Tip 42

Copyright 2008-2012 AllCEUs.
com a subsidiary of CDS Ventures, LLC
TIP 42
Dawn-Elise Snipes PhD, LMHC, CRC, NCC
GUIDING PRINCIPLES
 Employ a Recovery Perspective

 Adopt a Multi-Problem Viewpoint
 Develop a Phased Approach to
Treatment
 Address Specific Real-Life Problems Early
in Treatment
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Essential Attitudes
 Desire and willingness to work with people with
COD
 Appreciation of the complexity of COD
 Openness to new information
 Awareness of personal reactions and feelings
 Recognition of one’s own limitations
 Recognition of the value of client input
 Patience, perseverance, and therapeutic

optimism
 Ability to employ diverse theories, concepts
 Flexibility of approach
 Cultural competence
 Belief that all individuals are capable of growth
Recognition
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Assessment Areas
 Background
 Substance use
 Psychiatric problems

Assessment Process
 Engage the client
 Universal Access/No Wrong Door
 Empathy/Acceptance of Client Choice
 Person-Centered Assessment
 Culture Sensitivity
 Trauma Sensitivity
 Identify other sources of information (collaterals)
 Screen and detect COD
 Determine diagnosis and symptom severity
 Determine Level of Care (LOCUS/ASAM)
 Determine disability and functional impairment

 Identify strengths and supports
 Identify problem areas
 Determine stage of change
 Plan treatment
 Assessment is about getting to know a person with

complex and individual needs
 Do not rely on tools alone for a assessment.
 Make every effort to obtain collateral information
 Don’t allow preconceptions about addiction to

interfere with learning about what the client really
needs
 Know diagnostic criteria
 Don’t assume that there is one correct treatment

approach
Empathy
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AllCEUs.com are the most
of CDS valuable
Ventures, LLC
components
Techniques
 Stage specific motivational enhancements
 Express empathy
 Develop discrepancy
 Roll with resistance
 Support self-efficacy
 Use contingency management techniques
to target specific behaviors
 Use cognitive-behavioral techniques
 Visual aids
 Role playing/practice
 Outline sessions with specific behavioral
objectives
 Use relapse prevention techniques
 Daily inventory
 Recovery group participation
 Coping skills training
 Medication adherence
 Skill building to address functional
deficits
Precontemplation
 Express concern about the client’s substance
use, or the client’s mood
 State nonjudgmentally that substance use (or
mood, anxiety, self-destructiveness) is a problem.
 Agree to disagree about the severity of the issues
 Consider a trial of abstinence to clarify the issue
 Suggest bringing a family member to an
appointment.
 Explore the client’s perception of the problems.
 Emphasize the importance of seeing the client
again and that you will try to help.
 For involuntary clients, develop mutually
acceptable goals
Contemplation
 Elicit positive and negative aspects of substance
use or psychological symptoms.
 Ask about positive and negative aspects of past
periods of abstinence and remission
 Summarize the client’s comments
 Make explicit discrepancies between values and
actions.
 Consider a trial of abstinence and/or
psychological evaluation.
Preparation
 Acknowledge the significance of the decision to
seek treatment
 Support self-efficacy
 Help the client decide on appropriate,
achievable action for each issue
 Caution that the road ahead is tough
 Explain that relapse should not disrupt the
client–clinician relationship.

Action
 Be a source of encouragement and support

 Remember that the client may be in different
stages of readiness for change for different
issues
 Acknowledge the uncomfortable aspects of
withdrawal and/or psychological symptoms.
 Reinforce the importance of remaining in
recovery from both problems.
Maintenance
 Anticipate and address difficulties

 Recognize the client’s struggle with either
or both problems
 Support the client’s resolve.
 Reiterate that relapse or psychological
symptoms should not disrupt the
counseling relationship.
Relapse
 Explore what can be learned from the

relapse
 Express concern about the relapse.
 Emphasize the positive aspect of the
effort to seek care.
 Support the client’s self-efficacy
Special Populations
 Women
 Homeless
 Criminal Justice

