develop awareness of body cues for anxiety and training her how to breathe and relax her body. The clinician helps the client practice this and then to use a quick deep breath and relaxing thought when in social situations that bring on anxiety.

Many clients with dual diagnoses lack social skills, including conversation skills and assertiveness skills. Since interpersonal problems often lead to substance abuse, most people benefit from improving their ability to interact socially with others. The skills that usually help people cope with interpersonal issues include how to: start and continue a conversation, listen, assert an opinion, make a request, refuse a request, give and receive criticism, and refuse an offer to use a substance. Susan had problems with both conversation skills and assertiveness skills. She used alcohol to help relax in social situations. Even though she didn't want to use drugs, she had no idea how to refuse. Learning these skills continues in the relapse prevention stage of treatment.

Another important behavioral intervention is to help clients start new enjoyable activities that reduce anxiety and depression, increase enjoyment, and replace the substance-using activities. Engaging the family to help reinforce the new activities can be helpful, as it was with Susan.

REVIEWING THE ACTION PLAN
One key aspect of an action plan is that it should be reviewed at a specified time point or earlier if something unexpected occurs. Reviewing the plan helps the clinician and the client see how they are doing and whether they are on track with learning new skills and attaining sobriety. It also allows for changing the plan if it is ineffective. When Susan relapsed on dates with boys, she and her clinician looked at the events and saw that early on she was unable to get her worries about the boy out of her mind and became overwhelmed by anxiety. She then ended up at a party and drank.

The counselor refocused their work by helping her understand that parties where alcohol and drugs were present were a bad idea, practicing skills for saying no to going to parties, and using affirmation and assertiveness skills to say no to boys who she thought were probably not going to be respectful to her.

DUAL DIAGNOSIS AND TRAUMA
The majority of persons with dual diagnosis have experienced traumatic events during their lives, and many have post-traumatic stress disorder. It is important to ask clients about trauma and to screen for PTSD. Effective interventions for clients who have experienced trauma include education, support groups, and cognitive behavioral therapy designed to directly address symptoms of PTSD (for more information on how to help clients with these problems, see the reference at the end of the chapter.).

WORKING WITH TEENAGERS
Many teenagers who will develop dual disorders present for treatment in emergency rooms. Unlike Susan, they usually do not show up for follow-up appointments. Teens need close follow-up and assertive outreach to engage them into treatment early on in their illness. They need to be offered information and a menu of treatment options. When engaged into treatment early, we believe there is a good chance of greatly reducing or preventing the problems persons with dual disorders experience.

It is essential to involve family members in the treatment of teenagers. Family therapy may be appropriate as the main form of treatment for dually diagnosed teenagers. Because Susan's drinking was triggered by anxiety problems, her treatment providers chose individual treatment, but the counselor also engaged the mother by providing education and enlisting her to provide structure and limits that reduced Susan's access to substances, and to provide support for increasing other fun activities.

Recommended reading
There are many excellent books on cognitive-behavioral treatment of substance abuse. We recommend Treating Alcohol Dependence: A Coping Skills Training Guide, by Peter Monti, David Abrams, Ronald Kadden, and Ned Cooney (New York, Guilford Press, 1989). It offers a simple introduction to basic techniques that are effective with dual disorder clients in the active treatment stage.

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