Women
 Identify and build on each woman’s strengths.
 Avoid confrontational approaches.
 Arrange for daily needs such as childcare and
transportation.
 Have a strong female presence on staff.
 Promote bonding among women in the program.
 Help women reduce the stress associated with
parenting
 Develop programs for both women and children.
 Provide interventions that focus on trauma and
abuse.
 Foster family reintegration and family building
Pregnancy
 Careful planning for helping woman
address mental health issues during
pregnancy and postpartum
 Parenting often retriggers childhood
traumas.
 Focus on the woman’s interest in and
desire to be a good mother.
 Screen for dependence on substances that
can produce a life-threatening withdrawal
for the mother: alcohol, benzodiazepines,
and barbiturates.
Homeless
 Address housing needs.

 Teach clients skills for maintaining
housing.
 Work closely with shelter workers and
other providers for the homeless.
 Address real-life issues
Criminal Justice Offenders
 Recognize special service needs.
 Give positive reinforcement for small
successes and progress.
 Clarify expectations regarding
supervision.
 Use flexible responses to infractions.
 Give concrete directions.
 Design highly structured activities.
 Provide ongoing monitoring of
symptoms.
Suicidality
 Abuse of alcohol and other drugs is a major risk
factor in suicide.
 Alcohol abuse is associated with 25 to 50
percent of suicides.
 Comorbidity of alcoholism and depression
increases suicide risk.
 Substance intoxication is associated with
increased violence toward others and self.

What to do
 Take all suicide threats seriously.
 Assess the client’s risk of suicidality/homicidality
 Develop a safety and risk management plan
 Provide availability of contact 24 hours a day
 Refer high-risk clients for psychiatric intervention.
 Monitor and develop strategies to ensure
medication adherence.
 Develop long-term recovery plans

Personality Disorders
 Borderline Personality Disorder
Characteristics
 pervasive pattern of instability of
 interpersonal relationships
 self-image
 emotions,
 along with marked impulsivity
 Anticipate that client progress will be slow
and uneven.
 Assess the risk of self-harm
 Set clear boundaries and expectations
regarding roles and behavior
Antisocial Personality
Disorder
 Essential features of antisocial personality
disorder
a pervasive disregard for and violation of the
rights of others
 an inability to form meaningful interpersonal
relationships
 The prevalence of co-occurring antisocial
personality disorder and substance abuse
is high
 Most people diagnosed as having
antisocial personality disorder are not true
psychopaths
ASPD cont…
 What to do:
 Confront dishonest and antisocial behavior
 Stress immediate learning experiences that teach
corrective responses.
 Hold clients responsible for their behavior and
 Use peer communities to confront behavior and foster
change.
 Assess and correct antisocial and criminal thinking.
 Foster longer-term individual value change and the
establishment of new peer reference groups
Mood Disorders
 Among women with a substance use disorder, mood
disorders may be prevalent.
 Women are more likely than men to experience
clinical depression or anxiety
 Certain populations are at higher risk such as clients
with HIV, clients maintained on methadone, and older
adults.
 Older adults are at highest risk for combined mood
disorder and substance problems.

What to do
 Differentiate among the following:
 anxiety and mood disorders
 commonplace expressions of anxiety and
depression
 anxiety and depression associated with more
serious mental illness
 medical conditions and medication side effects
 substance-induced changes.
 Start low, go slow

 Combine addiction counseling with
medication and mental health treatment
Schizophrenia
 There is no clear pattern of drug choice
among clients with schizophrenia.
 What looks like resistance or denial may in
reality be negative symptoms of
schizophrenia.
 An accurate understanding of the role of
substance use disorders in the client’s
illness requires a multiple-contact,
longitudinal assessment.
 Clients with COD involving psychosis have
a higher risk for self-destructive and
violent behaviors, homelessness,
victimization, poor nutrition, and poverty
What to do
 Obtain a working knowledge of the signs and symptoms of
the disorder.
 Work closely with a psychiatrist or mental health
professional.
 Expect crises associated with the mental disorder
 Assist the client to obtain social services, housing,
vocational services.
 Monitor medication and promote medication adherence.
 Provide frequent breaks and shorter sessions or meetings.
 Employ structure and support.
 Present material in simple, concrete terms with examples
and use multimedia methods.
 Encourage participation in social clubs
 Teach the client skills for detecting early signs of relapse for
both mental illness and addiction
 Involve family in psychoeducational groups
 Monitor clients for signs of relapse and a return of psychotic
symptoms
AD/HD
 AD/HD in 5 to 25 percent of people.
 Approximately 1/3 of adults with AD/HD have
histories of alcohol abuse or dependence
 Adults with AD/HD have been found primarily to
use alcohol or marijuana
 The client may use self-medication for AD/HD as
an excuse
 The presence of AD/HD complicates the
treatment
 of substance abuse, since these clients may have
more difficulty engaging in treatment and
learning abstinence skills,
 Clarify for the client repeatedly what elements of
a question he or she has responded to and what
remains to be addressed.
 Eliminate distracting stimuli (e.g., noise, desktop
items) from the environment.
 Use visual aids
 Reduce the length of meetings
 Encourage the client to use organization tools
 Refer the client for evaluation for medication.
 Enhance the client’s knowledge about AD/HD and
substance abuse.
 Examine with the client any false beliefs about
the history of both AD/HD and substance abuse
difficulties.
PTSD
 The rate of PTSD among people with substance
use disorders is 12 to 34 percent.
 For women with substance use disorders, it is 30
to 59 percent
 55 to 99 percent of women with addictions report
a lifetime history of physical and/or sexual abuse
 Repeated trauma is common in domestic
violence, child abuse, and some substance-using
lifestyles
 People with PTSD tend to abuse the most serious
substances (cocaine and opioids); however,
abuse of prescription medications, marijuana,
and alcohol are also common.
 Proceed slowly
 Develop a plan for increased safety.
 Establish both perceived and real trust.
 Attend to behavior even more than words.
 Limit questioning about details of trauma.
 Recognize that trauma injures an individual’s
capacity for attachment
 Recognize the importance of one’s own trauma
history and countertransference
 Help the client learn to de-escalate intense
emotions.
 Help the client to link PTSD and substance abuse.
 Provide psychoeducation about PTSD and
substance abuse.
 Teach coping skills to control PTSD symptoms.
Eating Disorders
 Approximately 15 percent of women and 1
percent of men in inpatient substance abuse
treatment centers have had an eating disorder
 Individuals with eating disorders are significantly
more likely to use stimulants and significantly
less likely to use opioids
 Many individuals alternate between substance
abuse and eating disorders.
 Nicotine and caffeine must also be considered
when assessing substance abuse in people with
eating disorders.
 Individuals with eating disorders experience
urges (or cravings) for binge-foods similar to
urges for drugs.
 Develop a treatment plan for both the eating
and substance use disorder.
 Conduct a behavioral analysis of the foods and
substances of choice; high-risk times and
situations for engaging in disordered eating and
substance abuse behaviors
 Employ psychoeducation and cognitive–
behavioral techniques for bulimia nervosa.

Summary
 Co-occurring disorders are the rule not the
exception
 Mental health issues, especially trauma and
eating disorders may not be revealed during
the initial assessment
 Be alert for “substitute” addictions
 Adequate treatment must address the person
as a whole

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Copyright 2008-2012 AllCEUs.

com a subsidiary of CDS Ventures, LLC

 Employ a Recovery Perspective

 Openness to new information

 Awareness of personal reactions and feelings

 Recognition of one’s own limitations

 Recognition of the value of client input

 Patience, perseverance, and therapeutic

 Belief that all individuals are capable of growth

Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

 Determine stage of change

 Assessment is about getting to know a person with

 Make every effort to obtain collateral information

 Don’t allow preconceptions about addiction to

 Don’t assume that there is one correct treatment

Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

 Be a source of encouragement and support

 Anticipate and address difficulties

 Explore what can be learned from the

Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

 Address housing needs.

Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

 Start low, go slow

Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

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